Milestones in the History of Surgical Practice in the Sudan


By Abdel A`Al Abdella Osman
Introduction


Our knowledge of the pattern of medicine that was practiced in Sudan in the early 19th century is small. Broadly speaking, internal diseases were treated with herbs and magico-religious methods, while surgical diseases were mainly treated with cautery, scarifications, various forms of dressings and manipulation with or without modified splinting. Modern medicine was introduced in the beginning of the 20th century by the Anglo-Egyptian army that conquered the Sudan in 1898. It gradually passed through several phases before progressing to its present standard. The few doctors who first came to Sudan were army doctors, manning a small medical service whose main object were to look after the health of the troops.


Gradually, this small service grew, extending its service to civilians and so not only more army doctors had to be recruited but also civilian doctors were asked to join. The backbones were British doctors in the senior post and Syrian doctors in the junior posts. By 1955, they were all replaced by Sudanese doctors. These pioneers had to work under difficult conditions and quite often had to do additional work unrelated to their training. As a result of their experiences and cumulative hard work over the years, they made a slow but steady progress.


This paper is meant to give a broad outline of the events through which modern surgery in the Sudan passed; to acknowledge the debt we owe to those pioneers who paved the way for our present medical service and medical training; and to remind our young doctors that medical history, like that of all arts and sciences, is continuous. The past form basis for the present and the present for the future.


For convenience, this paper is divided into three periods:


· 1898-1924: The establishment of medical and health services.


· 1924-1949: The training of Sudanese doctors and medical auxiliary staff.


· 1949-1972: The development of specialized surgery and the promotion of para-surgical auxiliary functions.


Part 1: 1898-1924: The establishment of medical and health services


During this period, the history of surgery cannot be separated from general medicine. The first concern of Medical Corps of the British-Egyptian army was to look after the health of their own troops. The doctors were either British, holding the rank of Major and above, or Syrians (lieutenants and captains). After reopening of Sudan, their second concern was to look after cleanliness and sanitation in the large towns in the North in order to protect themselves and citizens from outbreaks of cholera, small pox, malaria, etc. and in 1898, the total revenue collected in Sudan amounted to 35,000 pounds only. With such an insignificant budget to start with, for such a large country, the only source of supply for new officials was against commissioned ranks in the Egyptian army (Squires, 1958).


In 1900, small civil hospitals were opened in Khartoum, Omdurman, Berber, Dongola, Halfa, Suakin and Kassala. The first three British civilian doctors arrived in Sudan early in 1901, and were given the rank of temporary Bimbashi (Major). They were: Dr. E. A. Gates, O.B.E, who work for one year at Omdurman and Kassala before going back to Britain; Dr. Webb Jones, who was stationed at Halfa and then left to Alexandria to become a surgeon there; Dr. E.S. Crispin, who graduated in 1898 and volunteered as a civil surgeon in South Africa during the Boer War. When his contract ended, he accepted the offer of the Principle Medical Officer of the Egyptian Army. He arrived in Cairo in February 1890. In 1902, he was sent to Southern Sudan to deal with health problems in that area.


Simultaneously, a similar offer was made by doctor Theodore Dyke Ackland, FRCS, Medical Adviser to the Governor General, to Mr. J.B. Christopherson, FRCS who accepted it. Dr. Ackland, who was a physician, had worked in Egypt since 1880 and came to be close friend of Sir Reginald Wingate. He was for a short time the Principle Medical Officer of health of the Egyptian Army. In 1900 he was appointed Medical Adviser to the Sirdar and the Governor General and was asked to select Medical Personnel for the Sudan Government. Both Dr. Crispin and Mr. Christopherson joined the Sudan Government service for 2 years, during which they led very distinguished careers. Their names were deeply engraved as founders of the medical services in Sudan (Squires, 1958).


Mr. J. B. Christopherson, CBE, FRCS, FRCP: He was the fourth civilian doctor and the first qualified surgeon to join the service. His career and that of other pioneer surgeons who worked with him or followed him will be described in some details. Mr. Christopherson graduated from St. Bartholomew's hospital and all his service in Sudan was in Khartoum.


In 1904 the Governor General decided to establish a civil medical service for the country, to be called the Medical Department. Mr. Christopherson was appointed as the first Director of the department.


Dr. Crispin protested and offered his resignation. However, he was appointed to the newly created post of Medical officer, Port Sudan when the present harbour was being constructed. During Mr. Christopherson`s directorship(1904-1908), the Medical Department was extended as follows: the authorized British cadre of civilian doctors was raised to six; Syrian civil doctors appointed in the Medical Department increased to more than thirty; three modern-type planed hospitals were built in Khartoum, Port Sudan and Atbara. They contained three classes of beds. The first and second classes were assigned to government officials: British, Egyptian and Sudanese. The hospital contained wards for the women. Operating theatres were included and two British sisters, Miss Pye Moore and Miss Jones joined the services.


In 1908, Mr. Christopherson was appointed as a Director of Khartoum and Omdurman Hospitals and so gave his time to clinical work. Colonel Mathias, who was the Principle Medical Officer of the Egyptian Army, succeeded him as Director Medical Officer of the Medical Department and Dr. Crispin was appointed as Assistant Director.


Also Mr. Christopherson was devoted to clinical surgery; he was in fact working as a general purpose doctor in addition to surgery and administration. In 1908, he reported the first case of relapsing fever in Sudan. The spirochete was detected by a Syrian Medical Officer in a routine examination of blood of a patient coming to Khartoum from a village 50 miles north. Mr. Christopherson confirmed the diagnosis.


In 1914, he was assigned to temporary duty with the Red Cross Hospital in Serbia during World War I, and was taken as prisoner of war by the Austrians but had an early release because of Slatin Pasha`s intervention in Vienna. After the war, he accomplished the most significant contribution to medicine made by a member of the Sudan Medical Service. On 15th of July 1919, he published in the Journal of Tropical Medicine and Hygiene the successful treatment of seventy cases of schistosomiasis with intravenous potassium antimony tartrate. He also injected the same drug through the dorsal vein of the penis, in an attempt to get maximum concentration of the same drug around the worm in the perivesical plexus of veins (I. El Maghrabi, personal communication). For this great discovery, he received the C.B.E and was elected Fellow of the Royal College of Physician of England while he was still abroad. This latter honour was similarly bestowed on the late professor Kirk, Director of the Stack Medical Research laboratory and first professor of pathology in Kitchener School of Medicine. In 1922, Mr. Christopherson retired on a pension and was succeeded by Dr. Hodson, MRCP, as a Director of Khartoum and Omdurman hospitals.


Dr. Hodson was the fifth civilian doctor and arrived in Sudan in 1903. He studied in Oxford and graduated at St. Thomas`s hospital. He worked in Kaser Ini for a while. He obtained his MRCP in 1908 when at Atbara. In 1921, he opened the Medical Assistants School. In 1924, he replaced Dr. Ackland as Medical Representative, Sudan Government in London (Squires, 1958).


Mr. N.E. Waterfield, CMG, FRCS: like Mr. Christopherson, Mr. Waterfield was a graduate of Bartholomew`s hospital. He obtained the fellowship and joined the Medical Service in 1905. Thus he was the sixth civilian doctor to arrive in Sudan and the second qualified surgeon after Christopherson. He had no settled post for a time, but was mainly at Khartoum. In 1908 he was transferred to Port Sudan to replace Dr. Crispin, there he spent the full tour of his service before retiring to Britain.


Mr. O.F.H. Atkey, CMG, FRCS: he was a graduate of King`s College Hospital, London. He spent his resident surgical post in the Royal Free Hospital and like Mr. Waterfield obtained his FRSC before coming to Sudan in 1907. He was the seventh qualified surgeon to join the Medical Service. For some years, he acted as leave relief in summer and was given special duties during winter. In 1919 he was entrusted with the medical supervision of Blue Nile Province with Headquarters at Wad Madani. In 1922 he succeeded Dr. Crispin as Director of Medical Service, till 1933 when he was succeeded by Dr.(later Sir) Eric Pridie. During the eleven years of his directorship, Mr. Atkey had a very distinguished career. The Medical service was greatly expanded and even more important was his contribution in collecting funds for Kitchener`s School of Medicine. His name will always be remembered in connection with the School. Besides this Dr. Atkey was a great horseman and air pilot in spite of the trouble with his visual accommodation, which used to give him a difficult time when he was landing with his small air craft (I. ElMaghrabi, personal communication).


Mr. G. R. Footner, FRCS: a graduate of St Thomas's Hospital, spent his surgical residentship at Derby before obtaining his fellowship. He was the fourth qualified surgeon to join the Sudan Medical Service. He arrived in 1909 and spent his early years of service as medical officer in charge of the personnel working the railway extension to El Obeid and Kassala.


In 1919, when Sudan Medical Service took the Gezira and Upper Nile Provinces from the military, Mr. Footner was posted as Medical Inspector in Malakal. To be able to get about in the province, he asked Dr. Crispin, the Director of the Medical Service, to provide him with a hospital ship. DR. Crispin made use of an old steamer, called Atbara, taken by the government from the Sudan Development and Exploration Company. The steamer was refitted to contain the dispensary and examination room on the lower deck leaving the upper deck for an operating room, an eight-bed room for in-patients and Mr. Footner's accommodation. The experiment proved to be practical and successful.


When there was an overflow of patients extra accommodation was provided on a barge tied to the side of the steamer. The ship was named Lady Baker by Dr. Crispin with the approval of Sir Lee Stack. About 1880, Sir Samuel Baker was sent to Southern Sudan to stop slave trade. His wife, Austrian by birth, was the first European lady to carry out medical work in tropical Africa. Sir S. Baker was related to Dr. Crispin by marriage; and also a direct relative of R.E.T Baily, governor of Kassala Province. About 1931, a new Lady Baker was specially designed for the purpose and still exists (Squires,1958).


While on duty Mr. Footner followed an injured lion into the Upper Nile jungles. He sustained penetrating wounds in his knee from the lion. Mr. Atkey was able to save Footner`s limb; but he lived with a stiffened knee for the rest of his life. Before the accident Mr. Footner was a keen cricketeer and tennis player. In 1924, with the emergence of Kitchener's School of Medicine, Mr. Footner was the first to fill the newly created post of Senior Surgeon and Lecturer in Surgery. Mr. Footner used to visit Omdurman Hospital three time per week to look after the surgical problems. Before completion of the White Nile Bridge in 1927, Mr.Footner used to cross in a ferry to Mawrada where the theater attendant stood waiting for him to accompany him to the hospital. (Ismail Ahmed, Personal communication). Mr. Footner retired in 1929, and was succeeded by Mr. Grantham Hill. He died in 1943 of carcinoma of the small intestine, a very rare condition.


Mr. Grantham Hill, FRCS: Mr. Grantham Hill is a graduate of Cambridge who worked in the London Hospital for some time. He arrived in Sudan at the end of 1920, and in 1922 was posted in Madani in place of Mr. Atkey who became the Director of the Medical Department. In 1928 Mr. Hill obtained the Edinburgh Fellowship. He was afterwards transferred to Khartoum to succeed Mr. Footner as Senior Surgeon and Lecturer of Surgery in the Kitchener School of Medicine. In 1930, he was also Director of Khartoum Civil Hospital. He retained these posts up to 1933 when he retired to settle as surgeon Beccles, England. He was fond of sailing (Dr. H. ElNagar, personal communication).
Summary


During the period 1898-1924, surgical practice did not develop into separate specialty due to the preponderance of the medical and public health problems of the country. Thus the qualified surgeons in the country were functioning as general duty doctors. Of course they still had to deal with the surgical and obstetrical problems that crossed their way. With the same understanding, the medical assistants, who were primarily trained as auxiliary medical staff to help in the fields of public health and internal medicine, were also taught to deal with minor surgical procedures. They opened abscesses, excised lumps, performed circumcisions and gave general inhalational anaesthesia (mask and ether). Sometimes the very experienced medical assistants were allowed to deal with hernias and amputation (A. Bayoumi, personal communication).