Published by : PROFESSIONAL MEDICAL PUBLICATIONS
|October - December 2007 (Part-I)||
Management of Chilhood abdominal
masses by Nigerian traditional doctors:
A worrisome cause of delay in presentation
Osifo O.D1, Evbuomwan I2, Efobi C.A3
Abdominal masses are very common in Nigeria. These have been managed by traditional doctors even before the advent of orthodox medications. Traditional doctors are however, not able to distinguish between the various causes of abdominal swellings, hence all are diagnosed and managed as splenomegaly (ude). Their modes of treatment are scarification, tattooing and concoction application in different combinations. We retrospectively studied twenty two patients who were mismanaged by traditional doctors before presenting to us at the University of Benin Teaching Hospital, Benin City – Nigeria. They all presented very late with life threatening complications and advanced diseases. Treatment offered on presentation included wound dressing, resuscitation, blood transfusion, antibiotics and laparotomy with resection of the masses, depending on diagnoses. These could only salvage 13(59.1%) of the patients while a high mortality of 9(40.9%) was recorded. The need to improve on our health care delivery system is stressed.
KEY WORD: Traditional doctors, Childhood, Abdominal masses.
Pak J Med Sci October - December 2007 (Part-I) Vol. 23 No. 5 809-813
1. Osifo OD,
2. Evbuomwan I,
3. Efobi CA,
1-3: Paediatric Surgery Unit, Dept. of Surgery,
University of Benin Teaching hospital,
Benin City – Nigeria.
Dr. Osifo O.D,
* Received for Publication: May 26, 2007
* Revision Accepted: August 30, 2007
Childhood abdominal masses are very common in Nigeria. Tropical splenomegaly due to malaria fever is frequently seen in children.1 This is called by various native names such as "Ude" by the Edo people. Traditional doctors often treat this by scarifications, tattooing and concoction application which they have come to regard as standard mode of treatment. Unfortunately, all abdominal masses and even abdominal swellings without mass are taken as "ude" and treated as such irrespective of location within abdominal quadrant. Even poorly treated malaria fever which persists longer than necessary is attributed to "ude" and is treated accordingly. Complications resulting from this and other forms of traditional treatment2-5 have been alarming & worrisome.
Nigerian traditional medical practice, like in other parts of the world was well established before the advent of orthodox medications. The practice is still, however, with us after over five hundred years of contacts with modern medical practice. It still remains as the only form of medical care that is affordable and available to the majority of Nigerian population. It also still serves as the first line of defense against diseases in a great proportion of people even amongst the enlightened city dwellers and the elites.6 Although the Nigerian traditional healers and herbalists are general practitioners, some of them do specialize, though in rudimentary form.6
Many patients who develop complications are not referred for orthodox care until it is too late. This is even worse in case of children who depend on their parents’ or guardians’ consent for treatment and hence for the quality of healthcare received. A number authors have reported complications resulting from management of gunshot injuries2 & fractures3-5 by traditional doctors. Not much has been said about management of abdominal masses by them.
The purpose of this retrospective study was to report our experience with abdominal masses treated by traditional doctors over a seven years period, so as to highlight the types of cases treated as abdominal masses, treatment received, complications and outcome. This also highlights the need to improve health education and bring community health services to the doorstep of our people especially the underprivileged and rural dwellers.
PATIENTS AND METHODS
University of Benin Teaching Hospital is a tertiary teaching hospital located in the South-south geopolitical zone in Nigeria. Complicated cases are referred from other hospitals within the region, from the paediatric department in the hospital and other health institutions including traditional health providers. A total of 37 patients who presented in our unit between January, 2000 and December, 2006 were studied. The patients (n=15) who presented to orthodox doctors from the start, those who presented stable and without abdominal mass and those whose case files could not be retrieve for analysis were excluded from the study. The remaining 22 were studied for variables such as age, sex, aetiology of abdominal mass/swelling, traditional treatment received, complications arising from it, orthodox treatment and final outcome. The data obtained from the study are presented in tables and figures.
There were 37 cases that presented with abdominal mass and swelling over the period of study and 22 of these cases were studied. All cause of abdominal swelling was treated as "ude". Abdominal swelling without a mass constituted 40.9% of the cases treated and Wilm’s tumour accounted for 18.2%. Only in 9.1% was splenomegaly (ude) correctly diagnosed. Ovarian mass constituted 9.1% and hepatoblastoma, neurolastoma, intussusception and mesenteric cyst constituted 4.5% each (Table-I).
Ages of the patients range between 6 days and 12 years with a male/female ratio of 1.2:1. Tattooing, scarifications and concoction application in various combinations were the usual mode of treatment. Scarifications was combined with concoction application in 18.18%, scarification alone in 36.50%, scarification/ tattooing in 18.18%, tattooing alone in 18.18% while tattooing/concoction application and attempted anal perforation were done in 9.1% (Table-II and Fig.1a-2b).
All the patients developed one form of complication or the other. These were minor in 9.1% but life threatening morbidities in 90.9%, ranging from wound infection, dehydration, shock, anaemia, advanced tumours and respiratory failures. Treatment offered on presentation included wound dressing, resuscitation, blood transfusion, antibiotics and laparotomy with resection of the masses, depending on diagnoses. Only 13 (59.1%) of the patients could be salvaged by our intervention and a total of 9 (40.9%) patients succumbed to the illness. The causes of death were multiple organ failures from advanced malignancy or overwhelming infections.
Childhood abdominal masses are quite common worldwide and neuroblastoma is most common, followed by Wilm’s tumour in Caucasian.7 From our series and previous report8 in Nigeria, Wilm’s tumour is the commonest cause of childhood abdominal mass, followed by tropical splenomegaly syndrome due to malaria endemicity. Other less common causes include liver tumours, ovarian tumours, mesenteric cysts, neuroblastoma lymphoma etc which are all treated as "ude" by traditional doctors as shown in (Tables-I, II). The high mortality rate recorded in this study is in keeping with other forms of treatment by traditional doctors. Osime et al2 reported the high morbidity and mortality associated with management of gunshot injuries by traditional doctors. Omololu et al3 and Onuminya et al4 from the western part of the country drew attention to the high complications and avoidable amputations resulting from traditional bonesetters treatment. Reports from the northern part of the country by Yakubu et al,5 also revealed the high rate of avoidable limb amputations due to treatment by traditional doctors. Encouraging revelation came much earlier when Oyebola11 conducted an interview on 156 traditional doctors and discovered that 125 (80%) of them were willing to cooperate and learn from the western-trained doctors in order to improve their efficiency. It is hoped that health policy makers in Nigeria will incorporate this into their curriculum in the nearest future.
Apart from complications resulting from poor management, all the patients presented very late and at times in terminal stage of the disease. Many of them got the assurance that the ailment can only be handled by traditional methods. This is in consonance with the work of other researchers who reported that superstitious beliefs still play a major role in delaying and at times prevent seeking orthodox medication in many African countries.11-13 Poor responses to treatment were blamed on some spiritual forces which cannot be handled by orthodox medications except sacrifice, incantations, tattoos scarification and application of concoction. These made even the enlightened people to have faith in them, only to seek orthodox help when the case was terminal.
Inspite of the high mortality recorded many patients still patronized them perhaps because they have no alternative means either due to non availability of modern health services or lack of funds to come to a sophisticated centres. These contributed immensely to the delay in presentation in this study. These traditional health carers are readily available, affordable and appeal to traditional belief that ill healths are caused by unseen forces which can only be appeased by traditional means without much financial involvement.12,13 Osuntokun9 reported that in Nigeria, because of gross shortage of western-trained health personnel, many patients frequently resort to traditional doctors who spend 8-10 years in training. Their phamacotherapeutics are based in part on observation tested through the ages, and not on cause and effect phenomena, hence the poor results. Many ailments such as gunshot injuries,2 bone fractures3-5 and psychiatric illness10 therefore, have established traditional clinics in Nigeria. We also noted from this study that a large proportion of cases who presented with abdominal swelling such as intussusception, imperforate anus, hirschsrung’s disease, malrotation and even persistent malaria fever were treated as splenomegaly. The distinction between other solid tumours was also not made, as only in 2(9.1%) patients was splenomegaly present. The remaining 90.9% were victims of not only result of poor treatments received but also of wrong diagnosis. Those who had anorectal anomaly and hirschsrung’s disease presented in neonatal period. They developed septic shock shortly after traditional treatment and died within few days of life. Findings from this study necessitate the need for us to improve our health awareness campaign. Poor access roads to most rural communities in Nigeria also make it impossible for people, especially children to benefit from standard health care services as obtains in developed countries of the world.
Abdominal masses/swellings are grossly mismanaged by traditional doctors in Nigeria with resultant high morbidity and mortality rates. Poverty, ignorance, superstitious beliefs, non availability and affordability of orthodox medication encourage their patronage. Cooperation between orthodox and traditional doctors may in the near future reverse this ugly trend.
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5. Yakubu A, Muhammad I, Mobogunje OA. Major Limb Amputations in Adults, Zaria, Nigeria. JR Coll Surg Edinb 1996;41(2):102-4.
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8. Nwako FA. Abdominal Masses in Infants; A Textbook of Paediatric Surgery in the Tropics, The Macmillan Press Ltd, London. 1980;165-9.
9. Osuntokun BO. The Traditional Basis of Neuropsychiatric Practice among the Yorubas of Nigeria. Trop Geogr Med 1975;27(4):422-30.
10. Aluede OC. Music Therapy in Traditional African Societies: Origin, Basis and Application in Nigeria; J Him Ecol 2006;20(1):31-5.
11. Oyebola DD. Some Aspects of Yoruba Traditional Healers and their Practice. Trans R Soc Trop Med Hyg 1980;74(3):318-25.
12. Nbiti JS. African Religion and Philosophy; Heinemann Educational Books Ltd, London 1976;25-7.
13. Awolalu JO, Dopamy PA. West African Traditional Religion, Onibonoje Press Ltd, Ibadan. 1979;15-7.
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