Ubuntu #2: Divination and a Diagnostic Dilemma
Author Victoria Stephen
Edited by Kirsten Kingma
You are on duty at uBuntu Hospital Emergency Department on a Tuesday evening when a 37 year old male is brought in by EMS. His neighbour had called EMS when she had noticed that he had not ventured out of his house all day. She doesn’t know his medical history but she is aware that he hasn’t been feeling well over the past week. Paramedics found him in bed, unconscious. His vital signs from triage are: blood pressure 115/66, heart rate 121 BPM, respiratory rate 28 breaths per minute, Sats 82% in room air, temperature 39.2 C and his finger stick glucose is 7.2 mmol/l.
The nurse puts him on face mask oxygen and IV fluids are started. He is unconscious and responds only to pain with no obvious focal neurological deficits. You identify his GCS as E2V2M3 = 7/15. His pupils are sluggish. His chest is difficult to auscultate due to transmitted sounds from his upper airways, but breath sounds are reduced on the right. After intubating him and getting him settled on the ventilator, you examine him more thoroughly.
He appears slightly wasted and has generalised lymphadenopathy, but what catches your eye are multiple small superficial lacerations over the 6th intercostal space of his anterior chest. What do they mean? Could they point towards a possible diagnosis?
These incisions are scarification marks; known as “izingcabo” in isiZulu, which is one of South Africa’s 11 official languages. They are made by traditional healers when patients consult them for their various illnesses and concerns. Traditional medicine is rubbed into the freshly made incisions in order to try cure the ailment the patient is suffering from. The contents of traditional medicine vary but usually consist of herbs, bark, leaves and minerals. Traditional healers are common in South Africa, with 60- 80% of the population consulting them for various illnesses and social problems. Patients frequently will consult a traditional healer in their community before seeking medical attention, especially in rural areas where hospitals and clinics are few and far between.
There are different categories of traditional healers in South Africa, the most common being herbalists (inyangas) and diviners (sangomas). Herbalists dispense traditional medicine made of plants, inorganic substances and occasionally animal extracts. Diviners believe that they can discern the cause of a patient’s illness by speaking to the patient’s ancestral spirits.
Scarification marks are usually made with razor blades. They are commonly made at the site of the patient’s pain, or over a swelling, such as over oedematous feet. They may be seen over the left hypochondrium if splenomegaly is present. In cases of sciatica , they may follow a dermatomal distribution. They are also made over the back of the neck, on the sternum, or around the umbilicus when a patient desires protection from illness or harm. Scarification sites can become infected particularly if traditional medicine is applied in the wounds, so they should be carefully inspected.
An abdominal ultrasound image of the right upper quadrant in the longitudinal plane: The liver is seen on the right of the screen. A densely consolidated lower lobe of the right lung is seen on the left.
This patient had community acquired pneumonia, which was complicated by meningitis. He had consulted a traditional healer after he had fallen ill. It may be that he had reported right sided pleuritic chest pain to the sangoma who then made the scarifications in an attempt to cure him. It is useful for medical doctors to know what scarifications signify as their presence can offer clues to a diagnosis. It’s also important to be aware of the cultural beliefs our patients may have and to educate them as much as possible about the aetiology of their illness.
Further reading:
Traditional healers and paediatric care. De Villiers FPR, Ledwaba MJP. SAMJ 2003;93:664-665
