Across the Wide Zambezi: A Doctor's Life in Africa (5 page)

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 party 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 effrontery 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.

Zorba the Greek, it will be remembered,
danced for grief when his little son died. Africans also dance for grief,
strange as this form of expression may seem to Anglo-Saxons.

Years later, I was performing a
post-mortem in Central Africa, when, through the window, I saw the family of
the deceased beginning to dance, twisting round and round and crying:
‘Mai-wei!
Mai-wei!’

Beyond the fence was a crowd of about a
hundred people at a bus terminus. Africans are nothing if not social beings.
Privacy, except in intimate physical matters, is anathema. They also have a
mass telepathy, like birds. In no time, the crowd beyond the fence took up the
dance in sympathy, until they were all twisting and leaping and crying,
‘Mai-wei!
Mai-wei!’