ment district hospitals and occasionally in one of the smaller mission hospitals. On many of these visits I was accompanied by medical stu- dents on elective ...
Annals of the Royal College of Surgeons of England (I98I) vol. 63
TRAVELS OF FELLOWS
Surgery in Western Kenya Frank J Branicki FRCS Research Registrar, Department of Surgery, University Hospital, Nottingham (Formerly Provincial Surgeon, Kisumu, Nyanza Province, Kenya)
Key words:
SURGERY; DEVELOPING COUNTRIES
Summary Experience gained during 24 years' work as chief government surgeon for Nyanza Province, Kenya, is outlined. The wide variety of surgical conditions encountered and the problems posed in dealing with these by a chronic shortage of essential drugs, instruments, hospital facilities, and fully qualified staff are emphasised. It is suggested that at present the solution must lie in wider instruction in surgical techniques for general duties officers and clinical officers together with energetic community health, family planning, and preventive medicine programmes. Introduction For 4 years until June 1979 I was employed by the Ministry of Health of Kenya under the auspices of the British Ministry for Overseas Development; main commitments involved clinical and teaching responsibilities at one of the larger provincial hospitals. Our total number of hospital beds in Kisumu municipality, Nyanza Province, was 6oo, but often our inpatients totalled over I000. At any one time 200 surgical inpatients were under our care. Outpatient attendances numbered perhaps 150 at each surgical clinic. Two Russian surgeons, one American, two Kenyan registrars, and three Kenyan house officers in Kisumu acted as assistants concerned solely with the care of surgical cases. As chief government surgeon for the province, it was necessary for me to make regular visits to operate in our three government district hospitals and occasionally in one of the smaller mission hospitals. On many of these visits I was accompanied by medical students on elective periods from Australia, Holland, Canada, the USA, and Great Britain.
The region and its people The main geographic feature of Nyanza Province is the Lake Victoria basin. The region forms an undulating plateau, the shores of the lake being lined by fishing villages under its spell. One hundred and fifteen years ago the
(KENYA) lake was the last great geographical problem of the world - according to Sir Roderick Murchison, President of the Royal Geographical Society, it was the problem of all ages (i). The main ethnic groups are the Luo, of Nilotic origin, and the Kisii, who are of Bantu origin. The population of the province was 2 222 000 at the '973 census. The rate of population growth is the highest in all of Kenya, being estimated at 3.89%b. Conservative tribal customs, especially resistance to land consolidation, and the lack of marketing facilities and of inputs such as seeds, fertilisers, and pest control result in the land not being used to its full advantage, and protein calorie malnutrition is not uncommon. The lakeside retains many traditions - for instance, the use of wooden stools carved in one piece from a solid trunk and thatched huts with mud floors finished with intricate patterns combed into the floor while it is still wet. Sadly there is often little outlet for smoke in the huts and this results in a high incidence of carcinoma of the postnasal space (2). Kenya's rural health service, which is the responsibility of the government and to which missions have been making a significant contribution, will, when present plans have been implemented, produce a more acceptable service.
Facilities Shortages or absences of particular drugs, especially expensive antibiotics, instruments, and items of equipment is an all too familiar story to those in out-of-the-way places. Essential items for routine use must be available before contemplating extravagance for new or particular instruments. It is of little comfort to receive a new supply of gentamicin if there are no urethral catheters for patients with acute retention of urine. When buying it is best to choose multipurpose instruments - I found de Pezzer catheters made excellent intercostal drains. Improvisation was often necessary. On one occasion it was my task to persuade our chief hospital administrator to buy 50 kg of
Surgery in Western Kenya
I
349
FIG. Operating theatre, Kisii. Non-disposable gloves can be
............seen
hanging
out to
dry before
autoclaving. Until 1978 this single theatre served a population of goo ooo people.
:.:.:_,. . . j
dried milk powder - unless prospective blood donors at the prison received this we were unlikely to replenish our stocks. Allocation of transport for donor blood collection at schools on schedule must be a priority. I recall a Masai wvith bullet wounds complaining to the nursing staff that he was not being provided with blood to mix with milk and urine to prepare his staple food. Paramedical workers - clinical officers after a 3-year training programme were invaluable for the assessment of patients for referrals and in particular for outpatient care in health centres. The majority of the national leprosy/tuberculosis control programme was undertaken by a few excellent clinical officers (Cotuleps), who visited I 39 treatment centres or tree clinics in Western Kenya. There were estimated to be some I5 000 lepers in the province. We were also extremely fortunate to have clinical officer anaesthetists. Unreliable oxygen and nitrous oxide supplies made the use of the Epstein Macintosh Oxford (EMO) vaporiser invaluable for surgery in the district. Local regional, and spinal anaesthesia were often employed (3) and great use is made in East Africa of ketamine anaesthesia (4).
Scope of surgery Burkitt's lymphoma, Kaposi sarcoma, chronic tropical ulcer, infective hepatitis, worm infestations, and rheumatic heart disease were endemic. Malaria was the commonest cause of postoperative fever. Cases of trypanosomiasis were seen in South Nyanza. A cholera outbreak of 324 cases with 6 deaths in the province occurred early in 1977.
RECONSTRUCTIVE SURGERY
Unfortunately many patients presenting in the course of disease were beyond the scope of curative surgery. Mr Jimmy James, a specialist surgeon of the African Medical Research Foundation (AMRF), made regular literally fly-
FIG. 2 Scrotal lymphoedema
350
Frank J Branicki These could be changed as required, being moulded to one aspect of the involved limb. Malignant melanoma (most often on the sole) and multiple squamous carcinoma (extremely common in albino patients) were dealt with in the district hospitals. Occasional referral to Nairobi for radiotherapy was required. Three cases of cancrum oris requiring staged surgery were seen.
INFLAMMATORY CONDITIONS
Incision and drainage of abscesses of, for exthe management of infected wounds, acute and chronic osteomyelitis, and septic arthritis was routine practice. Delayed primary suture was often indicated in the management of wounds (5). For large septic wounds the application of undiluted honey in a thin layer 2-3 times daily gave excellent results (6). Honey rendered the wounds bacteriologically sterile in 3-6 days and encouraged the formation of healthy granulaFIG. A Cancrum oris in a 14-month-old boy tions. Before application any pockets of pus ing visits to Western Kenya. Techniques of present were drained. hare lip, cleft palate, and meningocele repair, skin grafting, reduction mammoplasty, and ureth- LEPROSY AND POLIOMYELITIS roplasty have been taught to assistants. Split Transmetatarsal head resection for chronic skin can be taken with a Schick razor and either plantar ulcer is a simple procedure and has given sutured in place or applied with the aid of extremely good results in over 300 cases in Steristrips. Full-thickness burns resulting from Western Kenya (7). Amputations are not to be falls into open fires, especially in undiagnosed resorted to lightly in Africans; a farmer who and uncontrolled epileptic patients, were com- cannot work on his land may not be able to monplace. We preferred to treat such grafted support his family. Temporalis transfer for lagophthalmos has been used to preserve sight. areas by the open method - for example, grafted limbs in a plaster of Paris cage which Early surgery must be performed for hand allowed inspection but ensured immobility. deformities to give good results. Joyland, a Sal-
ample, pyomyositic or tuberculous nature and
FIG. 4 (a) Eight-year-old child unable to walk because of postpoliomyelitis contractures in both legs. (b) Same child after bilateral hip, knee, and ankle release.
Surgery in Western Kenya vation Arimy boarding school for over 200 children with poliomyelitis in Kisumu, provided us with many patients. Serial manipulations and applications of plaster of Paris or surgical release of contractures and achilles tendon lengthening took little time and gave gratifying results. It was a joy to see teenagers walking, some for the very first time. At least 30 new cases of acute poliomyelitis were seen each month in the province despite immunisation programmes. The manufacture of locally made callipers, which were cheap and reliable, became a priority for our local appropriate technology group. Tendon transfers and triple arthrodesis of the ankle were occasionally required. TRAUMA
It has been found that whenever possible conservative treatment for fractures in rural areas gives the most acceptable results. Perkins traction for femoral shaft fractures has proved a very useful technique (8). It is of the utmost importance to acquire competence in the closed reduction, repeated if necessary, of fractures. Internal fixation was occasionally required for double fractures, those involving joint lines, and in patients with multiple injuries or unacceptable closed reductions. Old disclocations and malunions proved extremely difficult to treat. Old dislocations of the elbow required open reduction to restore function. Maggots were evident in the wound of one patient with neglected compound subluxation of the knee and in another with carcinoma of the breast. Urgent craniotomy for trauma was performed personally on 20 patients. Less urgent cases requiring carotid angiography were flown to Nairobi.
35I
common (i case), as were appendicitis (I4 cases) and duodenal ulceration requiring surgery (9 cases). Only 2 cases of carcinoma of the rectum were seen and excised. Diverticular disease and femoral hernia, although reported to occur in Africa, were never encountered. Intestinal obstruction, especially due to inguinal hernia, was encountered frequently. Three-quarters of the patients coming to surgery required bowel resection. In the absence of gangrenous bowel conservative treatment for ascariasis obstruction was usually successful, anthelmintics being withheld until obstruction had resolved. Occasionally an impacted mass of worms or the development of a volvulus made resection unavoidable. Sigmoid volvulus was dealt with by a Paul-Mickulicz or Hartmann's procedure. Primary anastomosis was much preferred. Colostomy management in the rural areas is fraught with difficulties. Amoeboma will often resolve on medical management. One case of amoeboma of the caecum presenting as intussusception required resection. There were 4 cases of typhoid perforation; 3 of these were closed but I patient had sustained perforation 3 days earlier (evidence of free gas on X-ray) and made a full recovery after conservative management. Amoebic liver abscess must not be misdiagnosed as inoperable hepatoma as even large abscesses will resolve with metronidazole therapy, drainage occasionally being required. Hepatic and splenic hydatid disease and tropic splenic abscess were occasionally encountered. GENITOURINARY SYSTEM
Competence in urethral dilatation for long, tight, gonococcal strictures was required of the general duties doctor. Many patients with benign proTHORAX static hypertrophy have been dealt with at disRigid oesophagoscopy for removal of infected trict hospital level by the technique of lateral foreign bodies, usually fish bones, or assessment perineal prostatectomy (io). Carcinoma of the of oesophageal squamous carcinoma was often penis was seen in the uncircumcised Luo and I I required. This tumour has an extremely high amputations personally performed, using a techincidence around the Yala river basin in Siaya nique designed to prevent meatal stenosis (ii). District (g) and in highly selected cases I-, 2-, or To avoid the development of the late present3-phase oesophagectomy was performed. Bron- ation of metastatic nodes it is recommended choscopy was performed for removal of inhaled that suspicious nodes be biopsied at the time of foreign bodies, particularly maize beans in infants amputation. Only 2 cases of schistosomiasis(4 cases). Personal figures include 20 patients induced extensive bladder carcinoma were amenwith multinodular goitre undergoing surgery for able to total cystectomy and ileal conduit compression symptoms. Only I patient (a cigar- formation. ette smoker) was seen with carcinoma of the GYNAECOLOGY bronchus. Hysterectomy for huge fibroids, salpingectomy, ABDOMEN evacuation of retained products of conception, Penetrating thoracic and abdominal injuries with lower segment caesarean section, and the manarrow, spear, and knife were frequent. Bullets agement of puerperal sepsis following outpatient were removed from coffee smugglers, cattle rust- deliveries were commonplace in the district lers, and soldiers. Gastric carcinoma was un- hospitals.
352
Frank J Branicki
Conclusion Only 4-6 doctors complete a training programme for the Nairobi M Med degree in surgery annually. It has been reliably estimated by senior surgical and ministry staff that Kenya requires more than I50 surgeons to staff provincial and district hospitals adequately. There is no possibility of this demand being met in the foreseeable future. The answer lies in wider instruction in surgical techniques for general duties doctors and clinical officers, with early referral of specialist cases. While the emphasis must be on community health, family planning, and preventive medicine programmes, there is no better propaganda for these than the patient returned to his village life after surgery for a traditionally incurable disease. I did so enjoy
5
receiving live chickens from grateful patients!
8
I wish to express my gratitude to the Ministry of Health, Kenya, and Mr JRM Miller OBE for every encouragement. I am indebted to Miss Rachael Worley for typing the manuscript and for assistance from the Illustration Department of the Nottingham General Hospital.
References i
Jones DK. Faces of Kenya. London: Hamish Hamilton, 1977.
3 4
6
7
9
Clifford P, Beecher JL. Nasopharyngeal cancer in Kenya: clinical and environmental aspects. Br J Cancer I964;I8:25-43. Ajao OG, Adeloye A. The importance of spinal anaesthesia in surgical practice in tropical Africa. J Trop Med Hyg 1977;80:126-128. Kamm GD, Bewes PC. Ketamine anaesthesia by continuous intravenous drip. Trop Doct. 1978; 8:68-72. Bewes PC. The management of wounds. Trop Doct 1976;6: io8-i i. Cavanagh D, Beazley J, Ostapowicz F. Radical operation for carcinoma of the vulva: a new approach to wound healing. Journal of Obstetrics and Gynaecology of the British Commonwealth 1970;777: I037-40. Bewes PC. Fractures of the femur in a tropical context: a re-evaluation of Perkins traction. Trop Doct I974;4:64-8. Anderson JG. Transverse metatarsal head resection: a radical approach to the problems of forefoot ulceration. Lepr Rev 1975;46:191-4. Ahmed N. Geographical incidence of oesophageal cancer in West Kenya. East Afr Med J I 966;
43: 235-48. oGadhvi. Sushruta's lateral perineal approach for prostatectomy. Proceedings of the Association of Surgeons of East Africa 1978;I: 28-32. i i Abercrombie GF, Branicki FJ, Smart CJ. Partial amputation of the penis. Proceedings of the Royal Society of Medicine 1975;68: 783. i
