Review: 'Where there is no Doctor'

This book, published under the auspices of the Hesperian Foundation, is an excellent guide to all aspects of health, both preventative and curative.  There are over 400 pages packed with practical advice, reinforced with numerous line drawings.  The author is not a medical doctor but that is probably a good thing because it means that there is no medical jargon.  In view of the emphasis on the importance of prevention and the importance of first aid (e.g. in snake bite) the book is strongly recommended whether or not a doctor is available.  How else, for example, would we find out how to make a pair of crutches from a branch of a tree!

The book is available in over 50 languages with appropriate variations to suit different needs in different countries.  The edition under review is designed for Africa and, as well as dealing with tropical diseases, deals with matters such as African herbal remedies, taboos and witchcraft.  I will go through the book systematically, highlighting important points and offering suggestions and emendations.  This will give the reader a summary of the scope of the book.

The introductory Advice to Health Workers is good for all because it lays the foundations for healthy living.

Ch.  1  Home Cures: I have even stronger reservations about the use of purges and enemas.  Purges should not be used for poisoning and the home use of enemas is practically confined to relieving obstructive constipation in the elderly.

Ch 4. Healing without medicines is an important message, especially for Africans, who tend to be addicted to pills and injections and we all need to be reminded that diarrhoea needs FLUIDS – not medicine – and that healthy foods are better than vitamin tablets.

Ch. 7 Antibiotics: importance of limiting the use of antibiotics:  Western doctors are beginning to heed this advice!

Ch. 10  First aid: Good advice generally, but the author has the wrong concept of fever and shock.  Fever is part of nature’s defence against infection so should only be treated if it is very high, which is only likely to occur if children are over-clothed.  Therefore always use clothing which a child can kick off and do NOT give Paracetamol to lower the temperature.  High fever may cause fits in susceptible children, but there is no evidence that it leads to permanent brain damage or epilepsy.  Shock is also a defence mechanism – the body cools the skin to divert blood to the deeper vital organs.  So no attempt should be made to warm the shocked patient until blood loss has been stopped and the blood volume has been restored by oral or injected fluids.

In dealing with patients who have stopped breathing, we should first ascertain if they have a pulse.  If the heart is not pumping it is no use blowing into their lungs – we need to do chest compressions as well as artificial respiration.

The author correctly emphasises that nearly all bleeding from wounds can be stopped by elevation and local pressure, but fails to mention that in the case of nose bleeding a cold pack applied over the forehead helps by causing reflex constriction of blood vessels inside the nose.

In the case of abrasions and closed wounds, we are correctly advised that AIR is the best ‘dressing’, but for open wounds dry gauze is not to be recommended because it will stick to the wound and make changes of dressing very painful.  Honey is naturally sterile and because it retains moisture it is a very good open wound dressing.  For those who have deep or dirty wounds, and have not been previously vaccinated, I would certainly (not ‘perhaps’) advise both tetanus antitoxin and tetanus vaccination.

“Put a burned part in cold water at once”.  Yes, very good advice, but the cooling should continue FOR AT LEAST 10 MINUTES in order to prevent blistering.  Thin plastic gloves (used by food handlers) are ideal for burnt hands.  ‘Cling-film’ is an excellent first aid dressing because, inside the role, it is sterile.  Deep burns can also be dressed with honey.

Regarding fractures of limb bones, I would not advise “forceful traction to separate the broken bones”.  Bones heal more readily if the broken ends overlap so the aim should be to restore alignment by correcting angulation and mal-rotation.  A little shortening is a small price to pay for rapid and sound union.  In the lower limb the easiest first aid splintage is achieved by binding the broken limb firmly to the opposite limb from the toes to the groin.  There is no need to include the trunk.

Reduction of a dislocated shoulder is well described, but there is no mention of how to reduce a dislocated hip by laying the patient on his back, bending the hip and knee to 90 degrees and pulling the limb upwards while an assistant holds the pelvis down.

A common problem for first-aiders is whether a ‘sprained ankle’ should be X-rayed.  If there is no tenderness over the bones AND the patient can walk there is no fracture.

The otherwise excellent section on snake bite should start by insisting that cutting, sucking or squeezing the wound should be strictly avoided because this only serves to spread the poison.

Ch. 11  Nutrition:  Sound advice on healthy eating, but iron tablets should be used with caution, especially in children.  Iron cooking pots and iron-rich foods are much safer.  But a serious omission is the absence of any warnings about the role of salt addiction in high blood pressure which is especially common in Africans.  Although salt restriction is advised for swollen legs (p. 187), there is no mention of the important role of salt in aggravating diabetes.  We are correctly advised against milk for peptic ulcers and there is a brilliant drawing of a baby taking in a bottle of cow’s milk and giving out a large amount of diarrhoea!

Ch. 12  Prevention:  There are echoes of the Law of Moses in advice to bury faeces and how to construct a pit latrine to prevent the spread of gastro-enteritis and human parasites.  We are reminded of the dangers of living in close proximity with animals, especially dogs and pigs, in order to avoid acquiring animal infections.  The Bible statement “without are dogs” is good medical advice!  There are very good descriptions of the life cycles of various tropical worms and how to break these cycles.

There is a good section on drug abuse, but I would put more emphasis on the fact that the so-called ‘pleasure’ from drugs is illusory.  Very quickly the ‘pleasure’ becomes nothing more than the urge to take another ‘fix’ in an attempt to relieve the displeasure of being without the drug!

Ch. 13  Common ailments:  Do not lower the temperature in cases of flu because both flu and cold viruses stop multiplying at 40 degrees centigrade.  That is why steam inhalations can abort a cold.  The advice not to blow our noses needs qualifying because the sinuses become infected if we create high pressure in the nose by pinching both nostrils at the same time.  We should blow down one nostril at a time or, better still, create a negative pressure by sucking the secretions into the back of the throat.  Nature did not design handkerchiefs!

The advice not to suppress a productive cough is obviously sensible and it is interesting to note that it has recently been shown that cough medicines are no better than placebo.

Ch. 14  Serious Infections:  Good accounts of Aids and TB.  Rabies can develop very soon after a bite on the face or head and it is such a terrible disease that in these cases I would not wait for confirmation that the animal was rabid before giving anti-rabies injections.  The account of modern leprosy shows that it is an infection of nerves and bears little resemblance to the skin disease called ‘leprosy’ in the Bible.

Ch. 15  Skin disorders: Tumbu flies, which burrow into the skin, spread by laying their eggs on clothing put out to dry.  Aren’t they clever!  Ironing the clothes will kill them.

Ch. 16  Eyes: Abrasion of the cornea heal better without an eye pad.  Blinking repeatedly washes the eye with tears which are antiseptic.

Ch. 18  Genito-urinary: A good chapter on sexually transmitted diseases with the right message – ONE PARTNER FOR LIFE.  So much better than the wicked and dangerous advice given by the British government, which is – use a condom.

Ch. 19  Midwifery and neonatal care: Excellent advice with emphasis on giving control to the mother.  Midwifery is one area where a doctor can be counter-productive, as shown by the fact that in the developed world over 20% of babies are born by Caesarean section.  I have reservations about the method of circumcision illustrated because it could lead to excessive removal of skin and even to slicing off some of the end of the penis.  Such accidents do happen and are especially regrettable when the operation is being done solely for ritual reasons.

With regard to the third stage of labour, emphasis should be placed on the importance of bringing the baby to the breast immediately after birth because this encourages expulsion of the placenta (see p. 295).

Ch. 20  Family planning: More emphasis should be placed on the effectiveness of breast feeding as a contraceptive, providing suckling takes place AT LEAST every four hours and for a minimum of 80 minutes a day and continues for as long as contraception is needed.  In this way intervals of several years between children can be achieved.

Ch. 21 Childhood problems  In rheumatic fever nowadays some strains of Streptococcus  have developed resistance to penicillin, so in the absence of response give cephalosporin.

Finally, let me emphasize that, notwithstanding the number of my suggested emendations, this book contains vastly greater numbers of excellent recommendations and is thoroughly recommended.

Bro (Dr) Alan W. Fowler (Bridgend, Wales)

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