Across the Wide Zambezi: A Doctor's Life in Africa (48 page)

     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 40
⁰
. 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 those 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.

     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.