Milestones in the History of Surgical Practice in the Sudan


By Abdel A`Al Abdella Osman


Part 3: 1949-1972: The development of specialized surgery and the promotion of para-surgical auxiliary functions


The main features of this period were: Postgraduate training of Sudanese doctors in general surgery and in sub-specializations such as orthopaedics, E.N.T., plastic ...etc., and their acquiring of specialist posts in the Ministry of Health and University of Khartoum, and the promotion and expansion of Surgical Auxiliary Services.
Postgraduate Training in Surgery


The later years of the last period witnessed the dawn of postgraduate training for the Sudanese doctors. Before the Second World War, doctors were sent to the United Kingdom for short postgraduate courses; but following the war, proper postgraduate training was started. For example, in the years 1946-53, thirty seven doctors were in the United Kingdom. The candidates were given the opportunity to acquire higher qualifications in the various branches of medicine. This was the natural outcome of the increase in the number of Sudanese doctors, the high degree of efficiency and self-confidence they had shown, their desire to gain more knowledge, and of course the increasing consciousness of the public about the need for specialist services. For convenience, the development of postgraduate training of surgery will be discussed in various sub-headings according to their chronological order.
Pioneer Sudanese Surgeons


In 1948, Dr. Abdel Hamid Bayoumi was sent to the United Kingdom to acquire the fellowship in surgery. The candidate has to do both parts of the fellowship abroad. This system was not a success for two main reasons: candidates were selected many years after graduation, hence it was difficult to pass the Primary Fellowship Examination; and they were not sponsored by a teaching centre that may facilitate their training.


From 1948 to 1960 only three Sudanese doctors obtained the fellowship this hard way. They were Mr. Bayoumi, Mr. Bakheit M. Omer and Mr. I.M. el-Moghrabi.


Abdel Hamid Bayoumi, F.R.C.S.: He graduated from the Kitchener School of Medicine in 1934 (6th batch of Sudanese doctors to qualify). Having completed his internship, he served as Medical Officer in many stations, particularly Torit where he spent five years. In 1947 he was selected surgical registrar to Khartoum Civil Hospital, and in 1948 he left for the United Kingdom to attempt the fellowship. It was a real burden to be the guinea-pig for such a challenging mission. It seemed as if all eyes in the Sudan were on Bayoumi and his colleagues (to register their success or failure). In 1949 he passed the Edinburgh and Glasgow fellowships, thus proving that he was worthy of the responsibility.


He came back home and was posted surgeon at Omdurman Civil Hospital in place of Mr. Bartholomew who was promoted Senior Surgeon, Khartoum Civil Hospital. Four years later Mr. Bayoumi was the first Sudanese to become Senior Surgeon and lecturer after the death of Mr. Bartholomew.


Mr. Fleming, M.S., F.R.C.S.E., who was appointed lecturer in anatomy and Assistant to the Senior Surgeon in 1951, returned to the United Kingdom on the Sudanization of the latter post by Mr. Bayoumi.


Mr. Bayoumi held the Senior Surgeon post for twelve years, retiring in 1966, to be succeeded by Mr. Ibrahim el-Moghrabi. Collaborating with the Professors of Surgery in the University on the one hand and the Ministry of Health Authorities on the other meant that surgery was promoted both in quantity and quality during Bayoumi's tenure. He was elected president of the Sudan Association of Surgeons several times during the eight years since its formation.


Ibrahim M. el-Moghrabi, D.Chur., D.Orthop., F.R.C.S.: He graduated from the Kitchener School of Medicine in 1935. Having completed his internship he continued to work in Khartoum Hospital with the intention of becoming a surgeon; but he left the Sudan for Cairo to pursue his surgical training where he passed the D.Chur. and D.Orthop. He then left for England on his own initiative where he had further training in surgery and obtained the English fellowship in 1952.


He returned to Sudan and was posted Surgeon at Wad Medani Hospital in 1953. In 1965 he was transferred to Khartoum to become the Senior Surgeon after Mr. Bayoumi. He retired in 1968, and was succeeded by Mr. Ahmed Abdel Aziz.


During his stay at Medani, surgery was greatly developed in that hospital, so much so that the Royal College of Surgeons recognized a post of surgical registrar for the purpose of the F.R.C.S. examination. Mr. Moghrabi's reputation came from his research work on mycetoma which was of great contribution to Prof. J.B. Lynch in obtaining his Hunterian Professorship and Dr. El Sheikh Mahgoub in his thesis for Ph.D. on mycology.
Full-Time Surgical Staff of the Medical School


About the year 1952, it was decided by the University of Khartoum to create professorial posts in the various departments of the School.


Prof. B. Hickey: He was the first to fill the chair in the Department of Surgery. He was assisted by one or two lecturers or senior lecturers. The professor and his assistants were allocated surgical beds for which they were fully responsible. Later, posts for anaesthesia were created within the Department of Surgery.


Mr. P.R. Slade, F.R.C.S., was the first full-time senior lecturer appointed with the professor; he was succeeded by Mr. Mynors.


The Senior Surgeon and his fellow surgeons on the Ministry side-in both Khartoum and Omdurman Civil Hospitals-continued their contribution to the teaching of students. With the promotion of Mr. Bayoumi to Senior Surgeon in 1954, the Omdurman surgical post was filled by a German doctor. The latter did not prove a success and was soon replaced by Mr. Barst, F.R.C.S., who successfully filled the post till his retirement in 1963. Mr. Barst had worked for over ten years in the Sudan; first at Port-Sudan and then at Juba when he got his F.R.C.S.


Not all British doctors who were surgeons or later became surgeons, are mentioned in this article. An example of the former was Mr. O. Grattan, F.R.C.S., who worked in Khartoum and Port-Sudan before going to East Africa in the mid-forties. In addition, mention should be made of Mr. Husband and Mr. Owens. The latter is now a urological surgeon in St. Mary's Hospital, London.


Prof. Julian Taylor, C.B.E., M.S., F.R.C.S.: he was a graduate of University College Medical School and spent his career in University College Hospital. He obtained the English fellowship in 1914 and was consulting surgeon to the Eighty-five Field Ambulance in France and Macedonia during the First World War. In 1920 he obtained M.S., London. In University College Hospital he was at first a consulting surgeon but later became the Senior Surgeon. He also served in the Malayan Command (Singapore) during the Second World War. He was also a Member of Council-Royal College of Surgeons-and before retirement he was Vice-President to the College (Who's Who 1972). Sailing was his favourite recreation.


Mr. Taylor was the visiting examiner to the Kitchener School of Medicine in 1953. On his retirement from University College Hospital, Mr. Taylor succeeded Prof. Hickey in 1956. The history of the making of Sudanese surgeons was accelerated by the appointment of Professor Taylor to Khartoum University. No professor had been made in the making of surgeons since Mr. Moghrabi passed the F.R.C.S. in 1952. All Sudanese candidates sent to the United Kingdom to get that qualification failed in their mission. One of Professor Taylor's main concerns was to solve this problem. He tackled it from various angles.


For those who were already selected surgical registrars, he insisted that they should work for two years in the basic medical sciences and undergo a test before being allowed to proceed to the United Kingdom. They (Dr. Osman Awadalla, Dr. Ahmed H. Adam, Dr. Abdalla Saad, Dr. El-Nazeer Fadl el-Mula), being relatively young graduates, thought the plan to be unnecessary. However, they all successfully passed the primary and final F.R.C.S. examination in the United Kingdom.


Secondly, Professor Taylor decided to send new graduates for the F.R.C.S. mission. From among the 1956 graduates who finished their housemanship in April 1958, he focused on three, namely Dr. Haddad Omer, Dr. Nasr el-Din Ahmed, and Dr. A. Abdel Aziz. Dr. Haddad's first desire was to become an obstetrician and so he preferred Prof. Daly's offer. Dr. Nasr el-Din who was Medical Officer El Dueim-immediately after his internship-was taken by Professor Dean Smith for the Department of Physiology. Thus Dr. Ahmed Abdel Aziz accepted Professor Taylor's offer to be the guinea pig. However, the 1959 guinea-pig was better fed than the 1948 one. So he succeeded in his mission and obtained his F.R.C.S. in 1961.


The third intervention by Professor Taylor to solve the problem was to ease the way to the fellowship for all competent applicants. Being a Vice-President of the Royal College of Surgeons before coming to Sudan, it was a comparatively easy job for him to convince the College to hold a Primary F.R.C.S. examination in Khartoum each year. The first examination was held in 1960, and every year up to now Khartoum Centre has been running with a very high percentage of pass rates. The candidates are given training courses in the basic medical sciences at the Basic Science Department of the University. At first the candidates were few in number. They were surgical registrars of the Ministry of Health-averaging four-plus one or two private candidates. This did not satisfy Professor Taylor, and so in 1961 he wrote to the Vice-Chancellor of Khartoum University asking the University to select its own research assistants to qualify as surgeons and lecturers. By so doing, the process of Sudanization was started in the Department of Surgery. The author of this paper, Dr. Ali Kambal and Dr. Atabani were the first Sudanese to join the Department as research assistants in surgery. The number of candidates sitting for the examination in the last few years was from 14-18; mostly on their own initiative. The total number of those passing the Primary F.R.C.S. in Khartoum Centre amounted to about 60 Sudanese and a few others from neighbouring African countries.


Through his great influence in England, Professor Taylor was able to provide accommodation for those who passed the Primary in certain big London hospitals with good teaching facilities. Thus most of them got through the Final F.R.C.S. examination within one year. It is very evident that Sudan owes a great deal in the making of its surgeons to Professor Julian Taylor. Following a heart attack in Khartoum, the Professor died on his way to London. He was a great loss to this country and to the surgical profession.


With the appointment of Professor Taylor to Khartoum University, specialized surgery found its way to Sudan. The Professor himself had experience in neurosurgery. Mr. McGowen, F.R.C.S., who joined the Department of Surgery in 1956 was a Chest Surgeon. Mr. J. Jacques, F.R.C.S., succeeded Mr. McGowen in 1959 as Lecturer and Chest Surgeon. He was very devoted to his work and extremely helpful to his younger Sudanese colleagues. Mr. Jacques died suddenly in London of subarachnoid haemorrhage in the summer of 1962. Mr. D. Crockett, F.R.C.S., was the first Plastic Surgeon appointed as Lecturer in 1959. He stayed for 5 years during which time he was promoted to Senior Lecturer. He was able to establish plastic surgery as a recognised specialty in Khartoum Civil Hospital; and to convince the author and Mr. Kamal Bushra to pursue this line of specialization. Mr. Crockett left the Sudan in April 1964 for Bradford as a Consultant Plastic Surgeon to the Royal Infirmary.


Prof. M.F. Nicholls, K.B.E., M.A., M.Chir., F.R.C.S.: He studied at Clare College, Cambridge, and then St. George's Hospital, London. He served as a soldier in the First World War. After graduation he ascended the ladder of appointments from house-officer, surgical registrar, resident assistant surgeon to full surgeon (1939) in St. George's Hospital. During the Second World War, he was Brigadier to the R.A.M.C. He became Dean of the Medical School, St. George's Hospital, and was a Member and later Chairman, Court of Examiners Royal College of Surgeons. Before retirement he was President Section of Urology, Royal Society of Medicine (Who's Who 1972). Fishing was his favourite recreation.


He arrived in Khartoum at the end of 1961 in place of late Professor Taylor. Professor Nicholls' mission was not an easy one. Besides the teaching and administrative functions of the department-with the doubling of students intake-he had to maintain and improve the standards reached by Professor Taylor, particularly in the field of making of surgeons. The latter was kept very well as shown by the record of Khartoum Centre for the Primary Fellowship. By his good and friendly relations with Dr. Daniel-British Council Representative-Professor Nicholls was able to induce the Council to offer a number of scholarships for Sudanese medicals-in Ministry and University-to study in England. Thus if we know that the Primary F.R.C.S. examining team comes against the fees paid by the candidates, it becomes clear that the process of the making of surgeons in the Sudan has been very economical and of course very efficient.


Professor Nicholls, being a urological surgeon himself, introduced this specialty to three of our colleagues now working in Khartoum Civil Hospital. In addition a Department of Orthopaedics was initiated for the first time in Khartoum Civil Hospital during his tenure: according to an agreement between the Nuffield Orthopaedic Hospital Oxford, Ministry of Health and University of Khartoum. The agreement catered for the training of Sudanese surgeons in orthopaedics at Oxford, and for sending a senior lecturer from the Nuffield to run the department and teach the students in Khartoum. Five orthopaedic surgeons have come to Khartoum over a period of about 8 years from 1962 to 1970. The first was Mr. O'Conner (now professor of orthopaedics in Oxford regional hospitals) who started the process running in the first two years. He was succeeded by Mr. Denman, Mr. Eckerzli, Mr. Neeser and finally Mr. J.S. Ferguson. Five Sudanese orthopaedic surgeons were thus trained in Oxford according to this agreement.


Both Mr. Jacques and Mr. Crockett worked with Professor Nicholls during the initial two years followed by Mr. C. Davidson, F.R.C.S., who worked as senior lecturer from 1964 to 1966. Mr. Davidson replaced Mr. Crockett and maintained plastic surgery besides general surgery and teaching of students.


After 1966 British staff in the department were reduced to the Professor and the Orthopaedic Surgeon. In 1967 the headship of the department was taken over by Professor Bakheit M. Omer, yet Professor Nicholls willingly continued to cooperate with all the Sudanese Staff in the department till his sudden death of a heart attack on Monday 25th August 1969. In the morning of that day he was at Khartoum Airport to see the Daniells off to Cairo on their way home. In the same plane the coffin of an Egyptian Professor of Engineering who died in Khartoum was being carried. Professor Nicholls told his wife at the Airport that if he died in the Sudan, he would not mind being buried in Khartoum. So his wish was fulfilled. Professor Nicholls was knighted on 9th July, 1969 by Queen Elizabeth II for his long, devoted service in war and in peace. A compelling coincidence to the death of Sir Marriot must be told at this junction. On Monday evenings there was always a clinico-pathological conference for 5th year students run by two members of staff, a surgeon and a pathologist. On the day of Sir Marriot's death, it was his turn and Dr. Sayed Dawoud's to conduct the lesson. "Sir Marriot after having lunch set the alarm clock at twenty minutes to five", said his wife. Dr. Sayed Dawoud is a man of strict punctuality. When it was a few minutes past five and the Professor had not arrived for the class, Dr. Sayed Dawoud said to the students "The khawaga must have died". Truly the Professor was dead.


Professor Bakheit M. Omer, F.R.C.S.: In 1928, he left the Sudan at secondary school level-with others-after the political uprisings following the death of Sir Lee Stack in 1924. They were welcomed in Cairo and granted scholarships to complete their education. Having successfully finished his secondary school course, he left for Scotland and qualified in Edinburgh University. He returned home and served his internship in Khartoum after which he was posted in Nyala. He was dissatisfied with the very small salary given to Sudanese in comparison to British doctors. He left the Sudan for Egypt and afterwards for England to train as a surgeon. Having passed the English fellowship in 1951, he returned home again and applied for the Senior Surgeon post, which was later given to Bayoumi. He decided to immigrate once more to Cairo where he was offered a teaching post in Ein Shams University. In 1967 he was appointed Professor of Surgery in Khartoum University-the first Sudanese to attain this post.
The Era of Sub-specialization


It is evident from the previous section that surgical sub-specialization was first introduced by Professor Taylor and expanded during Professor Nicholls' reign. This process was by no means confined to the full-time staff of the Medical School. The candidates sent for sub-specialization were from both the Ministry of Health and the University. Beside this the Ministry of Health had its own plans for providing specialized surgical services to the public; priority was given to Ear, Nose and Throat and the first specialist was Mr. Branco Melosev from Yugoslavia. At the present time there are Sudanese surgeons covering all surgical sub-specialties namely E.N.T., Orthopaedics, Chest, Urology, Plastic, Gastroenterology, Paediatric and Neurosurgery.
Local Postgraduate Training


The initiation of a local diploma in surgery was first contemplated by the Department of Surgery, University of Khartoum. The success which the diploma in obstetrics and gynaecology, University of Khartoum, has achieved over the last two decades was a strong incentive for Professor Nicholls to draw a similar plan for a local diploma in surgery. The latter was planned to be of the same pattern and standard as the Fellowship of the Royal Colleges. In 1970, a Postgraduate Medical Education Board was established consisting of staff from both the Ministry of Health and the University of Khartoum. The Board has more or less adopted the plan drawn by the late Professor Nicholls for the local diploma in surgery. There are sincere efforts to implement the local diploma, but the fact that 180 students will be starting their clinical training of surgery in July 1973 will swing priority of training in favour of the undergraduates. There is no doubt that all hands must unite in order to maintain the well-reputed standard which the graduate of this Faculty have achieved over the last half-century.
Promotion of Para-Surgical Services


Anaesthesia: Surgery cannot progress without safely and properly conducted anaesthesia. The training of qualified anaesthetists started in the late fifties. The candidates were first sent to the United Kingdom to acquire the Diploma of Anaesthesia; but some of them managed to get the primary and later on the final diploma of Fellow in Anaesthesia of the Royal College. At the beginning they were centred in Khartoum, but as their number increased they started to spread to the provincial hospitals. They also established a training school for technicians in anaesthesia which proved most valuable in supplying personnel to the provincial and big district hospitals.


Radiography: Like the anaesthetists most of the qualified radiographers were centred in Khartoum. They too started to spread peripherally and have also established a Radiology Teaching School in Khartoum. The technicians graduating from the school provide manpower for most of the provincial and big district hospitals in which x-ray machines are available.


Laboratory Services: Specialized laboratory services run by qualified doctors are only available in Khartoum. However, the provincial and district hospitals are provided with trained technicians who can do simple tests for urine, stools and blood. The problem of blood banks was solved in part by local public contributions for the buildings while the Ministry of Health provided equipment and personnel.


Other Auxiliary Services: Theatre attendants are also trained in Khartoum Hospital. Candidates from provincial and district hospitals go back to their stations after qualification. Attention has also been given to the training of personnel in physiotherapy, artificial limb fitting, instrument repairing and provision of specialized qualified nurses for sub-specialties such as Chest and Neurosurgery in Khartoum Hospital.
Sudanese Association of Surgeons


It would be improper to describe the progress and expansion of the surgical services during the period 1949-1972 without mentioning the Sudanese Association of Surgeons. The latter was established in 1963 in order to promote the art and science of surgery in the Sudan. Its membership which, to begin with, was about half a dozen is now approaching sixty (SAS 2003 membership now exceeds 250). It holds an annual conference in which academic as well as administrative surgical problems are discussed. It is officially recognised by the Ministry of Health and its opinion on surgical matters is given great consideration.
Acknowledgements


I am greatly indebted in the production of this paper to Mr. A. Bayoumi. Firstly for his encouragement that the history of surgery in the Sudan must be written. Secondly for providing me with a lot of relevant information, without which the story of surgery would have been incomplete. Thirdly for the trouble he undertook in reading and correcting this paper. And finally for writing the introduction.


I am also indebted to the useful information provided by my older colleagues whose names are shown in the references.


I must also be grateful to Sayed Abdalla Mohd. Kheir and Sayed Ismail Ahmed, theatre attendants, Khartoum and Omdurman Hospitals respectively, for their help in looking up the operation records for the earlier surgeons.


References
1. Mr. Abdel Hamid Bayoumi (personal communication)
2. Dr. Ali Badri (personal communication)
3. Dr. El Hadi El-Nagar (personal communication)
4. Mr. Ibrahim El-Moghrabi (personal communication)
5. Sayed Ismail Ahmed (Theatre Attendant, OCH) (personal communication)
6. Dr. H.C. Squires, 1958. The Sudan Medical Service: An Experience in Social Medicine. London, Heinemann.
7. Who's Who 1972. London, Adam & Charles Black.