Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Medical Adventures in the Nigerian Bush
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designations for some patients may be “bed 18” and “bed 18 1/2”, the ”1/2” representing
the floor mat space between beds filled by supernumerary patients. The
fundamental medical care is of amazingly good quality; the patients lack no essentials
for the management of treatable diseases, and the treatment is faster without
the frill of university technique. Diagnosis is a sophisticated as the best physical
examination, although the trained laboratory boys are helpful in diagnosing many
treatable disorders and are astute than we were in differentiating parasitic diseases.
The native nurses serve as “house staff” and interpreters for the local vernacular
tongues, translating the questions in history-taking into Hansa, the lingua franca of
Northern Nigeria, or into English the official language of the country. In the outpatient
clinic the nurses screen from about 500 patients those patients whom the doctor
should examine (averaging about 50), treating the remainder for obvious maladies
such as most infectious diseases. On the wards the nurses perform most of the treatment
functions, freeing the physician’s time for only the sickest patients. As an example
of one function the MD delegates, everyone in this primitive society is
intimately acquainted with death, and since death is such a common experience, it
does not require the presence of an observer entitled with an MD to pronounce it.
No certification is required so the doctor does not have the added paperwork of vital
statistics.
Our computers had to be reprogrammed according to the cardinal signs that
signify disease entities other than those familiar to us in medical center civilization.
Right lower quadrant abdominal pain meanes appendicitis in Ann Arbor (a disease
not seen during our stay) but it means amebic cecitis in Takum. Hematuria is almost
never a warning of urinary tract neoplasm, but usually signifies bilharzia. Right
upper quadrant abdominal pain does not mean gallbladder disease—nearly unheard
of in the bush—but should alert one for amebic abscess of the liver. We had to
discard a number of our more common pathognomonic patterns in favor of local
predominance of pathology. In medical school terms it might be said that zebras
more common than horses in Africa (Table 1).
Mnemonics are formulated as check lists to run down causes of postoperative
fevers in the United States, but none of them includes the most common in Nigeria—malaria.
It might be postulated that in response to operative stress the spleen
contracts, a physiological reaction at infuses leukocytes into the circulation; but in
this part of the world the circulation is also showered with the tissue phase protozoa
carried by everyone. Whatever the theory, postoperative fevers respond so dramatically
to chloroquin that it is often given as routine prophylaxis. In many patients the
spleen is not only palpable, but visible. We collected an interesting series of splenomegaly
patients that have an idiopathic enlargement of the spleen that in some
cases become so big as to fill the abdomen and enter the pelvis. After ruling out all
causes of splenomegaly, they fit the diagnosis described in the literature as “tropical
splenomegaly”.
Infectious Disease Mortality
Many exotic diseases we encountered we were unacquainted with except as illustrations
in books about classic diseases disappearing from civilization. It is interesting
to consider that the chief causes of mortality and morbidity in this primitive
culture are the infectious diseases—the great showcase of modern medicine in which
civilization displays the control achieved over disease. The control that Western culture
has accomplished over these preventable and treatable diseases presupposes a
great deal more technology than just possessing chemotherapy. Before infectious