The most significant new thing I learned was the technique of turning a bone flap for epidural haemorrhage: previously, most of us had relied on the crude method of enlarging a burr-hole.
The wisdom of the professor’s policy and his technique was to be borne out at my hospital two weeks later.
About two o’ clock in the afternoon, an African clergyman of seventy was brought into the ward, having been involved in a road accident. He had a head injury but nothing else. On admission, he was confused (Harare scale, IV). I ordered the usual management, including skull X-rays. Within an hour of admission, he was down to grade I (no response to painful stimuli), with stertorous breathing and a fixed dilated pupil on the left side. His skull X-rays showed multiple fractures on the left side: his skull there looked like a jig-saw puzzle. Obviously, he was not going anywhere: we would be lucky to get him to theatre alive.
We intubated. I drilled a temporal burr-hole and came upon a blood clot. I then proceeded to drill four further holes around the first, as instructed by the professor, which I joined with a wire saw, and was soon able to turn a flap of skin and broken bone, as big as my hand, in the already fragmented skull. Beneath was a clot as big as my two fists, occupying a quarter of the cranial space, and dangerously compressing the brain. Clearly, the man had only minutes to live. With the new approach, the clot was easily evacuated.
I slipped a stitch around the bleeding artery, and proceeded to hitch up the dura, which covers the brain like a plastic bag. This was like trying to lift up a heavy fallen tent. I stitched it to the galea (underscalp), as best I could, to reduce the dead space and discourage secondary bleeding - more new stuff to me, I had learnt at the course. Then I got the jig-saw pieces of the skull together (some of which had come loose and I had washed with saline), before closing the scalp.
(Anything wrong with that lot is down to me, not the professor!)
In this operation I was assisted by Stephan, who next time round would be doing it himself, with little supervision from me. Indeed, I should hope head injuries are part of the house officer’s curriculum at Harare now.
After we got the old man back to the ward, he lay unconscious for about five days. He was a Matabele, and his family wanted to take him to Bulawayo. I was not averse to this. They had a capacious car and our patient was becoming a feeding problem.
When we got in touch with the Central Hospital, some days later, we learned that he had been discharged fit.
Two months later, I was doing afternoon outpatients, when in walked our patient, as bright as a button. He was back in the pulpit, he told us. I called Stephan to join in the celebration.
I met the professor a year later at a surgical conference. He told me his one-day course had rather misfired. Since then, he was getting more transferred cases of head injury, if anything, than before. He thought perhaps all he had done with his lectures was to frighten people. When I told him about our case, he felt it had been worth it, after all.
By 1985, reports showed that malaria, resistant to the drug, chloroquine, was appearing in many countries neighbouring Zimbabwe. Chloroquine had, of course, been (still is) the chief drug used, not only to treat, but to prevent the disease. First, the countries of the east coast, then Zambia, were affected. I knew it was only a matter of time before this problem reached Zimbabwe.
At first, Fansidar was the drug recommended to treat these resistant cases, but soon the merits of the old drug, quinine, became recognised as appropriate too.
I decided to be prepared, and discussed the matter with the pharmacist.
‘We should lay in stocks of Fansidar and quinine.’
Fansidar, he went along with; but ‘quinine!’ he questioned with astonishment and ill-disguised contempt, perhaps thinking the old doc was getting past it. ‘That went out with Livingstone.’
‘Well, it’s coming back in again.’
He grabbed at his Martindale, after the manner of his kind.
‘You needn’t look at that,’ I forestalled him. ‘I’ll show you the latest editions of Medicine Digest.’
He found the Fansidar without difficulty. Quinine was another matter: there was none in any of the principal medical stores of the country, government or private. I kept him at it, unbelieving as he was. Eventually, he ran some to earth on the back of a shelf in Gweru.
That year I took a holiday with my family in Malawi, with Terry’s sister, Bobby and family. Malawi rivals West Africa as the white man’s grave for malaria, and the resistant strains were reported there. At that time, the WHO recommended chloroquine prophylaxis in such areas, and to use Fansidar in cases of a break-through: not as stupid as it may sound, as there are three grades of resistance, and chloroquine exerts some delaying action against the first two. Nevertheless, it was a policy soon modified.
Ten days after we returned, Terry and I woke up feeling very ill. Terry had felt low the night before. Now she was shaking the bed with rigors, and I was burning up.
We telephoned the hospital for a nurse to take blood smears, and sure enough, they were positive. Stephan came to the house and gave us Fansidar. He gave it also to the children as a precaution; though, thank God, they were not affected. Everywhere in Malawi we had used mosquito nets. Only on the last night, in Bobby’s house in urban Lilongwe, Terry and I dispensed with them; though, as parents caring more for our children than ourselves, we used them on their beds.
We telephoned the Dutch friends who had looked after Michael before. They now lived in Bulawayo, but kindly came and took the children away with them. Terry and I were quite incapable of looking after ourselves, let alone the children. Norah did everything for us.
Fansidar did nothing for us. It may be slow to act, or we may have got a bug resistant to that also. (Nowadays it is no longer used as a first-line drug, but as a back-up.) After forty-eight hours, Terry and I were still rolling on our bed of fire, like the souls of the damned. I suppose we got some sleep in the troughs of the fever. But by then, we were begging Stephan to give us quinine, which he did, and within hours, we were better.
Be prepared! When I got in the stock of quinine, little did I suppose my wife and I would be the first people to need it in Zvishavane.
A few months later, the first home-bred cases appeared. The PMO rang me up. ‘I believe you have quinine in your hospital?’
There was corn in Egypt. Now we were able to help them.
One day, we got a big case of books from America - a gift to Africa. The Yanks don’t do things by halves. Such books! They made the usual British thing look like the old war economy standard: the binding, the paper, the printing. There must have been well over a thousand dollars worth. All were about a year old, which I suppose made them dead ducks on the American market, but the shipment alone must have cost them. But the Americans’ ideas about African country hospitals were as big as their hearts, as we discovered when we looked at the titles: Magnetic Resonance Imaging of Brain Tumors, The Chemical Pathology of the Endocrine Disorders. Just the kind of bread-and-butter stuff you need in a bush hospital! We selected a book of surgery - entirely theoretical: the actual business of operating would no doubt be set out in lavishly illustrated atlases in America; and a book on pharmacology: ninety per cent of the drugs were unobtainable in Zimbabwe, but it was nice reading about them - and sent the rest back to Head Office, which later admitted the arrangement had been disappointing.
Beside this, about every quarter we got catalogues from the same large-minded source - six copies of each; addressed to the ‘Head of Surgery, Zvishavane Hospital’, ‘Head of Paediatric’, etc, innocently unaware that these titles belonged to the same person. I did pass the ‘Head of Pathology’s’ copy to the lab assistant, telling him not to get any big ideas. And the ‘Head of Anesthesiology’s’ copy raised a few laughs in the theatre, where we saw an anaesthetic machine illustrated, that delivered half-a-dozen gases we had never heard of and none that we had, monitored all vital signs and measured blood gases; and, I told them, played Ishe Kom
berera Afrika at the end of the operation.
Then one night, a bus went over a bridge and into a river: a burst tyre, an accident becoming commoner as the country got poorer and imports fell. Not much water in the river, but a big enough fall to kill ten on the spot and produce fifty casualties, twenty of them serious. Most of these were compound fractures: the sort of thing we could have dealt with in twos or threes; but twenty would have taken us a week, without going to bed - quite impossible. It was a good exercise in triage.
I called out all doctors and staff. We moved patients from the beds in the first bays, and went to work on the serious cases as they came in, with drips, dressings, antibiotics, and morphine. We secured an open lorry from the district administrator, and loaded most of the bad cases into the back, with blankets, as it was a cold night. We put some more in the ambulance, and sent all to Bulawayo, after warning them to stand by. The ambulance turned back, after one old man, who had lost the top of his head, died on the way, and whose body would have had to be expensively recovered by his relatives; before setting out again. That left five dislocations of hips and shoulders, we doctors dealt with between us, and many more cuts and bruises, the nurses dealt with. All done between 10pm and three the next morning. Not bad for a small hospital!
More other cases return to mind than the unrecorded cases of Sherlock Holmes - ‘for which the world is not yet prepared’.
A man bitten on the hand by a puff adder. His arm crackled with gas gangrene to the shoulder. A surgeon had told me you could deal with these cases by debriding and packing, like gunshot wounds. I laid open the black flesh to its full extent and did my best, but the man died within two hours of the operation. I should have taken the arm off at the shoulder right away, but he was probably too far gone with toxaemia anyway.
A little boy with a fractured elbow - the commonest fracture we saw in little boys. But this had a tiny break in the skin - technically compound. Another surgeon told me you could safely suture such tiny cuts. Two days later, this arm was also crackling. This time, I took it off at the shoulder, without hesitation. Nor did I close the wound, but packed it open. After three days on penicillin, I inspected it. The black flesh was spreading. I debrided further (reluctantly removing the head of the humerus, which is usually left to preserve the contour of the shoulder), and re-packed. In another three days, the wound was clean. I closed it and the lad lived. Never again did I fail to do a full operation on a fracture with the smallest break in the skin.
A little boy with an abscess of the scalp. When I opened it, a litre of pus came out. I put my hand into the child’s head, and felt - nothing! In alarm, I placed a drain, and sent the lad to Bulawayo. He returned in a few days, after no further surgical intervention, his brain re-expanded and the wound healing. Epidural abscess, caused by osteomyelitis of the skull, caused by head injury. He recovered on antibiotics.
A young woman with pelvic sepsis and peritonitis. We had more and more of these, which I treated by removing the tubal abscesses and washing out. It dawned on me that this was the onset of the Aids epidemic. But when I opened this abdomen, the pelvis was solid - ‘frozen pelvis’, the sort of thing caused in Europe by cancer (in my student days, at that). I suspected Tb, made a biopsy, closed the abdomen, and started Tb treatment. The biopsy was positive. The young woman was cured (unless it was Aids-related (not tested)) but would never bear another child.
A young soldier from Mozambique, with a fractured femur. I inserted a Küntscher nail: an easy operation, which took me twenty minutes. But after three days, this one was pouring pus: something that had never happened to me before. I suspected Aids, and the test report came back positive. Meanwhile, I removed the nail, and the fracture healed on traction.
(Like all surgeons, I got dozens of needle-sticks, many surely from Aids patients. I just carried on: I didn’t even think of squeezing my finger. A surgical needle is less dangerous than a hollow needle. When I got back to UK, I tested negative.)
A young man was brought in, unconscious. I tested his urine, which was loaded with sugar and ketone. I diagnosed diabetic coma, but two things were wrong. His pupils were constricted, and he was sweating: the opposite of diabetic coma. As I did not understand these signs, I ordered diabetic treatment. The lad died within the hour. Never ignore the anomalous sign. The anomalous sign is the significant sign: one ignores it at one’s peril - and the patient’s.
Soon after, came a carbon copy of this case. I was about to repeat my folly. Fortunately for the patient, I was due to depart for the annual bush doctors’ refresher course at Bulawayo. (This was while Jock was still at Belingwe.) I was reluctant to leave the patient with the nurses, so ordered him to Bulawayo, where the correct diagnosis was made, and the case successfully treated. Organophosphorus poisoning from insecticides.
I had more cases which I successfully managed myself. But no one had then reported the ketone in the urine (I later heard that these cases had lain semi-conscious in huts for some days and had evidently developed acidosis). I wrote a letter to the Central African Journal of Medicine, and got an inquiry from as far away as East Germany about it. In the ensuing correspondence, someone added a ‘Van der Merwe’ touch (as the racialist black humour of South Africa is known) by suggesting that farmers use posts, instead of Africans, when marking out crops for aerial spraying.
A young girl, with all the signs of perforated typhoid ulcer. By now, I was having good results with these cases. I opened up her abdomen, and found the bowels all stuck together - plastic peritonitis. I explored and got a gallon of pus from the left side. Next thing, I found my exploring hand high up in her chest - empyema. Same thing on the other side. Good wash-outs throughout and bilateral chest drains secured a cure.
An ectopic pregnancy. The old books used to say, never forget to look at the other tube. I always looked, and this time, found a bilateral case, and had to resect both tubes. No more children, but a life saved, which could have been carelessly lost.
Not only black Africans are tough (if that is the word in this case). A white corporal dislocated his elbow, carried on - God knows how - to the end of his tour of duty in the bush, and came in after three weeks. After an enormous struggle, we reduced it, but the poor fellow would have trouble for life.
A black man, blown up by a land mine. His arm was jellified, and his urine loaded with protein. I took the arm off at the shoulder, but he died, probably of shock. Should have sent him to Bulawayo, but he may have died on the way.
Then, at last, a case of locked twins: the thing I had expected at my first caesar. But a case with a difference. I did a vaginal examination, and could not believe my hand. I found the legs of a breech with a head between them. How had the baby done this circus trick? I did a caesar and got two live babies, the head of the second between the legs of the first, or vice versa: take your pick!
A girl with two upper front teeth knocked out by her boy friend. I cleaned them with saline and replaced them. She looked like Dracula. Wrong way round! I changed them, and after a week, she was her pretty self again. And achieved, in my ignorance, without splinting!
A young white cop, who drank a bottle of ouzo, straight off, in the police club, for a bet, and immediately collapsed. This was before independence, and he was admitted to the white ward, where the sister passed a stomach tube, and the place stank of aniseed. We dripped him, and when he came round, wondering where he was, he was greeted with the same riotous laugh such cases always received on white or black wards.
The old man with fifty per cent burns. He was a proud old Matabele, and when he forgot his manners he would complain, ‘I’ve lived so long among the Shona dogs (Maswina) I’ve become a Shona dog myself’ - to the huge delight of the (mostly Shona) nurses. As a lad he had met the great ‘Rodzi’. ‘And did you once see Shelley plain?’ asked the nurses, or rather, ‘What did you say to Rodzi, sekuru?’ ‘I said, “Good morning!”’ ‘And what did he say to you?’ ‘He said nothing.’ Shame on Rhodes! Perhaps he was lost in his great
thoughts, or already dying. It doesn’t sound quite like him. Not many people can save a fifty per cent burn, and we did not save the old man.
Few of these cases would be seen in Europe, or, at any rate, in those circumstances.
And at week-ends, I would get out into the bundu - to begin with, leaving the family behind, as the children were not yet up to fishing, and ended up boiling in the car with their tormented mother. This situation would improve as they got older and we could all get out together, usually with Granddad, when he came to live in the old folks’ cottages in Gweru; the children busily working with toy fishing tackle at imaginary fish (not much more imaginary than my own, most times).
So, in the early (post-bachelor) days of our marriage, it was more usually with companions such as Koos; and, no doubt, I was a selfish pig, as many ‘post-bachelors’ are.
For in my bachelor days, even during the war, I had gone fishing with Koos, he with his FN propped against a rock, and me with my cowboy set. Koos said (echoing D H Lawrence) that life was better on the qui vive, or the pas op, as Koos would have said. But one day, we were so little on the qui vive, engrossed in a conversation about Mahler, that we left our artillery draped over the chairs of the Portuguese cafe, frequented by Africans, some of them ‘freedom fighters’, no doubt, or in touch with them; before we remembered in the street and rushed back for it while it was still there.
One afternoon, Koos and I were fishing at a dam, when we heard screams from the kopje behind. Almost immediately, I guessed what they meant. We dropped our rods and scrambled up the steep stony hill, among the thorn trees, the sun baking the earth and our sweating, panting bodies. We wandered here, we wandered there, and still the rhythmic screams continued - scream! scream! scream! After a full ten minutes, they died down and we came upon the scene of the drama - a sight men have spent a lifetime in the bush and never seen - a python killing a buck. It had a baby duiker in its coils. The mother stood by, poised on her little toes.
Across the Wide Zambezi: A Doctor's Life in Africa Page 40
