I did not offer this lad antidepressants. I tried to offer him comfort. Prospects were better for further education since independence (so I hoped more than I believed): he should read anything he could lay his hands on - books, newspapers - advice hardly necessary, as said, to any African who can read. But I was sorry for the lad. What can be sadder than the unsatisfied hunger for education? Think of Jude the Obscure!
Teachers going to Africa will rarely have unruly pupils to contend with, any more than doctors will find litigious patients, in a continent where health and education are regarded as privileges, not rights. There are some sad exceptions to this rule: the demo at our hospital, a local school burnt down. But these are uncommon and usually due to failures of communication and other misunderstandings.
Schizophrenics we did see, probably because they caused the most social disruption, and the witch-doctor was less successful with them. And I am sorry to say our methods of dealing with them were necessarily crude. When they came in raving, we quite frankly chained them to the bed, until the massive doses of Largactil took effect. Then, after a day or two, they graduated to shackles and shuffled about the premises, while the nurses tried to keep an eye on them. They were nursed in the general wards, and, unless so restrained, with the limited staff available, could easily have wandered off into the bush, and the next we saw of them might be when the police brought in a box of bones, described on the form as ‘found in the veld’.
When the lunatics were tranquil, we let their relatives take them home, where an African village was more adapted to ‘community care’ than a British inner city. Thereafter, they would be taken to their local clinic for monthly injections. Alas, some of them came into the bus terminus category, and gave the same recurrent problems.
Some of the schizophrenics were highly intelligent and well-educated. It almost seemed as if the culture clash in their brains had been too much for them. One in particular was called the fundi (student, or expert), who always had a book in his hand. One day, he challenged me on the ward.
‘What’s a beldam?’
I hesitated.
‘Come on!’ he bullied. ‘It’s your language.’ The neighbouring beds sat up and took notice.
‘It’s an old woman,’ I ventured.
‘It means a wicked old woman;’ coming down on me with the severity of a schoolmaster. Big grins all round.
When I consulted Collin’s dictionary, I found we were both right.
The reader may ask about snake-bites, and I suppose a little lecture is in order. They rarely give much trouble in Africa, or at any rate, cause death.
They divide into two main kinds: adders, whose venom attacks blood and tissue, causing swelling and internal bleeding; and cobras and mambas, whose venom attacks the nervous system, causing paralysis. Serious, or systemic, effects (as opposed to local effects) rarely occurred; so our policy was to set up a drip, in case the antivenom (which has its own allergic dangers) was required, give a shot of penicillin (for infection and to reassure the patient), and observe. Six hours would decide the matter.
For there are two kinds of bite: the ‘business bite’, intended to kill prey, when the snake actually injects the poison; and the defensive bite, intended to deter a larger animal (such as man), when the poison is not injected, but the victim receives accidentally what the snake has on its fangs. This was the usual case with humans, and naturally, less dangerous.
The antivenom was kept in the fridge, and I had to remember to renew it yearly, even though it was used but once while I was in Zvishavane - by my colleagues from the mine on a white man whose whole leg turned black from an adder bite (internal bleeding), and who was very ill indeed. His haemoglobin fell to five grammes (one third normal), and he was in shock. They transfused him and gave him 50ml of antivenom - half our stock. He made a good recovery, and he was lucky.
If that cobra had bitten Michael, I would have been faced with more than one doctor’s dilemma. First, whether to treat one of my own family, which is always inadvisable, as one’s judgement is swayed by personal emotion; call in a colleague, with whom I might have disagreed; or take him to Bulawayo, a three-hour journey. And if I had treated him, whether to give him the antivenom right away, with its own risks, or wait for signs of paralysis. In a child, all the dangers are greater.
The cobras also spat - a syringeful (10ml) of venom into the eyes, which means a timely and copious wash-out. I only had to do this once - on a dog, when a woman brought in her little terrier with his eyes screwed up. This was before independence, after which we were forbidden to treat animals (see the chapter on Zambia); when I would have taken him to my garden and put him under the tap.
I had treated other animals - one or two dogs, stitched up under ketamine (hope vets approve) - but gave it up even before independence, as the African nurses were not happy about it. For one thing, they were afraid of getting bitten, or said they were. I think it offended their dignity, really: a feeling one must always respect.
As at Umvuma, at Zvishavane I had at least one distinguished patient: the sister of my neighbour, the former prime minister, Garfield Todd. True to the liberal principles of the family, she was content to be admitted to the common ward of the government hospital, but I got her into a side ward, if only because she was so ill.
There was some difficulty about the diagnosis; while I was thinking about it the lady died.
Sir Garfield (as he now was) proved as perfect a gentleman as Dr Mazarodze. His sister would probably have died anyway, and it might have been difficult to carry an action against me - which would not have stopped many people from trying, if rather fewer in Zimbabwe than elsewhere.
‘I am not very proud of this case,’ I confessed to Sir Garfield, in my office.
‘Don’t worry, Dr Durrant,’ he said. ‘Edie had had many operations before and would not have consented to another. Nor would we have wished it. She came to this country forty years ago from New Zealand for her health. She has had forty happy years here and she was only too grateful for that - and so are we.’
Terry’s father was also an admirer of Mr Todd, as he was in his day; at any rate, as a performer. As to his politics, I am not sure. Bill’s politics, I should guess, consisted of an enlightened fatalism. He recalled how an Irish candidate of Todd’s party tried to make headway against a Rhodesian audience. ‘You can’t frighten me,’ he boasted. ‘I’ve fought elections in Ireland.’ Before long, he was forced to change his mind and give up in disgust. ‘You said you’d fought elections in Ireland,’ they jeered. ‘Yes,’ he retorted. ‘But in Ireland, I was talking to gentlemen.’
Garfield, who was supporting his candidate, then stepped forward, took his jacket off and threw it over a chair. He was a big man, as well as a distinguished-looking one. He rolled his sleeves up, and pitched into them. ‘Now!’ he retaliated. ‘We’ve heard what you’ve got to say - now you’re going to hear what I’VE got to say!’
As Terry’s father commented, his candidate didn’t win, but Garfield shut them up.
I could hardly connect this with the Christian gentleman who sat in my office; but, of course, he wasn’t the first of his kind to put down the mob.
Behind the hospital was a kopje, Zvishavane Peak, the highest hill in the neighbourhood. Before the troubles, the white nurses would hold braais (barbecues) on the top. Later, it was considered dangerous: the guerrillas could be ensconced there (or at any rate, mujibas), watching the town. After independence, I often climbed it. About 500 feet high from its base, it gave wide views over the green sea of the veld. One could see the slag heaps of the next asbestos-mining town, Mashava, forty miles away, the road running north to Selukwe, and the toy town, sprawling widely and untidily below.
On certain nights, when I was called to the hospital, this hill took on a strange appearance, which was not shared by the other hills around the town. It was unique, like a magic mountain. It had to be a clear night under the stars. With cloud or with moon the effect was not seen. On the rig
ht nights the hill glowed white, less like a hill in tropical Africa than a hill in England at night, under the snow of winter. Terry’s nephew, Hugh, the geologist, saw it; had never seen anything like it, and thought it must be a high load of quartz in the soil. I think it meant something to the Africans, as Inyangani did, and so many hills and rivers in the country. I regret that I never asked them. Perhaps they would not have told me. It loomed, on its special nights, a disturbing and ghostly apparition.
Then came sad news from Umvuma (now called Mvuma). The owner of the Falcon Hotel, John Holland, was killed in a car crash. The place was bought by a Canadian, who appointed the head waiter, Nelson, an excellent man, as manager. Nelson had a brother, who became head waiter. The brother was not an excellent man. The new owner conspired with the bad brother (who may have been called Satan, or Poison - both popular names for boys in a mythology which carries different values from ours, in which the Devil may, indeed, be accorded the status of a gentleman) - conspired with Satan to burn the place down and collect the insurance money.
Unfortunately for his scheme, he did his conspiring over the telephone, and he had insufficient knowledge of the operation of small town telephone exchanges in Africa.
During the often empty and tedious hours of her duty, Mrs Van Oysterbar would vary the reading of her novel with listening in on private conversations on the line, and in one of these, she overheard the final exchange of the plotters. She telephoned the police, who arrived to find Satan setting fire to a quantity of petrol in the lounge. I don’t know how they got the fire out: I never heard of a fire engine in Mvuma. But the place was badly damaged.
The bad brother was arrested. The Canadian fled the country. Nelson got a job at the Enkeldoorn Hotel. The mine bought the building and turned it into a hostel for their male staff. The jolly days of the Falcon were over.
One day, Percy and his wife, Marguerita, added to the gaiety of nations, or, at any rate, Zvishavane, by laying on an expensive entertainment in the main street.
Percy had bought a new car - a Mercedes with automatic gears - and Marguerita went shopping in it. She parked it outside Toni’s cafe, in the way permitted by the broad streets of Central Africa, that is, tangentially, with its boot pointing into the street. When she attempted to drive away, she did something to the unfamiliar gears, and shot the car backwards across the street. A Mercedes, of course, is built like a Tiger tank. Marguerita killed three ordinary cars, before ram-raiding the Parthenon cafe, on the other side of the street; admittedly, boot first, but ram-raiding was in its infancy then anyway, and this was Marguerita’s first attempt. (Now, I understand, this mode has been widely adopted, so it seems Marguerita was ahead of her time, after all.) In the startled bowels of the Parthenon, she fiddled with the gears again and took off on a second voyage of destruction, killing three more cars and ram-raiding Toni’s in turn, this time in the conventional way.
By now, the main street looked like the battlefield of Kursk, with wrecked cars all over the place, some on their backs, wiggling their legs in the air, like immobilised beetles. In the whole affair, nobody was hurt, or, at any rate, the only one to appear at the hospital was a badly shaken Marguerita, with a scratch on her cheek.
But then it turned out that Percy, in his leisurely old-fashioned way, had not got round to insuring the vehicle. Percy was not a poor man and his wife was said to be a South African millionairess. All the same, it was voted a most munificent spectacle.
One morning, a little girl was brought in, bitten by a hippopotamus, on her way to school. She had a big hole in her left upper abdomen. When we gently turned her over, there was another big hole in the back of her chest, on the same side, in which the collapsed lung was plainly visible, ineffectually trembling. She lay panting and grey on the bed in deep shock.
We resuscitated with fluids and blood, gave antibiotics, and when she was fit for surgery, got her to theatre. We started anaesthesia with a tube down the windpipe. When I was scrubbed up, I was able to make a closer inspection.
There was little damage to internal organs: some bruising of the lung, an abrasion of the stomach, and a six-inch tear in the diaphragm. The hippo had, in fact, performed what is called a thoracolaparotomy, an incision designed to open abdomen and chest at the same time. There was really little left for me to do but close up, like a registrar after a somewhat perfunctory chief.
Under the intubation anaesthetic, the lung had begun to re-expand, and the little girl was looking a better colour. First, I trimmed the tear in the diaphragm and stitched it up. Then I trimmed the chest wound, washed out the chest with saline, and closed it over a water-sealed drain (already described). As I put in the last stitch, a triumphant burst of bubbles came through the water and announced the full re-expansion of the lung. I trimmed the abdominal wound, over-sewed the abrasion of the stomach, and washed out the abdomen, before closing it also.
Next day, the little girl was sitting up in bed quite happily, but on the third day, she developed respiratory distress. I thought of respiratory distress syndrome (something first diagnosed after bomb explosions in Belfast), and thought the lung must have suffered more punishment than appeared. I ordered a chest X-ray, which showed the lung fields perfectly clear, but the heart displaced a whole width to the right - away from the wound.
I could not fully understand this picture. (In respiratory distress syndrome, one expects to see the lung solid with fluid.) But I decided to transfer her to Bulawayo, in case she needed mechanical respiration.
After a few days, she came back, perfectly well. She had required nothing more than oxygen, and the head of the intensive care unit explained in his letter that although this was indeed a case of RDS, the lung fields might well appear clear in the early stage.
Soon after that, I went away on my annual holiday with my wife and children, to the deep peace of the bush, where the cry of the fish eagle by day and the bush baby by night take the place of the ringing of the telephone.
When we returned, after two weeks, we found Charles had discharged our little patient, perfectly fit, and we never saw her again.
Then a sadder case. There are two important pitfalls in diagnosis. One is jumping to conclusions; another is taking the wrong turning. There are others, but these two are perhaps the commonest. In the second, you can go so far down the wrong road before you realise it.
I first saw him on my morning ward round, a little fellow of about ten, sitting up in bed with a cheerful grin on his face. It was about the beginning of the rainy season. He had been coughing for two days and had a temperature of 400. There were no signs in the chest.
I started him on penicillin. Next day, his temperature was normal, but he was still coughing. There were still no signs in the chest, and he still had his cheerful grin.
Next day, all was as before, but his temperature had risen again. I ordered an X-ray.
I did not see this till the fourth day, when there was no change, except that his temperature was normal. The X-ray showed central areas of consolidation on both sides. I suspected virus pneumonia, and changed the antibiotic to chloramphenicol.
After another forty-eight hours, things were the same: the cough, the temperature up and down, no chest signs, and still the cheerful grin.
I thought of Tb and started investigations. Of course, these took another three days, and the results were negative. I decided I was getting nowhere, and transferred the child to Bulawayo. He was there four days before he died.
Which means they did not make the diagnosis when he came through the door.
Medical or nursing readers may have made it already. All the clues have been given: Central Africa, the rainy season, an intermittent fever.
Of course it was malaria!
Several textbooks describe a pulmonary form of malaria. I searched the notes and made the miserable discovery that in all the investigations I had not ordered a blood smear. At any time, a couple of chloroquine tablets could have saved him.
Malaria is one of tho
se so-called ‘protean’ diseases, which can take disguised forms, presenting pitfalls to the unwary. A well-recognised such presentation is vomiting and diarrhoea. Another, which I have never seen described anywhere, is catatonia.
I wish I had made a closer study of the several cases I saw, which might have added my name to a new eponymous syndrome.
Catatonia is usually a form of schizophrenia. In the malarial form, I have observed several of the classical features. Stupor, when the patient lies on his back and stares at the ceiling. Waxy flexibility, in which, with the patient lying on his back, the limbs may be manipulated into various positions, remaining there for minutes, at least. Another is statuism - such as the famous ‘tea-pot position’. On one occasion, I had two girls on the same ward standing to attention at the foot of their beds like soldiers for hours together. The condition is differentiated from true schizophrenia by the absence of previous history and by a response to antimalarial treatment - and often (but not always) by a positive blood smear. The temperature is not always raised, and may be depressed. It is, I suppose, a form of cerebral malaria, and therefore a dangerous stage of the disease.
Professor Levy of Harare believed, like Potter of Oxford, that head injuries should be managed ‘by the first one competent to do so’, for reasons already indicated, which apply even more in Africa than in Britain. To this purpose Professor Levy (who was a neurosurgeon himself, one of only two in the country) gave a one-day crash course in Harare for district doctors, which I attended. His lectures included the three main conditions of depressed fractures, epidural haemorrhage and subdural haemorrhage. Depressed fractures, whether closed or compound, are not matters of urgency, and can be safely transferred elsewhere. But they are the commonest of the major head injuries, and for this reason are the more likely to amount to a burden on the limited specialist centres, and, conversely, will the more rapidly accustom the general doctor to opening the head and reducing his natural fear of handling the naked brain.
Across the Wide Zambezi: A Doctor's Life in Africa Page 39