Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Distribution and Incidence of Tropical Surgical Diseases
279
tis and sought treatment at the hospital in the Nigerian bush—and he was a very
rare white visitor, a Peace Corps Volunteer from the Bronx!
With this shift in patterns of recognition of common incidence conditions, I
had learned of first-world rarities that might even have been nonexistent in my prior
experience and listed them, but was even more impressed by the conditions with
which I had become very familiar, strikingly absent. Both the causes of death and
the incidence and complications of the infectious diseases called “tropical” were
quite apparent in this setting, but to practice surgery, one needed to know the Western—or
universal—fundamentals of surgery, and improvise in putting them into
practice in the modifications required by the resource constraints. This “reprogramming”
has been an essential part of clinical practice learning in each subsequent
venue in which I have worked in the tropics.
Presentation
Pathology is often late in its presentation to the attention of health care workers.
This is a simple statement often reiterated in regard to tropical surgery conditions.
What it means is that, far from being a challenge, diagnosis is often apparent at a
glance, or a sniff, and not necessarily by a physician. Few of the primary presentations
are subtle. The findings are so obvious, that simply exposing, or pointing is all
the “History and Physical” examination needed in many wordless encounters without
need for translation. An adult with a cleft lip or a child with an extremity bent in
a right angle are not diagnostic dilemmas. An outcast woman sitting outside the
clinic door and reeking of urea-splitting organisms hardly need be examined to determine
that she has a long-standing vesicovaginal fistula.
Some of these unfortunate patients presenting in such a late stage of disease
afford a fascinating “window” on the natural history of some conditions never allowed
to deteriorate before repair in other, more fortunate, parts of the world. I had
once seen a man with a rather unique situation that was at first puzzling—a scrotal
ileostomy. I then realized I was looking at the natural history of incarcerated inguinal
hernia that strangulate with the only unlikely outcome that could still result
in his survival.
I had encountered unusual physical findings associated with filariasis that were
advanced features of the disease. The “hanging groin” was not a clinical feature I had
encountered before my experience in filariasis endemic areas, where I had also learned
of onchocerciasis nodules appearing everywhere where a tumor might be suspected,
including intracranially. I discovered chyluria and a number of other late stage features
of several of the filarial complications.
When I had accommodated the spectrum of filariasis, I saw it everywhere, even
where it was not. I had encountered elephantiasis of the extremities in areas where I
thought it odd that there had been no filariasis being recorded. One such patient
was seen in Ecuador, where he was completely disabled by the distortion of his legs,
and only later did I learn that the characteristic elephantiasis I had identified as
filarial in origin could also result for silica lymphangitic obstruction in pedoconiosis,
or “mossy foot” 8 for which an entire surgical treatment and prevention project is
supported in an Ethiopian hospital.
Environmental Conditions
There are but two seasons in the tropical latitudes, marked by extremes of inundation
and desiccation, with illnesses and hygiene conditions reflecting water-borne
27