Across the Wide Zambezi: A Doctor's Life in Africa

by Warren Durrant

  One of the first on the list was Horace, of the engineering department, which surprised everybody, as this was the first pint Horace had even put his name down for, still less stood in the club; though he had never been known to cause offence by refusing one. On top of which he had the cheek to call himself Lovewater.

  I will not labour the point that Sam put him in charge of the swimming pool: but one day in the club he asked me what pH I preferred.

  Being a bit tired at the end of day, I thought for a wild moment he was offering me a drink, until it dawned on me he was referring to the swimming pool.

  I rejoiced in the catholicity of my new job, but this was a bit of a facer. However, resourcefulness is the first quality required in an African country doctor, and I decided to exercise some.

  'What pH did Dr Burns prefer, Horace?' I asked, in a discursive tone.

  'Dr Burns preferred a pH of 7.5, doc.' (I hope I have got that right.)

  'I'm sure a pH of 7.5 is just right for this climate.'

  Meantime, Mills the lab boy was going to work on the blood groups of the volunteers. When the list was complete, I announced it (probably in breach of confidentiality), more or less openly, to the interested parties round the bar.

  (One thing the reader must understand: the existence of a certain blood group called universal recipients. In a word, while most people can give blood to most other people, universal recipients can give it only to members of their own exclusive circle, but they can take it from anybody.

  Perhaps because our God has taught us it is more blessed to give than to receive, this particular group is not numerous.)

  'Horace has a most rare and interesting blood group,' I said. 'He is AB positive, which means he is a universal recipient.'

  The laugh which followed this was not as big as the next one, which was raised by the chief of the club wags, Danny Wilson.

  'Horace is a most rare and interesting person!'

  Horace had the cheek to join in both laughs, but perhaps he had no option.

  Another caesar I performed on a hunchback: a victim of Pott's disease, Tb of the spine. This had to be a classical operation, as the lower segment operation was physically impossible on the doubled-up little body: Ten days later, she marched off, proudly bearing her prize in her arms. It was also impossible for her to carry the baby on her back.

  The police brought in a man with an arrow stuck in his upper arm. He was a thief and had been shot by an 'NT', a guard from the Northern Territories, who watched the company premises, armed with a bow and arrow. One could recognise these little people by their almost Mongolian or Bushman-like features.

  I knew that this arrow was barbed, like a fish-hook. I gave the man a shot of Pentothal and simply pushed it through: I could see there were no vulnerable structures in the way. There was a gush of venous blood, soon staunched with a pressure bandage.

  In the inevitable crowd that gathered outside the theatre on this interesting occasion was Alassan, the little old cook of my fishing companion, Les Cady (who, incidentally, was the European manager who nearly died laughing at Jenny in the spitting crisis). Something did not add up as far as Alassan was concerned. I must say he was an 'NT', and in his part of the world thieves were usually dealt with by nailing them to a tree by the head.

  Later he questioned Les on the matter. 'Massa,' he asked. 'Wha' for dee docketa go make dat boy better? Dun dee docketa nebba savvy dat boy be tiefman?'

  Nigerians were the greatest exponents of 'pidgin'. A large Nigerian lady (I recognised her by her turban, instead of the headscarf of the Ghanaian women) sat down in the chair before me. 'Docketa,' she announced. 'I nebba see my flower tree munt. I tink I go catch belly.' I will simply say the subject was obstetrical.

  Blackwater fever (that dangerous complication of malaria) is rarely seen nowadays. Nevertheless we had a case in a little fellow of ten. I assembled the regulation rack of test tubes, and we watched his urine samples turn from port wine to normal over the next few days, as the treatment took effect. We also transfused him and monitored his haemoglobin by the only method available to us - a finger prick and the Talquist coloured papers.

  He was duly discharged, and his father asked to bring him back for review a week later. Faithfully they turned up. I looked the little fellow over, said, 'fine' and his father led him away. This was not good enough for the little chap. He doubled back, stood before me and pointedly tapped his thumb. I obediently sent him for another blood check. That lad should go far.

  Towards the end of a hard day, Miss Lemaire found me and informed me: 'We have a woman with severe abdominal pains. She is overdue her period by two weeks.'

  'Wearily I commented: 'An ectopic! That's all we need.'

  I examined the patient and made a proof puncture: a needle thrust into the abdomen. Sure enough, the syringe filled with blood, making the diagnosis very probable. I ordered her to theatre.

  At that time, I was still using spinal anaesthetics for everything major, until my neighbour, the young Dutch mission doctor at Mango, warned me of their dangers in cases of potential shock. At any rate, I got away with it in the present case.

  For those interested, our anaesthetic resources, besides spinals, consisted of an EMO miniature ether machine, which broke down early on and had to be sent to England for repair. We were not to see it again for a year, most of which time it lay on the docks at Takoradi. Meantime I did the best I could with various substances per rag and bottle, and combinations of local anaesthetic and morphine.

  Incidentally, the less sophisticated Africans (and some of the other kind) preferred to stay awake during their operations and had a profound suspicion of general anaesthesia. True, the doctor spun you some yarn about 'putting you to sleep', but what kind of child did they think they were talking to? Everyone knew that you could not operate on someone in his sleep. Obviously, that injection the doctor gave you was poison which killed you. Only then could he go to work on you with all those knives and things. When he had finished, he gave you some more medicine to bring you back to life again. The whole business seemed altogether very uncertain. Much better to stay awake, when you could keep an eye on things and have a nap now then when you felt safe.

  And by golly, they were tough! Especially the 'NTs'. For a reason which will appear later, I went off spinal anaesthetics for caesars for a time and relied on local, adding morphine after the delivery of the baby, when its respiration would not be compromised by the latter drug. I experimented a good deal with the amounts of local, and eventually found that ten millilitres under the skin was enough for the tough little women of the north, but would not do for the more 'civilised' ladies of the south, who were almost European in their nervous sensibilities. Most of the pain of a caesar occurs, of course, as the knife enters the skin of the abdomen: then some later, as the womb is cut and the baby's head extracted. But the tough little NT women happily fell asleep after the first ten mil of local, and never woke up until the little present was put into their arms. I came to the conclusion that they could well take a caesar with no anaesthetic at all - just a quick slash and scream. But needless to say, I never carried my experiments that far!

  The abdomen is a fearful place to enter for the first time. I am not counting the several caesars I had done by then, where you come on the uterus right away, and your bearings are clear. But here, after sundry gingery cuts, I came upon a mass of bowels, swimming in a sea of dark blood.

  The latter was cleared fairly quickly with the sucker. And Miss Lemaire had set up the equipment for autotransfusion, which means collecting the patient's own blood to be returned into the vein. Soon Miss Lemaire was bottling blood as calmly as ladies in England bottling jam.

  With the use of abdominal towels, I found the offending tube, cut it out and stitched up the gap. Mr Sackey reported favourably on the blood pressure. I had the great feeling that we were winning.

  At that moment Jenny entered, like a good matron, hearing about the serious case. She was dressed in a pa
rty frock, on her way to a social evening. I called for a catheter, and Jenny donned an apron and dropped one into the steriliser. When she tried to remove it, the thing took on a life of its own, wriggling through the holes of the trays. 'Drat the thing!' cursed Jenny. 'Ye'd think it was a snake!', which provoked much laughter in the happy celebratory atmosphere that attends the triumph of life over death.

  A sadder case was a woman, heavily pregnant, brought in bleeding profusely. She was in great pain. One question only was required: did the pain come and go, or did it stay all the time? The latter: which told me it was an accidental haemorrhage (nowadays called an abruptio) caused by bleeding behind the placenta, or afterbirth.

  Suffice it to say that my efforts failed to save her. I stood at the door of the little theatre with blood all over me and my heart in my boots. Emilia stood sympathetically beside me.

  I saw a woman sitting on the edge of the gangway, wailing bitterly.

  'Who is that woman, Emilia?'

  'That is the rival.'

  'Who?'

  'The rival. The junior wife.'

  At the end of the Saturday morning clinic one day, a crabby little old woman was brought in by her crabby little old husband. She had a lump in her groin, which I recognised as a hernia. It had been there three days and could not be pushed back. This was a strangulated inguinal hernia. I suspected the lump contained gangrenous bowel, which would need a resection (which means cutting out the bad section and joining the rest up again). Otherwise, the little woman was going to die a lingering and painful death.

  Once more I went to get the book out. On the famous shelf in my office lay two or three surgical books, as Des had said. I selected one of them.

  Classical scholars recognise two approaches to science: the Greek approach, occupying itself with theory and leaving the grubby practical stuff to low fellows like carpenters and Romans; and the Roman approach itself, which gets down to the nitty gritty. My first selected book (which shall be nameless) belonged to the Grecian category.

  After a learned dissertation on the subject of gangrenous bowel, the writer concluded with the lordly words: 'the many methods of operation are sufficiently well known as to require no further rehearsal in these pages'.

  'Marvellous!' I thought (and probably shouted: soliloquy is not unknown in the jungle). ''And here I am a hundred miles up in the bush!'

  Fortunately, my second choice was the Roman kind (Scottish, actually, which is the same thing) - the redoubtable Professor Grey Turner. Quickly seeing that Professor Turner meant business, I took him home with me and studied him over lunch.

  Of the 'many methods' known to the Grecian gentleman (if he kept them to himself) Professor Grey Turner knew only one - a good honest method, which was unfortunately the most pedantic and time-consuming, as you might expect...but that's enough cracks about the Scots! Anyway, after I returned to the theatre I removed four inches of gangrenous bowel. The operation lasted four hours - and a spinal anaesthetic lasts an hour and a half.

  I realised this when the little woman started grunting. Happily, we were able to keep her comfortable with local and morphine.

  We got her back to the ward in good condition, with the regulation collection of tubes, and strict instructions for NIL BY MOUTH.

  Then I went home for supper. After a couple of hours at the club, I looked in on her on my way home. To my horror I found the little woman had pulled all these tubes either up or out. Moreover, her husband was bending over her, shovelling fufu down her throat (which is cassava mash, slightly less stiff than cement), demanding angrily, what sort of hospital was this, where they left the patients to starve?

  The fact that the little old woman made a good recovery on this post-operative regime will be of interest to physiologists.

  One afternoon, an old man brought in his son, a lad of about sixteen, whom I found on a stretcher. He had been ill for a week and three days ago had developed abdominal pain and become much worse. He was hiccupping and his cheeks were sunken. When I felt his abdomen, it was board-like. In England I would have diagnosed a perforated peptic ulcer.

  I opened the abdomen but found no ulcer. In despair, I closed the abdomen and started antibiotics. Later that evening the lad died.

  I wrote about this case to Howell, but received no reply. I expect Howell was past correspondence by then, if he was still alive: when I returned from West Africa, he was dead. At the end of my letter, as an afterthought, I mentioned typhoid.

  Few British surgeons who had not worked in the Third World would have made the diagnosis. Howell had served in the Middle East in the Second World War, so might have guessed. The answer arrived in an article on the subject in the West African Medical Journal.

  Well, I had got the two main clues, but had failed to connect them. The case was one of perforated typhoid ulcer, which occurs at the other end of the small bowel from where I was looking. The article described it as the commonest cause of acute abdomen in West African males. In the lad's condition his chances would have been small, even in the best circumstances.

  A number of small children were brought in, very ill. I had barely time to examine them before they all died. But I had seen enough: a thick grey membrane over the back of the throat. Something I doubt a living Englishman has seen in his own country - diphtheria.

  I informed the public health, and a couple of Indian doctors came up from Takoradi with a lorry load of vaccine and serum. They stayed at my house. Over sundowners and supper, we laid plans.

  All the cases had come from one village - Bekwai. We had to vaccinate all the children under five in that place. The doctors would offer serum to all medical and nursing staff in contact. I excused myself as an already vaccinated Englishman.

  The village headman was notified, and the vaccination programme planned for next day. News travels fast in Africa, and so did this news. Not the news about the epidemic - that was no more news than dog bites man - but the news that injections were being given out at the hospital. There is nothing your African peasant appreciates more than a good painful injection, and even if the babies are not actually born with the taste, they are quickly trained up to it.

  I started my mornings at a separate clinic at the sawmill, designed to get the malingerers back to work as early as possible. The two other doctors went straight to the hospital.

  When I arrived there later, I thought the revolution had broken out. Not one village, but the whole countryside, had received the news. The hospital was practically buried in a crowd that would have done for the Cup Final. The police were hard at work with truncheons: village headmen were beating one another's flocks with not so ceremonial staffs, each battling for his own .The Bekwai kids were a drop in the ocean: how many got their rights was anybody's guess. The doctors ran out of vaccine long before a fraction of the crowd was satisfied. Their only concern now was to save their skins before the police could remove their clientele. When the police had beaten a path for my car near enough for me to see the hospital, and Dr Patel on the veranda to see me, he waved his arms and shouted:

  'The whole thing has been a disastrous failure!'

  Two Ibo women staged a stand-up fight in the market place. Such is the implacability of the race, especially the female of the species, and especially the Ibo of the species, that the fight went on for three days, knocking off for meals and sleep, like a test match. It ended with one receiving a decisive kick in the abdomen; whereupon she skulked in her tent for another three days, evidently hoping to mend her wounds and return to the fray. If so, she was to be disappointed: she was brought to me instead (as Mr Pooter might have said).

  In short she had a ruptured spleen, and died on the operating table.

  An inquest was held in the club by the district magistrate, when I gave my melancholy evidence; which was received without question, or at any rate, without criticism. Nobody blames the doctor in Africa who, like the pianist at the party, is credited with doing his best. Years later, in Zimbabwe, a murderer had the effront
ery to suggest from the dock that the doctor might have done better, and was promptly put in his place by the magistrate. (This was not a hanging matter, or I wouldn't be joking about it.)

  The other woman, of course, appeared: as like as two peas in a pod. She had her baby on her back. I suppose they must have taken breaks to feed their infants. I forget the outcome of the case.

  Finally, my saddest case at that time. At caesarean section, just after I had delivered a healthy baby girl, Mr Sackey informed me that the patient had stopped breathing. All our efforts at resuscitaion failed. There seemed no explanation. I sent a letter to the queries column of The Practitioner, and received a kind and elaborate reply from one of the most eminent anaesthetists in Britain - for I suspected it was an anaesthetic death. I had used a spinal but there had been no evidence of pre-existing shock.

  The specialist made a number of suggestions, ending, almost as an after-thought, about a circulatory failure in the blood returning to the heart.

  Nowadays, this would be the one and only diagnosis, called supine hypotensive syndrome, caused by pressure on the main vein (which is usual), uncompensated because of a rare defect in the collateral circulation. The condition was barely understood at that time. On my return from Ghana, I read in the British Medical Journal about three cases in UK that year, one of them fatal. The condition can be corrected simply by placing a sand bag under the right buttock, which displaces the uterus enough to relieve the pressure.

  Now I had the miserable task of informing the husband, who was waiting outside. I simply said: 'The pickin she live. The mammy she die.'

  The man burst into the theatre, where the dead body of his wife lay as on a sacrificial altar. He did not throw himself upon her. He did not weep or do anything a white man would have done. He danced. He danced round and round the table, shouting with grief. He danced outside. He danced away to his village, still shouting.