- Email: [email protected]
Hand Surgery in developing countries
HAND SURGERY IN DEVELOPING COUNTRIES
G. P U L V E R T A F T t
PULVERTAFT G. -- Hand Surgery in developingcountries. Ann Chir Main, 1987, 6, n° 4, 329-331.
Since retiring in 1972, I have had the privilege of visiting or working in countries which do not have our advantages. During 1973 I spent three months in a leprosy hospital and training centre in Ethiopia. Hail6 Sdlassid was still on the throne but the famine was starting which set off the Revolution of the following year with its change in the political philosophy of Ethiopia. Next year I visited several hospitals in India and in 1975 I was attached to the Suhrawardy Orthopaedic Hospital (as it was then called) in Dacca and the University Hospital in Kuala Lumpur for short periods and visited Singapore and Burma. From 1976 to 1979 I was engaged in establishing a Service for Hand Surgery in Kuwait, spending several months a year in that country. It is of these experiences that I wish to share with you something of the countries, the patients that 1 saw and the lessons that I learned. We never cease to be students and it is fitting that I should begin with the All Africa Leprosy an Rehabilitation Training C e n t r e ( A L E R T ) in Addis Ababa where I was very much a learner. I was deeply impressed by the dedication of the staff and the standard of the work that I observed. I found the same qualities in leprosy hospitals I visited in India, Bangladesh and S.E. Asia. 1 learned many things, among them being that tendon transfers for intrinsic palsy of the hand are successful only when the indications are correct, the surgery is precise and the aftercare is unrelenting. A L E R T was founded in 1965, largely due to the .influence of Paul Brand. Felton Ross, the medical s u p e r i n t e n d e n t , and E r n e s t Price, physician in charge of leprosy control, have told me how a survey of the incidence of leprosy was made before the hospital was built. With the assistance of the provincial governors and the local chieftains, the towns, the villages and the scattered communities were visited in the search for leprosy sufferers. At that time the population of Ethiopia was 25 million and it was estimated that there were 100,000 suffering from the disease.
PULVERTAFT G. - - La chirurgie de la main dans les pays en voie de ddveloppement. (En Anglais). Ann Chir Main, 1987, 6, n° 4, 329-331.
A L E R T is supported by numerous missionary and leprosy organisations and by the Ethiopian G o v e r n m e n t . The Centre is responsible for : - - Leprosy Control. - - Training of doctors, nurses and paramedical workers who went on to work in different parts of the world. - - Research. - - A hospital of 200 beds, which also acted as a base for several small leprosy hospitals elsewhere in the country. Dacca, the capital of Bangladesh, has a University Medical School and Hospital but it was lacking in facilities for Orthopaedic surgery until the Ministry of Public Health invited D' Ronald Garst, an American surgeon then working in the Mission Hospital at Ludhiana in the Punjab, to design and set up such a hospital. This was opened in part in 1972 and has recently been completed, having 350 adult and 350 children's beds. The full title is the Rehabilitation Institute for the Disabled and Dacca Shishu Hospital and is a lasting tribute to Ron and Marie Garst. The UK Ministry of Overseas Development has give assistance over the years by providing orthopaedic surgeons from Britain to work and teach in the hospital and prepare the junior hospital staff for the degree of MS (Orthopaedics) of Dacca University. I spent a few weeks there in 1975 teaching basic hand surgery. The population of Bangladesh was then 90 million and increasing and there are great demands upon the orthopaedic service. When I was there, the Clinics were invariably overcrowded and continued over the closing time. No one was turned away. Congenital malformations, fractures, tendon and nerve injuries, infections, burn contractures and paralytic conditions attended in endless variety in the hand clinic. Many of them were challenge problems and it was difficult to think straight at the end of the day. I was impressed by the number of VSO's (Voluntary Service Overseas) I met from the UK. and from the Republic of Ireland. School teachers,
330
H A N D S U R G E R Y IN D E V E L O P I N G C O U N T R I E S
nurses, p h y s i o t h e r a p i s t s , o c c u p a t i o n a l therapists were there giving of their talents to these people Bengalis, despite their poverty, are a happy race and the teenagers are always laughing - - they were delightful people to treat. Kuwait is a desert country at the northern end of the Arabian Gulf, bounded to the north-west by Iraq and to the south-west by Saudi Arabia with a long shore line on the Gulf to the east. The population is nearly one and a half million and less than half are Kuwaitis. The remainder have come in from other countries and include about 250,000 displaced Palistinians. Originally nomads, the Sabah tribe settled in their present site in 1710 because they discovered freshwater springs in that area. For over 200 years, Kuwait was a small fishing, pearling and trading community. Because of its position, Kuwait became an important staging post between Britain and India. Oil was discovered in 1937, but owing to the World War, development was delayed and the first tanker did not sail from Kuwait until June 1946. Since then a most remarkable transformation has taken place. Kuwait is now a great modern city with fine buildings and roads, schools and a University. All state education is free. The shops are stocked with manufactured goods from many countries. All water comes through desalination plants from the Gulf. Internal telephone communication is free and there is no income tax. The hospital services have shared in this dramatic development. In 1911, a small Mission hospital was founded by an English doctor, C.S.G. Mylrea, who worked for 30 years in Kuwait. The first modern general hospital - - the Amiri - - was opened in 1949 and contained 100 beds. There are now many hospitals including the Sabah complex with its medical, surgical, paediatric central laboratory and radio-therapy services ; a maternity hospital which has 25,000 deliveries annually, a tuberculosis hospital, a new orthopaedic hospital and a new University hospital and two new District General Hospitals. There is a total of approximately 6,000 public service hospital beds. There are also two private hospitals. The Medical School has an annual entry of 60 ; clinical instruction began in 1980 and the first degrees were conferred in, at the present time there are a few service Kuwaiti doctors who have had their medical education overseas, but the majority of hospital staffs are Egyptian or Indian. The Orthopaedic hospital has been greatly helped during the 1970's by Professor Rennie from Aberdeen and Professor James from Edinburgh. In recent years there has been similar help from Sweden. The Hand Service is part of the Orthopaedic division. One of the younger staff surgeons, Kamal Helmi, was appointed in charge in 1976 when I first went to Kuwait. My duties were to teach him the practice of hand surgery and also to instruct the registrars and house surgeons. There was a normal work programme of outpatient clinics, ward rounds
ANNALES DE CHIRURGIE DE LA MAIN
and theatre sessions. I conducted a weekly instructional course for the junior staff in basic hand surgery. Helmi and I also held an annual Course open to surgeons of the surrounding countries. These International Courses were greatly enjoyed by the , Class ,, and by the Faculty, which was augmented by distinguished surgeons from abroad. The outpatient and theatre staff appointed to the hand service were clearly determined to make this new venture a success and I received wholehearted support from them, for which I am deeply grateful. I was able to say with sincerity that the theatre conditions matched those to which I was accustomned at home. It soon became routine for me to hold out my hand and have the correct instrument placed in it without taking my eyes off the target. It was a pleasure to work in these conditions and I am glad to be able to give this precise. Kamal Helmi showed himself to be a thoughtful and skilled surgeon and we developed a mutual trust which made me look forward to each return visit to Kuwait. One of the important aspects of the teaching programme was the instruction of the registrars, each of whom was attached to our service for a month. In time all the junior staff were exposed to the philosophy and techniques of hand care. We saw a wide range of conditions, a few of which I will describe. When it became known that there was a hand service at the Orthopaedic Hospital, patients found their way to us on account of congenital deformities, burn contractures, skeletal, tendon and nerve injuries, tumours and diseases of many kinds. This girl of ten years sustained a palmar burn at the age of two due to misuse of a pressure stove, a cause of burning which was all too common. She was treated by opening up of the hand and the application of an abdominal flap. This woman in her twenties had a division of both flexor tendons in the proximal segment of the index finger (zone II). She was treated by a palmaris graft by Kamal Helmi with a good result ; the finger was splinted for three weeks according to my usual practice but Helmi is now using early protected motion after grafting with gratifying results. This teenage lad fell from a truck in the desert some months before coming to hospital. He had sustained a complete brachial plexus lesion and had been treated by cautery burns, the marks of which are clearly visible. As we were not competent to deal with this formidable injury, the boy was referred to Professor Millesi of Vienna. There is a system in Kuwait wherein any full Kuwaiti citizen suffering from any medical or surgical condition for which there is no adequate treatment facility in Kuwait may be transferred to another country where such facilities exist ; all expenses for the patient and one companion are paid by the State. This small boy is one of five similar cases seen in Kuwait. The case illustrates the dangers of modern
VOLUME 6 N,, 4 - - 1987
HAND SURGERY IN DEVELOPING COUNTRIES
power equipment being used by those who are unaware of the risks involved. This boy was cared for in the central emergency service at the Amiri hospital by a young Sudanese registrar who had shown much promise while he was on his month's attachment to the Hand Service and to whom incidents I had taught the importance of photography. This boy was playing in the desert when an asp came out of his hole in the ground and bit him on the hand. He was taken to the Sabah Hospital which saved his life but there followed the death of the hand from local clotting. He was referred to us for the inevitable amputation. Tears were mingled with laughter for there were many avoidable disasters arising from ignorance or neglect that came to us, but there was frequently the joy in parents faces when a child's hand was converted from a useless paw to something approaching what it is intended to be. It is Bedouin custom to treat fractures by tightly applied wooden splints and ischaemic complications are not unknown. Some were correctable by serial splintage, others by muscle slide. One day a Bedouin of some 50 years came with a severe contracture following a forarm fracture which had occured 20 years previously. The contracture was so severe combined with median and ulnar nerve paralysis that I was not in favour of surgery and said to Kamal ~
said (~ M. Pulvertaft, you cannot say that ; he has had this deformity for 20 years and now he has heard that there are doctors here who operate upon the hand ; perhaps he has been persuaded by this relatives to come and you would turn him away ,,. My reply was to the effect that surgery in this case would carry a considerable risk without much expectation of improvement. Eventually, I gave in and agreed to perform a muscle slide. This was done and I was relieved there was no vascular crisis afterwards. At this stage 1 was obliged to leave for Britain. When I returned, six months later, Gergean was one of the first patients that I saw. H e was smiling and held out his hand with pride. It was far better than I had any right to expect. There was a good wrist and finger position and, although understandably there was no change in the nerve function, there was a much better digit position and control. Ah, he said, it was not you that did this great thir for me and he drew from his robes the small tin that the p h o t o g r a p h shows-tiger B a l m , the cure for all complaints and used extensively in the East. ~( I run this ointment into my hand every morning and night and during the day and many times | work my fingers ,,. If I had instructed him to work his fingers, as I have no doubt I did, it would not have been done so effectively as by his own enthusiasm. We all laughed and congratulated him. Our Clinic Sister, who had followed the case f r o m the beginning said ~ poor M. Pulvertaft ,,. He went off immensely pleased and so, indeed, were we.
mmm
ANNALES DE CHIRURGIE Redaction : 39, bd de L a t o u r - M a u b o u r g , 7 5 0 0 7 PARIS
ABONNEMENTS (10 n u m e r o s par an) Service ,< A b o n n e m e n t s -
: 15, rue S a i n t - B e n o i t - 75278 PARIS C E D E X 06 - Tel, (16.1) 45.48.42,60 F R A N C E : 800 F
331
I~TRANGER : 1 100 FF
Reglement au C.C.P. La Semaine des H6pitaux Paris 877-22 F ou par cheque bancaire a I'ordre de - La Semaine des HbDitaux ,, Les abonnements sont payables au comptant et ne sont mis en servi(~e qu'apres la reception du reglement.
G. P U L V E R T A F T t
PULVERTAFT G. -- Hand Surgery in developingcountries. Ann Chir Main, 1987, 6, n° 4, 329-331.
Since retiring in 1972, I have had the privilege of visiting or working in countries which do not have our advantages. During 1973 I spent three months in a leprosy hospital and training centre in Ethiopia. Hail6 Sdlassid was still on the throne but the famine was starting which set off the Revolution of the following year with its change in the political philosophy of Ethiopia. Next year I visited several hospitals in India and in 1975 I was attached to the Suhrawardy Orthopaedic Hospital (as it was then called) in Dacca and the University Hospital in Kuala Lumpur for short periods and visited Singapore and Burma. From 1976 to 1979 I was engaged in establishing a Service for Hand Surgery in Kuwait, spending several months a year in that country. It is of these experiences that I wish to share with you something of the countries, the patients that 1 saw and the lessons that I learned. We never cease to be students and it is fitting that I should begin with the All Africa Leprosy an Rehabilitation Training C e n t r e ( A L E R T ) in Addis Ababa where I was very much a learner. I was deeply impressed by the dedication of the staff and the standard of the work that I observed. I found the same qualities in leprosy hospitals I visited in India, Bangladesh and S.E. Asia. 1 learned many things, among them being that tendon transfers for intrinsic palsy of the hand are successful only when the indications are correct, the surgery is precise and the aftercare is unrelenting. A L E R T was founded in 1965, largely due to the .influence of Paul Brand. Felton Ross, the medical s u p e r i n t e n d e n t , and E r n e s t Price, physician in charge of leprosy control, have told me how a survey of the incidence of leprosy was made before the hospital was built. With the assistance of the provincial governors and the local chieftains, the towns, the villages and the scattered communities were visited in the search for leprosy sufferers. At that time the population of Ethiopia was 25 million and it was estimated that there were 100,000 suffering from the disease.
PULVERTAFT G. - - La chirurgie de la main dans les pays en voie de ddveloppement. (En Anglais). Ann Chir Main, 1987, 6, n° 4, 329-331.
A L E R T is supported by numerous missionary and leprosy organisations and by the Ethiopian G o v e r n m e n t . The Centre is responsible for : - - Leprosy Control. - - Training of doctors, nurses and paramedical workers who went on to work in different parts of the world. - - Research. - - A hospital of 200 beds, which also acted as a base for several small leprosy hospitals elsewhere in the country. Dacca, the capital of Bangladesh, has a University Medical School and Hospital but it was lacking in facilities for Orthopaedic surgery until the Ministry of Public Health invited D' Ronald Garst, an American surgeon then working in the Mission Hospital at Ludhiana in the Punjab, to design and set up such a hospital. This was opened in part in 1972 and has recently been completed, having 350 adult and 350 children's beds. The full title is the Rehabilitation Institute for the Disabled and Dacca Shishu Hospital and is a lasting tribute to Ron and Marie Garst. The UK Ministry of Overseas Development has give assistance over the years by providing orthopaedic surgeons from Britain to work and teach in the hospital and prepare the junior hospital staff for the degree of MS (Orthopaedics) of Dacca University. I spent a few weeks there in 1975 teaching basic hand surgery. The population of Bangladesh was then 90 million and increasing and there are great demands upon the orthopaedic service. When I was there, the Clinics were invariably overcrowded and continued over the closing time. No one was turned away. Congenital malformations, fractures, tendon and nerve injuries, infections, burn contractures and paralytic conditions attended in endless variety in the hand clinic. Many of them were challenge problems and it was difficult to think straight at the end of the day. I was impressed by the number of VSO's (Voluntary Service Overseas) I met from the UK. and from the Republic of Ireland. School teachers,
330
H A N D S U R G E R Y IN D E V E L O P I N G C O U N T R I E S
nurses, p h y s i o t h e r a p i s t s , o c c u p a t i o n a l therapists were there giving of their talents to these people Bengalis, despite their poverty, are a happy race and the teenagers are always laughing - - they were delightful people to treat. Kuwait is a desert country at the northern end of the Arabian Gulf, bounded to the north-west by Iraq and to the south-west by Saudi Arabia with a long shore line on the Gulf to the east. The population is nearly one and a half million and less than half are Kuwaitis. The remainder have come in from other countries and include about 250,000 displaced Palistinians. Originally nomads, the Sabah tribe settled in their present site in 1710 because they discovered freshwater springs in that area. For over 200 years, Kuwait was a small fishing, pearling and trading community. Because of its position, Kuwait became an important staging post between Britain and India. Oil was discovered in 1937, but owing to the World War, development was delayed and the first tanker did not sail from Kuwait until June 1946. Since then a most remarkable transformation has taken place. Kuwait is now a great modern city with fine buildings and roads, schools and a University. All state education is free. The shops are stocked with manufactured goods from many countries. All water comes through desalination plants from the Gulf. Internal telephone communication is free and there is no income tax. The hospital services have shared in this dramatic development. In 1911, a small Mission hospital was founded by an English doctor, C.S.G. Mylrea, who worked for 30 years in Kuwait. The first modern general hospital - - the Amiri - - was opened in 1949 and contained 100 beds. There are now many hospitals including the Sabah complex with its medical, surgical, paediatric central laboratory and radio-therapy services ; a maternity hospital which has 25,000 deliveries annually, a tuberculosis hospital, a new orthopaedic hospital and a new University hospital and two new District General Hospitals. There is a total of approximately 6,000 public service hospital beds. There are also two private hospitals. The Medical School has an annual entry of 60 ; clinical instruction began in 1980 and the first degrees were conferred in, at the present time there are a few service Kuwaiti doctors who have had their medical education overseas, but the majority of hospital staffs are Egyptian or Indian. The Orthopaedic hospital has been greatly helped during the 1970's by Professor Rennie from Aberdeen and Professor James from Edinburgh. In recent years there has been similar help from Sweden. The Hand Service is part of the Orthopaedic division. One of the younger staff surgeons, Kamal Helmi, was appointed in charge in 1976 when I first went to Kuwait. My duties were to teach him the practice of hand surgery and also to instruct the registrars and house surgeons. There was a normal work programme of outpatient clinics, ward rounds
ANNALES DE CHIRURGIE DE LA MAIN
and theatre sessions. I conducted a weekly instructional course for the junior staff in basic hand surgery. Helmi and I also held an annual Course open to surgeons of the surrounding countries. These International Courses were greatly enjoyed by the , Class ,, and by the Faculty, which was augmented by distinguished surgeons from abroad. The outpatient and theatre staff appointed to the hand service were clearly determined to make this new venture a success and I received wholehearted support from them, for which I am deeply grateful. I was able to say with sincerity that the theatre conditions matched those to which I was accustomned at home. It soon became routine for me to hold out my hand and have the correct instrument placed in it without taking my eyes off the target. It was a pleasure to work in these conditions and I am glad to be able to give this precise. Kamal Helmi showed himself to be a thoughtful and skilled surgeon and we developed a mutual trust which made me look forward to each return visit to Kuwait. One of the important aspects of the teaching programme was the instruction of the registrars, each of whom was attached to our service for a month. In time all the junior staff were exposed to the philosophy and techniques of hand care. We saw a wide range of conditions, a few of which I will describe. When it became known that there was a hand service at the Orthopaedic Hospital, patients found their way to us on account of congenital deformities, burn contractures, skeletal, tendon and nerve injuries, tumours and diseases of many kinds. This girl of ten years sustained a palmar burn at the age of two due to misuse of a pressure stove, a cause of burning which was all too common. She was treated by opening up of the hand and the application of an abdominal flap. This woman in her twenties had a division of both flexor tendons in the proximal segment of the index finger (zone II). She was treated by a palmaris graft by Kamal Helmi with a good result ; the finger was splinted for three weeks according to my usual practice but Helmi is now using early protected motion after grafting with gratifying results. This teenage lad fell from a truck in the desert some months before coming to hospital. He had sustained a complete brachial plexus lesion and had been treated by cautery burns, the marks of which are clearly visible. As we were not competent to deal with this formidable injury, the boy was referred to Professor Millesi of Vienna. There is a system in Kuwait wherein any full Kuwaiti citizen suffering from any medical or surgical condition for which there is no adequate treatment facility in Kuwait may be transferred to another country where such facilities exist ; all expenses for the patient and one companion are paid by the State. This small boy is one of five similar cases seen in Kuwait. The case illustrates the dangers of modern
VOLUME 6 N,, 4 - - 1987
HAND SURGERY IN DEVELOPING COUNTRIES
power equipment being used by those who are unaware of the risks involved. This boy was cared for in the central emergency service at the Amiri hospital by a young Sudanese registrar who had shown much promise while he was on his month's attachment to the Hand Service and to whom incidents I had taught the importance of photography. This boy was playing in the desert when an asp came out of his hole in the ground and bit him on the hand. He was taken to the Sabah Hospital which saved his life but there followed the death of the hand from local clotting. He was referred to us for the inevitable amputation. Tears were mingled with laughter for there were many avoidable disasters arising from ignorance or neglect that came to us, but there was frequently the joy in parents faces when a child's hand was converted from a useless paw to something approaching what it is intended to be. It is Bedouin custom to treat fractures by tightly applied wooden splints and ischaemic complications are not unknown. Some were correctable by serial splintage, others by muscle slide. One day a Bedouin of some 50 years came with a severe contracture following a forarm fracture which had occured 20 years previously. The contracture was so severe combined with median and ulnar nerve paralysis that I was not in favour of surgery and said to Kamal ~
said (~ M. Pulvertaft, you cannot say that ; he has had this deformity for 20 years and now he has heard that there are doctors here who operate upon the hand ; perhaps he has been persuaded by this relatives to come and you would turn him away ,,. My reply was to the effect that surgery in this case would carry a considerable risk without much expectation of improvement. Eventually, I gave in and agreed to perform a muscle slide. This was done and I was relieved there was no vascular crisis afterwards. At this stage 1 was obliged to leave for Britain. When I returned, six months later, Gergean was one of the first patients that I saw. H e was smiling and held out his hand with pride. It was far better than I had any right to expect. There was a good wrist and finger position and, although understandably there was no change in the nerve function, there was a much better digit position and control. Ah, he said, it was not you that did this great thir for me and he drew from his robes the small tin that the p h o t o g r a p h shows-tiger B a l m , the cure for all complaints and used extensively in the East. ~( I run this ointment into my hand every morning and night and during the day and many times | work my fingers ,,. If I had instructed him to work his fingers, as I have no doubt I did, it would not have been done so effectively as by his own enthusiasm. We all laughed and congratulated him. Our Clinic Sister, who had followed the case f r o m the beginning said ~ poor M. Pulvertaft ,,. He went off immensely pleased and so, indeed, were we.
mmm
ANNALES DE CHIRURGIE Redaction : 39, bd de L a t o u r - M a u b o u r g , 7 5 0 0 7 PARIS
ABONNEMENTS (10 n u m e r o s par an) Service ,< A b o n n e m e n t s -
: 15, rue S a i n t - B e n o i t - 75278 PARIS C E D E X 06 - Tel, (16.1) 45.48.42,60 F R A N C E : 800 F
331
I~TRANGER : 1 100 FF
Reglement au C.C.P. La Semaine des H6pitaux Paris 877-22 F ou par cheque bancaire a I'ordre de - La Semaine des HbDitaux ,, Les abonnements sont payables au comptant et ne sont mis en servi(~e qu'apres la reception du reglement.