Bilharzia, the world’s second commonest parasite after malaria, was common in Zululand. Intermediate snail hosts, carrying the parasite, lived in the streams and small lakes around the hospital. The picture shows the smaller female worm which resides in a groove on the side of the body of the larger male. The worms attach themselves to the veins draining the bladder, ureters, bowel and liver where they deposit their eggs.
The mainly bare-footed kids get the infection by crossing infected streams on their way to school and back home or while swimming in contaminated waters. We found 100% of the Ceza village schoolchildren had urinary bilharzia/schistosomiasis - years later it could block off their kidneys, cause bladder cancers or destroy their livers with a form of cirrhosis.
The area was also endemic to amoebiasis, capable of producing a virulent colitis with bloody diarrhoea or spreading to the liver to produce large, potentially fatal liver abscesses as in the autopsy image here. In the days before ultrasound or CT scanning to guide needle or catheter placement, inserting a thick needle blindly into a liver abscess always raised my heart rate, but it was a satisfying moment when one aspirated 100mls or more of “anchovy sauce” pus from the larger lesions.
As an intern, in preparation for my time in the rural environment, I tried to do as much surgery as the supervising consultant surgeon of the day would allow me to do. I was unlucky during my 6-month surgical rotation when I never encountered a single case of appendicitis. It was not a common diagnosis at CMH and I only ever had to deal with one case during my time there. As luck would have it, the appendix was not in it’s usual position at the base of the right colon/caecum, but ran an unusual full-length course behind the right colon. A nearly bursting, red-hot tip of the appendix stuck out from under the liver at the top of the abdomen. Not having Professor Google available for consultation in 1973, meant I had to go to the alternative Bible, Hamilton Bailey's Emergency Surgery to establish that a retrograde removal was better than a prograde technique for this type of appendix. Enough said, of what turned out to be a successful op.
One learnt to be judicious with the use of local anaesthesia (LA). I never had occasion to do a Caesarean section under LA which could be done in an emergency situation without an anesthetist, but thee moist pleasing major surgery one performed under LA was a neurosurgical emergency procedure.
Hardwood traditional Nguni stick-fighting is a form of African martial arts. The “kierrie” or “knopkierrie” is a club with an irregular head obtained from the base of a suitable bush with the rounded main root attached to the stem base. The smoother bevel shaped head was also popular. At local parties it was not unusual to end up with a young unconscious fighter with a bleeding head wound inflicted during a stick fight. Urgent surgery was essential as the depressed skull fracture often had an arterial injury causing a large intracranial blood clot with a rapid build up of pressure on the brain preceding death.
One injected dilute LA in a large U-shape flap around the injury before removing bone fragments, debris and then scooped out the blood clot to depressurise the brain. With the pressure easing off, we then had to give intravenous sedation to keep the patient still. After tying off the bleeding artery just under the fractured bone, one sutured the u-flap of skin as quickly as possible in a patient who always threatened to wake up completely. Talk about drama in “die kamer!” (the room). I always had this weird idea that the waking patient would want to continue his fight with us there in the operating theatre.
I’ve saved one of the worst experiences for last. Another ancient killer in unvaccinated people is diphtheria. We had an outbreak of 70+ cases over a month. A third of the patients died before the spate of cases settled while we scrambled around the neighbouring kraals (homes) immunising everyone. It was a terrifying experience which did not merit any of the news media headlines which would have resulted had there been just one White person having the disease. I can still picture the thick off-white membrane at the back of the throat - lower down it would shut off the vocal cords; the disease also produced a fatal toxin. I dreaded the prospect of having to perform an emergency tracheostomy on a young child; fortunately, we never had a case in need of one. I learnt to recognise nasal and cutaneous diphtheria in the course of the outbreak. None of the patients had been vaccinated, almost the norm in the impoverished land of the Zulus. It's this kind of experience that makes me think of how foolhardy are the anti-vaxxers in today's COVID world.
In my professional life, my mistakes still haunt me. Could I have saved the life of the girl gored by a bull? There were a few others that still come to mind, like losing a severely ill child or two. Tragically, life is what it is, rather than what it may have been. I’m not one to dwell on the “what-ifs” of life. More important is learning from them, not repeating them and passing the knowledge on to less experienced colleagues. Through my years in teaching hospitals in Cape Town, Kuwait, New Zealand, Oman and Australia it has been my fortune to instruct my junior colleagues. Some of this started in Kwazulu where I enjoyed lecturing to our trainee nurses.
Not only did I get my family life in order, but the medical experience was unparalleled. I even performed the job of being a district surgeon for the area together with my colleagues. One day the superintendent and I enucleated the severeley injured eye of a calf brought in by a local farmer. At best we were four doctors on site; most of the time there were only two of us which reduced to one when we went out to our weekly, district day clinics - only possible with sturdy 4-wheel drive Landrovers. The ox-drawn transport of the old patient below was a Y-shaped tree trunk with cross- branches. No doubt this “ambulance” design went back centuries.
Like the patients, our staff were predominantly locals with a sprinkling of Swedes and English. Not being linguistically gifted, I struggled with the Zulu language as I would with Arabic in the Middle East. We lived in the hospital grounds and related well to all. I joined the hospital tennis club where I stumbled my way through games alongside superb local players who were the regional champions. The family went on neighbourhood walks or trips to the rhinoceros reserves a few hours north of us; there was fishing at Richard’s Bay where I caught myself during the annual Shad runs; and I became a keen vegetable gardener. While out in the garden on Sunday mornings, I greeted many of the staff on their way to church, a short distance away from where I lived, so I was pleasantly surprised when the local Reverend father referred to Zonjia and myself as very “Christian people” at our farewell. It’s interesting how we were regarded as very “Muslim people” when we left after our three-year stint in Kuwait ten years later. We must be doing something right!
On the down side were the bad cases, the worst of which I cited earlier. CMH exposed me to some of the worst aspects of poverty-related illnesses known to mankind. They were a direct product of the apartheid system with families split apart with the so-called migrant labour system, and where displaced citizens from the cities were dumped for not having a hated Dompas. Without the pass-containing reference book, the bulk of South African citizens could not be domiciled in most of the country, except in the so-called Homelands or Bantustans, even though they had never been there before. Millions of citizens were afflicted by the vile Group Areas Act (over a quarter of a million in Cape Town), but it ranked a low second to the Dompas abomination as the 1952 law allowed the detention of over a quarter of a million people per year in the mid 1980s.
My time in Zululand was the most satisfying all-round period of my life. Socially, it provided all of us with a unique opportunity to live together, unlike our segregated lives in the major cities. Much of this has changed in the more integrated modern day South Africa, though, sadly, our years of separation, still fragment the nation.
Besides allowing me to experience a much more normal family life, Zululand was significantly transformative in terms of my decision to do radiology on my return to Cape Town. It proved to be a life-changing experience which resulted in many years of professional fulfilment around the world as a radiologist in Cape Town, Kuwait, New Zealand, Oman and Australia.
For all those bad and good times, I am eternally grateful for the three years I spent at Ceza Mission Hospital.
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