In many of the villages of the developing world, the burden of chronic disadvantage, poverty, ignorance, and insanitation are the background to life. A surgical disease on top of this may be the last straw.
As the result, patients often present late. If yours is a really disadvantaged community, tapping a hydrocele may yield litres rather than millilitres of fluid. An elephantoid scrotum may have progressed so far that it hangs to the ground (31-7). If a patient has a urethral stricture, he may leave it until he has multiple fistulae (23-10) or massive extravasation (23.10). If he has carcinoma of his penis (32.33), he may wait until much of it has been eaten away. Most carcinomas of the breast (21.4) and cervix (32.35) present too late for any hope of cure. Too often, patients only present when complications have made their lives unbearable. When even the struggle to keep alive may be a losing battle, the fact that surgical disease is normally treatable is irrelevant.
There are usually good reasons why a patient presents late. His family may have had no money for the operation or for transport, or there may be no transport. Perhaps it is the planting season, or there is nobody to look after his children or his goats? Perhaps his disease is painless, so that he does not realize that he is ill. Perhaps his tolerance to pain, disability, deformity, and misery is so high that he has to be desperate before he seeks help? He may only come to you when he has exhausted local remedies and and the services of traditional practitioners.
Transport, which may have been difficult before the rainy season, can become an insurmountable problem during it, when roads become quagmires, and rivers even more perilous. Acute surgical emergencies, in particular, may only come when patients are in the direst straits.
When a patient does come, you will not be able to send him off for an extensive series of investigations before you start treatment. Instead, you will have to learn to make a firm diagnosis from the history and examination. Expect to find that he has other diseases also. In Nepal, for example, only 15% of operations are in otherwise healthy patients. So expect your surgical patients to be malnourished, anaemic, malarious, tuberculous, or worm-ridden[md]or all of these things. They help to make a patient weak and wasted and a poor operative risk. Anaemia increases the risks of surgery, and in some communities the average haemoglobin may be only 80 g/l. Some patients may still be walking around with 40 or even only 20 g/l. Apart from a little breathlessness on the hills of Nepal, one 12 year old girl with a haemoglobin of only 20 g/l had no other complaints. So try to prepare your patients for surgery before you operate, especially if the cause is readily treatable.
Pain and disability are unlikely to rate highly when there is rice or maize to be planted, or when there are festivities and holidays. Although the economy may be poor, the culture may be a rich and compelling one. The cultural objections to colostomy, for example, may be so firm that a patient is unlikely to agree to have one, even temporarily, and even after you have explained how it can be managed with colostomy bags. Mastectomy may be similarly abhorrent.
Death is the great enemy of doctors and evidence of our failure. But a patient may have faced up to his own mortality, and may not always share your view. He may have learnt to live with death since childhood, and both his own attitude to it and that of his closest relatives may be very accepting. One of the greatest mistakes you can make is to send him home to die after a useless operation, having used up much of his own resources, and those of the hospital in an unsuccessful attempt to cure him.
Fig. 1-4 A PRIVATE WARD in an Indian rural hospital. For a village family an illness is more than a biological disorder[md]it may be a social and economic crisis. After GR Howard with the kind permission of the editor of Tropical Doctor.