Your surgical work

Ten to fifteen per cent of your admissions will probably be surgical, but because operating is time consuming, and some patients remain in bed for a long time, surgery may take 30% of your time, and fill half your beds. How much you will do will depend on how good you are at it. Patients will travel hundreds of kilometres to a doctor with a good surgical reputation. A bad one will soon do little surgery. Look carefully at the ages and sexes of the patients in your wards. When modern medicine first reaches a community, the first patients to present are the men, followed by the women and children. Only when medicine is well established, will you see a proportionate number of older women. If you don't find them in your wards, medicine has not reached this stage in your community. You will see few hypochondriacs, and there will be comparatively few repeat visits to the outpatient department because travel is so difficult.

You will see many of the diseases that are common in the industrial world, but in different proportions, a major difference being that so many of them present late (1.5). ''Western diseases' such as appendicitis, diverticulitis, carcinoma of the colon, haemorrhoids, and varicose veins are rare. Urethral strictures, tubal infections, fibroids and hernias are common, so are some diseases that are almost extinct in the industrial world[md]osteomyelitis, for example. You will probably see amoebiasis and tuberculosis of the chest, lymph nodes, abdomen, and bones. But you will seldom see carcinoma of the colon, or the thromboembolic complications of surgery that are so common in Europe; you will probably never see diverticulitis. No branch of surgery will differ more starkly from that in the industrial world than orthopaedics, where the cases you see, particularly those with polio contractures, will not have been seen in Europe for thirty years.

You will have to do many kinds of operation. For example, of nearly a thousand patients operated on at Nanyuki district hospital in Kenya, 175 different diagnoses were recorded in the theatre book. Of the patients needing general anaesthesia, only tubal ligations, the evacuation of inevitable abortions, and Caesarean sections came to more than 10% of the whole. Excluding tubal ligations, only about 5% of patients needed a laparotomy. About half the total were obstetric or gynaecological cases of some kind, about 15% were fractures and dislocations, and about 8% a variety of abscesses that needed to be opened under general anaesthesia.

Three-quarters of the bony injuries you will see are likely to be dislocations of the shoulder and elbow, supracondylar fractures in children, extension fractures of the wrist, and fractures of the radius and ulna, or tibia and fibula. All other bony injuries combined will only form the other quarter. Many will be the result of road accidents.

The cases you would like to refer[md]if you can[md]will be even more varied. A consecutive list of referrals from Nanyuki were an anaplastic carcinoma for radiotherapy, gas gangrene of the buttock in a diabetic, a brachial plexus injury in a patient with a head injury, rape causing a third degree tear in a girl of 8, and a patient with carcinoma of the stomach. Nanyuki had no instruments for craniotomy, so one referral was a patient with severe headache following a head injury. Another had a burnt scalp followed by osteomyelitis of his parietal bone and cerebral symptoms.

KALPANA (a Nepali aged 46) presented with mild abdominal pain for several days, severe for four days, and diarrhoea with two loose stools tinged with blood daily for a week. She had a tender, fluctuant mass in her right lower quadrant, and a marked leucocytosis. At laparotomy she had a patchy necrosis of her caecum with a localized perforation. A right hemicolectomy was done for suspected necrotizing amoebic colitis (31.11). The operation was a nightmare. Her colon came to pieces in the surgeon's hands and there was gross faecal contamination. She died. LESSONS (1) Expect a different spectrum of disease from that found in the industrial world. There, a fluctuant mass in the right lower quadrant is most likely to be an appendix abscess. (2) Avoid doing a right hemicolectomy for amoebiasis if you can. Fig. 1-3 SOME OF YOUR PATIENTS. Here are a random collection of patients who were in the ward when Fig. 1-1 was drawn. Patients A, and B, are sharing the same bed. They were admitted at nearly the same time time with head injuries, having both fallen off different motor cycles, neither wearing helmets (63.1). Child C, has Perthes' disease (27.14). Child D, broke his femur in the playground at school (78.3), and child E, has his fractured forearm in a cast (73.6b). Patient F, was assaulted (63.6). Patient G, a very old man, fell and fractured the neck of his femur (77.7). Patient H, is to have his prostate removed (23.19). We have described the care of all of them. Note also the prevalence of trauma, both from the roads and assault, and the geriatric complaints of patients G, and H.