Working with Dr. Schweitzer

Chapter 8. The Children's Clinic

By Louise Jilek-Aall, M.D.
In vain have I tried to train myself to that equanimity which makes it possible for a doctor in spite of all his sympathy with the suffering of his patients, to husband, as is desirable, his spiritual and nervous energy.

(Albert Schweitzer, My Life and Thought p. 166)

- Author's translation

One day while I was working at the children's clinic, Anne-Lise came and whispered in my ear, “Please come and help me with a child.”

She was talking about a patient “treated” by a professor of pediatrics who was visiting Lambaréné for a few weeks. He would sit amidst the noisy activities of the hospital and discourse with Dr. Schweitzer for hours. When Dr. Schweitzer was busy, the professor would come over to where the children were lined up and watch Anne-Lise and me at work. When he offered to give us a helping hand, we gladly accepted. Soon, however, we began to dread his presence.

The professor, a rather small and nervous elderly man, seemed to lack any humor or affection. He soon began to lecture us, as he obviously was used to doing. But due to the heavy workload, we could not possibly give him the attention he expected. To our great disappointment, he totally failed to be of any practical help to us and, in spite of his growing resentment, we had to carry on our daily work regardless of his presence. When I had to listen to his indignant comments on the “lack of hygiene” he found in our clinic and on the quick decisions we made in the treatment of our little patients, I began to realize the gulf that existed between what was taught in modern medical schools and what one has to practice in remote tropical areas.

I remembered with a sigh the spacious wards of children's hospitals in Europe; the air of cleanliness and tranquility, where smiling nurses go about tending to relatively small numbers of children. Some of these would be seriously ill, of course, but a large percentage were overfed rather than undernourished and emotionally disturbed rather than physically diseased. I saw before me the brightly painted playrooms filled with toys and books and the gaily decorated dining areas where delicious meals are served several times a day. In such facilities, physicians can safely keep their patients under observation for days. They can delay specific treatment until the complicated machinery of modern diagnostics has given them all the information they need.

And here we were, in primitive, overcrowded, tin-roofed barracks, the stifling air filled with the piercing cries of children in pain and with the humming voices and shuffling of people coming and going all day long. Anxious mothers in their sweaty garbs, scrambling desperately to reach the doctor with their sick little ones, pushing forward, hardly leaving any space for physical examination. Only one physician, one nurse, and an interpreter to service the clinic, sometimes treating up to fifty little children a day.

I knew the basic principle taught in European medical schools: never to diagnose in a patient more than one illness at a time and to always use medication conservatively to give nature's healing tendency a chance to unfold.

What our visiting professor had completely failed to comprehend, however, was that the worm-infested, malaria-ridden children of the tropics, undernourished and anemic as they are, often lack the physical resources to fight off an acute illness. Children suffering from high fever, or diarrhea, quickly succumb to heat collapse, dehydration, pneumonia, and heart failure.

I shall never forget the consternation with which this old university professor watched some of our emergency procedures. He was shocked when we injected fluids into the peritoneum because there was no time to lose by surgical insertion of a needle into a collapsed vein, or when I transfused my own universal donor blood directly into the jugular vein of an unconscious child instead of waiting for the matching blood of a relative. The professor simply refused to recognize that we had more than once helped a child over a deadly crisis with such drastic methods. To him, things just were not done that way.

Admittedly, it was a desperate, last-minute attempt to save the life of an anemic child, already in the fangs of death and gasping from the lack of oxygen, which its thinned-out blood could no longer provide. It was an oft-repeated wonder for us how such a child suddenly fell peacefully asleep, after receiving but a small amount of fresh blood. The temptation to repeat this procedure to my own detriment was only halted when Dr. Schweitzer firmly forbade this kind of blood donation once he became aware of it.

So, in the midst of the hectic activities of our clinic, the pediatrics professor would stand, stiff and indignant, incessantly giving out his impractical advice and confusing the relatives of our patients who, finally, did not know whom to trust. If a child caught his special attention for some reason he would simply forget, or ignore, the long row of waiting mothers and request time-consuming investigations, even in children we could recognize as moribund. Anne-Lise, in time, learned to keep him occupied with less urgent cases and to discreetly ask me to “re-treat” the seriously ill children he had seen.

When she came to me that morning, I therefore understood right away that another child was in danger. Avoiding the professor, who was just conversing with Dr. Schweitzer, I followed Anne-Lise to the pharmacy where she had kept the sick child for me to examine. It was the most beautiful little girl of about four years, with intelligent dark eyes and the sweetest smile on her face. She was sitting on her father's lap. The professor had given her only aspirin to combat her burning fever, although she showed the heaving respiration of pneumonia. When I placed my stethoscope over the lungs and heard the typical crepitation, I felt bitter toward the professor. This charming little child would have a very slim chance of survival if intensive treatment were not started immediately. We gave her penicillin and cardiovascular support and taught the parents how to keep her cool during the hottest hours of the day.

All went well until on the third day, when the professor happened to see Anne-Lise giving the little girl her penicillin injection. He was furious and ordered the treatment stopped. This use of antibiotics was irresponsible, he said. Our polite attempts at explanation fell flat before the learned man. He always adhered to scientific principles, he told us, and we were just young girls who rather easily gave way to sentiments. He had long observed our liberal way of using antibiotics, which could only be excused by inexperience and over-anxiety when treating children. We were only able to see the patient right in front of us, while he was looking into the future. By using antibiotics too frequently now, we would jeopardize their efficiency in the future, as bacteria would become resistant, he explained.

In all his theorizing, he forgot that he was in deepest Africa. These children of the tropics would probably never again come in contact with modern medicine, or at any rate not long enough for any bacterial resistance to develop. The little girl and her parents lived in a remote village on the banks of one of the tributaries of the Ogowe River. Only because the child was very special to them had they taken upon themselves the long and arduous journey to seek help from Albert Schweitzer. They had paddled days and nights without rest to reach the hospital in time.

The harsh words of this senior physician and friend of Dr. Schweitzer intimidated us, and influenced us to the degree that we let him take over the treatment of the little girl again. She did appear out of danger and seemed to be recovering well from the acute crisis.

A few days passed. Then the parents appeared one night with their daughter and knocked at Anne-Lise's door. They were too worried to sleep, they said; the little girl was not well at all. The professor was not available so they came to us again for help.

Together we examined the patient. She was burning hot and breathing with great difficulty, restless and anxious. We immediately reinstated antibiotic treatment. For hours we tried to relieve her suffering with all kinds of medicines, watching for a sign of improvement. It did not come.

In the morning, Anne-Lise placed the little girl in an aerosol tent, which gave her some relief. Very soon, however, we realized that the child was at the point of choking. I hastily consulted with Dr. Müller; would he consider opening her airways by tracheotomy? The surgeon hesitated; even the professor had no explanation for what was happening. The child's temperature was extremely high--even the ubiquitous worms, the ascarids, felt uncomfortable in her intestines. They began to leave her body, creeping out of mouth and nostrils, an ominous sign. The parents pleaded with us to save the life of their daughter and the little girl thrashed her arms in an effort to get air. Her eyes were wide open and glazed.

Suddenly a death grimace distorted her face. There was no time to lose. We grabbed the child from the arms of her crying mother and rushed into the operating room. Abdominal and neck muscles of the little patient were sucked in by her tremendous efforts to breathe. Her eyes had a pleading expression as she watched us manipulate the surgical instruments. She lay as still as a sacrificial lamb even while the blood began to flow, as Dr. Müller pushed aside the vessels in the child's throat and laid open her windpipe. As he cut through the cartilaginous rings of the trachea, the child took a few deep breaths. Great relief showed on her face as her lungs filled with air. The surgeon inserted a metal cannula into the new opening and arranged a bandage around the child's neck.

“Do you feel better now?” he asked.

The little girl nodded cautiously. She grabbed our hands and her lips formed words of thanks which could not be heard. The gesture and the sweet expression on her face moved us deeply and, hiding our tears, we hurried to fetch her parents.

The child stretched out her arms to her mother and her lips said “Mama,” but since all air now went through the tracheotomy opening, no sound could pass her lips. This was a new and frightening experience, both to her and to her parents. With apprehension, they looked at the metal piece sticking out of her throat and shrank off horrified by the noise which came from it each time the girl coughed. We tried as best we could to explain to them what we had done, but their revulsion made us feel guilty, as if we had violated their child. An uneasy tension began to develop between the parents and the two of us. It grew as the days passed without the child getting better.

The little girl, however, harbored no ill feelings towards us. She seemed to understand better than her parents that whatever we did was intended to help her. With a passionate will to live, she accepted every painful treatment with a courageous smile. By the next day, she had learned to drink by plugging the tracheotomy opening. When she was not too tired, she would sit up and play contentedly with toys we had given her. Anne-Lise and I had arranged a room for her and her parents close to our quarters, where we could watch her better during the night. There the air was fresher and the evenings cooler. People passing by threw fond glances at the little girl sitting there in her bed, smiling and waving at anybody in sight.

The only one who seemed to have lost interest in her was the professor. He never asked to see her again, nor did he ever mention her with a word. He was soon to leave for home and he appeared happy to escape the many problems of our children's clinic. What did the fate of one of these children matter? What mattered to him was that the principles of modern school medicine were upheld, even in the remotest jungle.

Anne-Lise and I, however--we could not help it--we just loved that little girl who so patiently endured her suffering. The parents never left her alone. Father would collect wood and buy food for meals and mother would make a small fire and cook outside the open door, so that their daughter could take part in their everyday life. When one was sleeping, the other would stay with the child.

They did hate the artificial airpipe, however, and were deeply disturbed because their daughter could not talk to them.

“It is not the head of our child any more,” they said reproachfully, and every day they asked us to take out “that thing sticking out of her throat.”

Their constantly blaming attitude and the strain of having to inflict painful treatments and see the child's mouth open in silent cries became nearly unbearable to us, especially when we realized that the child was not going to make it.

Before our astonished eyes we saw a profound change take place in the relationship between parents and child. It had been the parents who gave the child comfort and reassurance before; now, as her death approached they became like helpless children themselves, while the dying girl seemed to reach a spiritual maturity far beyond her age. The wide-opened eyes were filled with love and compassion for her parents, and as long as she was able to express herself, she was the one who gave strength and courage to them.

For a long time after she had passed away, we sat immobilized at her bedside. It was the wild cries of sorrow of the mother which tore us from the feeling of serenity that had held us spellbound while the little girl was dying. Suddenly, the father threw himself upon the body of his dead child and, with trembling hands, he ripped out the hated cannula from his daughter's throat. He wrapped her dead body in a blanket and defended it against us like a wild animal when we wanted to keep the bandages we sorely needed at the hospital. Now the tense feelings of the parents erupted into full-fledged hatred against us. We could not stand it and left them alone with the deceased child.

For days Anne-Lise and I were in a state of physical and emotional exhaustion. We could hardly eat or muster enough strength to carry on our daily work and, as soon as it was possible, we withdrew to our quarters. There we would sit together and for hours relive the tragic events with the little girl. We asked ourselves over and over again what we should have done differently and whether it would have been better to spare the girl and her parents the ordeal they went through because of the tracheotomy.

We tried to hide our depression from the others, but Dr. Schweitzer noticed our misery. He must have found out what troubled us, for it was he who finally helped us overcome our futile ruminations.

About a week after the little girl had died, Dr. Schweitzer called Anne-Lise and me over to his table in the hospital to see a boy who was in acute respiratory distress. His parents were of the Fulani tribe of merchants who peddled their goods up and down the Ogowe River. Their only son, a boy of about eight years, traveled with them. He had run a fever for a few days and when his illness took a turn for the worse, they had steered their boat to Lambaréné. This morning, when the boy began gasping for air, they had hurried to ask Dr. Schweitzer himself to save the boy.

With alarm, we recognized the same symptoms of choking we had seen in the little girl. Dr. Schweitzer asked our opinion on how to treat the boy. Patiently, he listened to our story of the other child's ordeal and our apprehension regarding the usefulness of tracheotomy. He therefore let us try every other measure to help the boy. But when there was no improvement and the boy's condition became critical, he ordered tracheotomy to be performed.

“It is our responsibility as physicians to use any means of modern medicine at our disposal to relieve suffering and pain,” he said. “When we have done all we can, it is not in our hands whether the patient survives or succumbs.”

Once again we went through the painful task of performing this operation with a child. But this time the patient recovered. When the cannula was finally removed and Dr. Müller had closed the tracheotomy opening, the boy did not dare to speak for a long time. Dr. Schweitzer, together with the parents, Anne-Lise, and I stood around his bed and assured the boy that he could indeed talk again. The boy looked around at us and started to cry. There was his voice! Slowly he stood up in bed, listened to the sound coming through his mouth, and then he stretched out his arms and said in a hoarse voice, “Mama, I am fine!” Laughing with joy, the parents caught him in their arms.

Anne-Lise and I looked at each other, thinking of the other child.... Above the heads of the happy family, we met the friendly eyes of the old Schweitzer. He smiled at us and nodded his head. We felt a well of goodness and love surging towards us. As if by magic, the heavy feeling lifted from our hearts and we were filled with new strength. Albert Schweitzer knew the trials we had been through. We understood that we had his full approval and support in our difficult work with the sick and suffering children who came to his hospital.

Copyright © 1990 Louise Jilek-Aall
Reprinted with permission

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