PLASTIC SURGERY EXPERIENCES IN THE POKHRA VALLEY, NEPAL : I By L. B. SCOTT, F.R.C.S.Ed. United and Regional Liverpool Hospitals THE country of Nepal holds for most people a particular fascination partly because of the towering snowcapped Himalayan peaks which have called for great feats of endurance by adventurous mountaineers, but also because of the veil of mystery which has shrouded this closed land for many years. For over a century the ban on all foreign visitors was absolute, the country being firmly held in the grip of rich feudal overlords. In 195o a surprising revolution overthrew the Rana regime and the King took his FIG. I Pokhra bazaar with " Fishtail " and the Annapurna range behind. rightful place at the head of his country. He then proceeded to set up a democratic government and invited medical, educational and agricultural personnel to come to help his backward people, who were living in conditions similar to those prevailing in this country in the Middle Ages. Nepal, tucked away between North India and Tibet, is rectangular in shape, 5oo miles long and 11o miles wide. The upper third is formed by the Himalayan range, the middle by high hills and valleys, and the lower third by thick forest, or terai, full of big game. The population is about IO million people, many Newars living in the Kathmandu valley, and other tribes, including the Gurkhas and Sherpas, inhabiting the smaller valleys and villages in the foothills of the great snows. The people are agricultural, mostly very poor, 9o per cent. illiterate and many live in remote and inaccessible areas. Although two new roads are under construction linking the capital city of Kathmandu with India at Raxaul and Nautanwa, apart from a few grass airstrips served by Dakota aircraft, travel is almost entirely by foot. The people as a whole know nothing of personal cleanliness, hygiene or simple medical remedies, and disease in this otherwise beautiful country is rampant. Tuber-
PLASTIC SURGERY EXPERIENCES IN NEPAL 7 culosis in all its forms is a terrible scourge and there is a high incidence of malaria, smallpox, rabies, leprosy and other tropical diseases. In 1965, three months before my visit, I,OOO people died from cholera in West Nepal during the single month of July, and 30o perished in one week in Kathmandu. Only a small number of trained Nepali doctors and nurses serve the whole country and these work mainly in the Kathmandu valley. Most of the outlying medical services are provided by Mission doctors and sisters, many of them working in very primitive conditions and surrounded by appalling physical suffering. One hundred miles west of Kathmandu lies the second largest valley of Pokhra, at one end of which is a long straggling bazaar (Fig. I). At the King's invitation in 1952 two doctors and four nursing sisters trekked to this area for eight days over the hills from the Indian border. On arrival there was no accommodation and no facilities for medical work, so they set about building their own bamboo huts and immediately started dispensary work. The next year they laid the foundations of a small hospital and set up sections of aluminium, brought by air to the local airstrip, to serve as Nissen huts. From these early beginnings the demand for medical help has grown enormously, the patients coming not only from the valley but toiling for several days along precipitous tracks to I716. 2 get skilled attention. There is no Patient arriving in basket having been carried in modern transport to and from the by husband. hospital, the present accommodation of 4o beds is quite inadequate for the needs and there is only a single spasmodic water tap at the corner of the field to serve the whole compound. However, as Dick, writing from Okhaldunga in N.E. Nepal, has pointed out in his article on " Surgery Under Adverse Conditions" (Lancet, 1966, 2, 9oo), it is amazing how much essential help can be given with the barest minimum of equipment and facilities. Operations are carried out during daylight, aided by a torch, but if expensive kerosene is available an emergency generator for electric light can be run for night emergencies. At present there are no X-ray or pathological facilities. Run in conjunction with this small general hospital there is a leprosarium isolated four miles away. Two local Tibetan refugee camps also provide cases and these are usually accompanied by personal livestock! Three doctors cover the Shining Hospital and the Leprosarium, as well as dealing with 45,ooo out-patients a year, doing health clinics in the bazaar and carrying out occasional visits to more distant areas. The majority of patients are admitted from the Pokhra valley and surrounding villages, many of which are perched on the foothills below Machhapuchhare (" Fishtail" mountain, 23,0oo ft., 15 miles to the north) and the Annapurna Range, towering z6,5oo ft. into the sky. Most of the patients arrive by foot during the hours of daylight, night travel being restricted because of fear of evil spirits. Those too ill to walk are brought by bullock cart or carried in by relatives on a bamboo litter or chair, in a basket on a man's back (Fig. z), or slung in a canvas sheet beneath a pole supported by two adults. Many patients arrive in extremis after all local remedies have been tried~ or in the last stages of childbirth, having been carried over mountain paths up to five days'
BRITISH JOURNAL OF PLASTIC SURGERY walk away. One such patient arrived who had been in labour for IO days. Treatment is further complicated by poor general nutrition, anaemia, hookworm, chronic dysentery and other tropical or specific diseases. Sepsis in wounds is the rule as the usual local application is mud or cow dung. Owing to shortage of beds only the worst cases can be admitted, whilst others find local accommodation in the bazaar and attend daily as out-patients. Those who are admitted will only stay long enough to feel some improvement in health and then return to their families to tend the buffalo, cut the rice or millet harvest and look after their homesteads. The follow-up of cases is very spasmodic due to the distances involved, which means that as much treatment as possible must be completed in one stage. Women are entirely dependent on the goodwill of their husbands as to whether they are allowed to stay for treatment, irrespective of the severity of their illness. Operative Conditions and Ana:sthetics.--The operating theatre consists of a small section of an aluminium hut and measures I6ft. by IO ft., with fly-proof netting over two outside shutters. Next door is a primitive sterilising room with small pressure sterilisers heated on two primus stoves. A recent explosion of this equipment blew two holes in the aluminium roof. Patients are carried into the theatre, on a canvas sheet supported by two bamboo poles, by any men available around the hospital. The nearest relative comes in to watch the operation over the surgeon's shoulder, whilst others look through the open shutters from outside. For major operations Largactil followed by morphia and atropine are given as premedication. The routine general anmsthetics, given by the sisters, are chloroform and open ether for adults, but ethyl chloride and ether is used for children. In cleft lip palate cases an endotracheal tube is passed and connected up to the E.M.O. inhaler, but no oxygen is available unless a mountaineering team returning from Dhaulagiri (26,800 ft.) or the Annapurna range donates it on their homeward journey. Pentothal drips were used for two cases of compound depressed fracture of the skull and a patient with a rodent ulcer of four years' standing adherent to her right malar. Many adult cases are operated on under local anmsthesia combined with a heavy sedative cocktail consisting of an injection of Omnopon gr. ½ and scopolamine gr. 1/15% given one hour pre-operatively together with phenobarbitone gr. I½ by mouth. Just before scrubbing up, when the patient is on the operating table, between 2 and 5 c.c. of a 2o c.c. solution of IO mg. of pethedine and 50 mg. of Largactil is given intravenously. This is given slowly because of tachycardia and flushing. If necessary I ampoule of Lethidrone is given as an antitode. Spinal Nupercaine is used wherever possible for lower abdominal and leg cases, and regional nerve blocks for the upper limb. Types of Surgical Cases. (a) Acute Emergencies.--Many of these are similar to cases seen in the more developed countries but appendicitis amongst the Nepalis is rare. Acute and chronic intestinal obstruction is common, arising from such diverse causes as tuberculous peritonitis with adhesions, amoebic colitis, perforated typhoid ulcers and roundworms. Delayed or obstructed labour (Fig. 3) often calls for C~esarean section or craniotomyo and one patient who had been in labour for io days had severe necrosis of the pelvic floor and bladder requiring a suprapubic cystostomy and a colostomy. (b) Accidents.--Closed and compound fractures and head injuries are common following falls from trees (when collecting foliage for animals), upper stories of houses, over cliffs (Figs. 4 and 5), or off swings. One patient with multiple injuries following a fall down the Sheti gorge had extravasation of urine up to his scapula from a ruptured urethra.
PLASTIC SURGERY EXPERIENCES IN NEPAL 9 (c) Cuts and l.vounds.--these frequently arise from the use of khukri knives to cut bamboo, rice, maize and millet, or to shape timber for building huts. Mud contaminated with cow dung is applied to stop bleeding and tetanus often results. Most wounds heal well after being cleaned with Hibitane and the use of antibiotics, which FIG. 3 Mother and baby return home two and a half hours after delivery. FIG. 4 FIG. 5 Fig. 4.--Compound depressed fracture of skull following fall over cliff. Fig. 5.--Returning home eight days after operation. work well since no insensitivity to these drugs has yet developed. Keloids are uncommon except amongst Tibetans. Many old scar deformities are seen, some following cancrum oris or facial injuries. One case treated in Kathmandu was a Tibetan woman whose nose had been cut off for adultery by her husband, a not uncommon punishment there. (d) Abscesses.mThese are often huge but respond well to wide incision and drainage. However, large amoebic abscesses of liver often do best on medical treatment, although drainage may be necessary later.
IO BRITISH JOURNAL OF PLASTIC SURGERY (e) Burns.--These are very common and extensive, resulting from the bamboo and thatched huts catching fire. Also many babies, having been well cleaned with mustard oil, roll into the fire in the centre of the hut at night. Most of the patients FIG. 6 Extensive deep burns treated by exposure. FIG. 7 Fig. 7.--Healing bear mauls three weeks after injury. Fig. 8.--Facial wounds just prior to grafting. carried to the hospital have full thickness skin loss (Fig. 6) or come later with gross scar contractures. Exposure treatment is complicated by the presence of flies, whilst dressings and bandages are in short supply as they have to come by air or be carried in by porters from India.
PLASTIC SURGERY EXPERIENCES IN NEPAL II FIG. 9 Bear mauls requiring reconstruction. FIG. IO Thakali mother and baby with cleft lip.
12 BRITISH JOURNAL OF PLASTIC SURGERY (f) Bear Mauls.--From time to time cases arrive following attacks by panthers and leopards (" tigers ") but the majority of these huge cats tend to shy away from humans FIG. I I FIG. 12 FIG. 13 Fig. I I.--Boy aged 14 with complete bilateral clefts of lip and palate, Fig. i2.--showing position of premaxilla and dental arches. Fig. I3.--Post-operative closure after 4 8 hours. FIG. 14 Figl I 4. - - M a n aged 19 with complete left-sided cleft. FIG. 15 Fig. is.--post-operative appearance after closure of lip and anterior palate. into the dense undergrowth unless cornered or injured. On the other hand the black Himalayan bear, living in the forests of the foothills, attacks on sight and causes dreadful injuries, such as deep jagged gashes or the tearing away of large flaps of soft tissue of face, scalp or limb. These wounds, caused by sharp dirty claws, quickly become infected. One patient (Figs. 7 and 8) had deep clawing of his back as he crouched over
PLASTIC SURGERY EXPERIENCES IN NEPAL 13 to protect two children, as well as flaps torn down from his scalp and face. He was found by searching villagers next day and taken home and finally arrived at dusk at the hospital two days after the attack. He had been carried on a bamboo litter for 12 hours over mountain tracks by 18 men in relays and when the dirty head-dressing was removed the main facial flap was found lying raw surface outwards. Many of the FIG. 16 FIG. 17 Fig. I6.--Tibetan man with sebaceous cyst. Fig. i7.--rodent ulcer of four years' duration adherent to right malar. patients who survive present difficult reconstruction problems, particularly under the hospital conditions prevailing (Fig. 9). (g) Clefts of Lip and Palate.--Whilst no figures are available, the general incidence of clefts of the primary and secondary palate appears to be similar to that in this country. These unoperated cases vary from babies in arms (Fig. IO), infants (one, 4 years old, was still being breast fed), children (Figs. 11-13) and adults (Figs. 14 and 15). No bacteriological examination of nose and throat was available but the more extensive cases were admitted two days before operation for local cleansing of the operative field. If they appeared fit, the lip and anterior palate was dealt with in the first instance, with systemic penicillin cover. Apart from the boy of 14 vomiting a roundworm at the end of his ether anmsthetic, and one case of bleeding from the anterior palate which required packing for a few days, there were no other complications. (h) Rodent Ulcers and other Skin Tumours.--These vary from simple cysts (Fig. I6) to more advanced malignancies (Fig. 17). These hardworking peasants, fighting for a living against very adverse conditions, are not interested in cosmetic disfigurements unless they interfere with marriage prospects or their ability to work at home or in their fields.