Highlights of phenomenal strides in surgical science

Surgical science has made tremendous progress in my professional lifetime. It started with antibiotics when I was a student in my pre-clinical years.

Penicillin, as everybody knows, was the first antibiotic, discovered by Alexander Fleming, a Scottish bacteriologist, for which he was knighted and was awarded the Nobel Prize in medicine.

It is interesting to know how penicillin was discovered. Fleming went on his usual holiday and when he returned, he found that part of the bacterial culture, he had left on a plate had disappeared and in its place was a mould, which was the first natural antibiotic accidentally produced by man.

That was in 1928 and it took up to the middle of the Second World War for it to be industrially synthesised and go on the market for use by doctors on their patients.

A steady chain of antibiotics followed until now when bugs have become wise, have developed resistance to them all, forcing researchers to frantically strive to find newer drugs, to which the most vicious bacteria is sensitive.

It would be impossible to enumerate all the highlights which I have seen in my professional career but I would like to mention a few important ones.

Another phenomenal progress I have witnessed with awe is transplant surgery.

Starting with kidney and going to liver, pancreas, heart, lungs and limbs, it is now entering into the realm of face transplant and I recently saw in the medical journals an Italian surgeon venturing into head transplant!

Then of course there is constant research to find newer chemo-therapy agents which have revolutionised the treatment of cancer. The public is naturally enamoured by laparoscopic surgery, popularly known as keyhole surgery, because it reduces morbidity, hospital stay and in most cases leaves a hardly visible scar. In the X-ray department, there is the mammogram, ultra-sound, CT and MRI scans, all of which arrived after I qualified as a surgeon.  Orthopaedic surgery has not lagged behind either.

With the advent of plastics, inert metals, corrosion resistant alloys and discovery of light and strong materials like titanium, orthopaedic surgeons often resort to the use of plates, pins, screws and nails to treat fractures.

They even replace worn out hips, knees, shoulders and elbows with artificial joints. It is in relation to an obsolete fracture management which lingered on for many years and which I used  when I treated fractures that I want to write about an amusing and hilarious episode, which occurred under my watch, before we forget the good old days in the avalanche of modern treatment.  It started with a call from Accident & Emergency. It was Dr Kaggia on the phone.”I have just received an emergency from Narok District Hospital. He is a young man by the name of Hassan Omar, whose self- driven car was involved in a head on collision with a truck in Narok, on the way to Governor’s camp. He injured his thigh and was taken to the local hospital where his right femur was X-rayed which showed a fracture in the shaft.”

“Have they sent his X-rays with him?” I asked.

“They have,” replied Dr Kaggia. “But they are of poor quality, so I repeated them and our X-rays show a grossly communited fracture.” Dr Kaggia was referring to a fracture where the shaft is broken in multiple fragments and continued. “Normally I would have put the limb in traction, but the patient wants to be treated privately in the private wing. You have operated on some members of the family and he wants to go under your care.”

“Please keep everything ready for me to put his limb in traction. I’ll be on my way soon.” I replied and drove to the hospital, where I first met the patient’s father, Hassan, whom I recognised instantly. “Omar was on the way to Maasai Mara on the first leg of his honeymoon.” He provided the social history. “He and his wife decided to do a safari in Maasai Mara and Samburu and then have a week at the coast.

“But this accident, in which by the grace of Allah, his wife, Jemima escaped unhurt has disrupted their plans.”

“It is indeed unfortunate but the couple can resume their honeymoon after Omar’s fracture has united.” I comforted him.

“Will he be left with any deformity or disability?” Hassan expressed his concern.

“I haven’t seen Omar or his X-rays but  he may have to be in the hospital for about three months and he will be fine after that.”

I then examined Omar, perused his X-rays, agreed with Dr Kaggia’s planned management, put the limb in traction and sent him to the private wing. Next day was my teaching round and I decided to teach my students on my private case so that I could discuss the changing pattern of fracture treatment from the old fashioned conservative method to that of internal fixation with metal and also show them the different components of traction and how to put it on. When the students were seated round the patient’s bed, I started my discourse. “Fracture of the neck femur was quite common in older women in the western world. We did not know at the time that it was the result of post-menopausal osteoporosis or lack of calcium in the bones. Fracture of the shaft femur is equally common in young people in our part of the world because of road traffic accidents like the one Omar was involved in. For a long time, before metal came into our armamentarium, treatment of both these fractures meant  putting the limb in traction and leave the patient in bed until the fracture healed which usually took three to four months. The drawback of this approach in old women was mortality caused by hypostatic pneumonia, pulmonary embolus or fatal clot in the lungs, urinary infection and bedsores due to prolonged immobilisation. In the case of young men, it meant cessation of work and earnings, social activities, sex, sports and resultant depression.”

“With the advent of plates, nails and screws made of inert metal, the management of fractures has changed radically. For example, in fracture neck femur, we put a nail-plate and get the patient out of bed on crutches. In the case of femoral shaft, we insert Kunschner nail, which was devised by Kunshner during the last war, to get his patients out of bed, when there was great pressure on beds on the war front.”

“Excuse me,” a lady student politely interrupted me. “Our patient has fracture shaft femur. Isn’t that an indication for a K-nail in his case?”

“Good question. Omar’s fracture is communited, which means his fracture is broken in many pieces and therefore is not suitable for a K-nail.”  

I then demonstrated how to put up traction. From then on it was a matter of a courtesy call on Omar on my daily rounds to see that he was comfortable and periodic X-rays to check that the fracture was healing. Over the next few days however, I noticed a frown on Sister Okundi’s face every time we entered Omar’s room and she hardly talked to him. So one day at the end of the round, while she was serving us coffee, I enquired and she replied. “He is trying to convert my private room into his honeymoon suite.”

“How do you know?” I asked.

“The lascivious look in his eyes when the wife is around.” She replied. “Moreover she visits him when I am not around and when the skeletal night staff is on.”

“Surely, the traction must be a severe encumbrance.”

“As you know, where there is a will, there is a way,” Sister Okundi pressed her point. I did not argue. Just as well because she was proven right as subsequent events showed.

Omar’s fracture healed after three months and after practising on crutches for a few days, he went home. Six months later, my obstetrician colleague rang me. “Could you please do an urgent ritual circumcision on a newborn baby delivered last night by a patient of mine?” she requested.

“What’s the urgency?” I asked.

“They are Muslims, believe in ritual circumcision and would like it done before the mother goes home. It was a normal delivery and the mother is ready to go home today.”

It was the era when general surgeons dealt with all surgical problems and before doing circumcision, I went and saw the mother, who to my surprise turned out to be Jemima. As I was operating on the child, I tried to calculate the date of conception, but I needn’t have done so because on finishing  I bumped onto the father. “Surely this baby was conceived in hospital.” I said to Omar.

“Sure,” he replied. “Next time you teach your students about traction, please inform them that though it proves a great impediment to intimacy, with a little bit of innovation, it can be accomplished.”

With a sarcastic smile on his face, he added. “Please also convey a message from me to Sister Okundi. Sex has driven men to do extra-ordinary things. The traction was a minor hindrance which we overcame easily. Our main problem was to dodge the vigilantes, she had put on us but we successfully duped them all!”