Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Medical Adventures in the Nigerian Bush
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Medicine
The fellowship offered experience with a wide spectrum of medicine, with a
high volume of patients with most of the diseases known to civilized countries as
wella s exotic afflictions. Tuberculosis, as an example, was widespread, with an inpatient
colony and a whole outpatient clinic full of complications of TB. We saw
scrofula, Pott’s disease, lupus vulgaris, and enteric tuberculosis as well as complications
of pulmonary TB such as pneumothorax, massive hemoptysis, and heart failure.
One of the most feared admission diagnoses written on a new patient’s chart
was the simple phrase “drank native medicine”. The local medicine men believed in
rigorous purgatives for any disorder, and would administer caustic potions as remedies
for most diseases. The “native medicine” was a potent nephrotoxin and hepatotoxin,
which caused a rather rapid failure in the patient whatever his original
disorder might have been. As seen in Table 2, “drank native medicine” figured prominently
in the mortality bills, most of the patients becoming jaundiced and then
progressively obtunded in liver failure and uremia.
One of the most fascinating medical problems with which we became familiar
with the management of snakebite. A common hemotoxic snake that accounted for
almost all of the victims we treated was the common viper, Echis carinatus. We heard
of, but did not see, victims of the tree snake, the dreaded green mambs; its potent
neurotoxin was instantly lethal far before ineffectual hospital care could be provided.
The Echis venom, however, antcoagulated the victim ot the extent that hemorrhage
occurred at every interface with the patient’s environment. The patients had
time to get to the hospital after being bitten, but arrived with hematuria, melena,
hemoptysis, gingival bleeding, and profuse bleeding from the envenomation site
and other superficial skin abrasions. Since most of the victims arrived later than a
few hours after being struck, our therapy was not so much directed at getting the
venom out (as with cruciate incisions, tourniquet, and so forth) as toward neutralizing
the local and systemic effects of the venom already circulating. The bites would
usually be on the hand or feet, and the most common victims were farmers working
the earth and children playing in the grass. There would be enormous swelling of
the extremity that had been bitten; in a few cases the edema caused such tension that
the arterial supply was compromised. These cases were treated by fasciotomies to
restore blood flow, and the others were wrapped and elevated. Since there existed no
precise knowledge of where the venom acted in the clotting mechanism, a specific
treatment was not available. However, antivenom for the Echis toxin was available
and was injected regionally and systemically. If blood could be obtained, it was
given to the patient as well. Some of the unproven treatment such as injection of
Vitamin K and steroids were used in those patients who did not respond to the
antivenom.
I wanted to obtain a few Echis specimens for my own interest, and many of the
patients obligingly brought in the snakes they killed after they had been bitten. I
wanted a live snake, however, instead of only the skins of the snakes that had bitten
patients. I figured the Echis venom could be investigated to see where it acts in
blood clotting, not only so that treatment for viper victims would be more rational.
But also because this purified venom might make a wonderful therapeutic coagulant.
But for reasons of quite understandable fear, no patient could be persuaded to
procure the live venomous specimen for me!
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