Sneak Preview Of The Country Doctor Alive And Well

Chapter 3

Fetal Physician

Childishness is one thing; childlikeness is quite another.

The switch had just been turned to "ON" by the labor-room nurse, and before the light had actually illuminated the room, I was wide awake and hightailing it to Delivery Room Number One to bring the first baby of my twelve-month rotating internship into its new world.

It is like that when one is on call for the obstetrical service. A switch clicks on, the eyelids snap open, then the light comes on. It was a very rapid series of events that vaulted me out of bed as I raced to the Delivery Room to arrive before the baby did! I almost always made it.

It took no time at all to get dressed, since I slept in the scrub suit that I also wore all day. The only accuracy necessary was to hit the floor running into my shoes. That was my twenty-four-hour uniform during the twelve months of internship. When internship was over, it felt strange to wear regular clothes again.

"Wow!" I had said to my fellow interns. "I really lucked out! What a way to start out a year's worth of hospital training between medical school and medical practice!"

I had chosen the obstetrical service intentionally, thinking it so symbolic as a beginning for my training and new life for babies. There was something poetic about that. It meant delivering babies for two months and rotating on the gynecology service at the same time. It seemed fitting to learn about the diseases, illnesses, and health of both mother and child at the same time.

It hadn't occurred to me that obstetrics meant night calls (when the majority of babies are born). That added up to a twenty-four-hour day, sometimes for two or three days in a row.

I could not have chosen a more exciting way to start. By the end of the first night, day number one of rapid transition from student to experiential doctor, I had six notches on my delivery stick. At the end of two months, after notching off number one hundred, there was no room left on the stick. The actual number of trips to the delivery room was ninety-eight, for twice I simultaneously delivered babies from two different mothers on adjoining delivery tables.

The challenge of delivering a baby safely--for mother, child, and doctor--can be so intense that it is easy to become lost in the technique of the task and miss the beauty and the miracle of new life.

In years to come, the miracle would return when I stood by the delivery table watching the specialist do the delivery while I, as a family doctor/pediatrician, was there to accept and examine the newborn and make sure a precious and delicate life was able to continue breathing.

Hearing a loud cry after the initial pat on the buns is an essential part of the miracle, but I decided early on that slapping the newborn child on the bare bottom is a cruel introduction to life. It is enough of a shock to leave the cozy confines of a floating waterbed and be squeezed through a tight birth canal into the cold, outside world. It's no wonder a tender and sensitive little one sometimes develops a complex about spanking.

The transition from the gentle confines of a mother's womb, where baby is comforted in a warm-water world and frequent pats through the abdomen, programs a new life for petting and hugging. It is a joy initiated at the time of the child's conception, when mother's egg takes in and embraces father's sperm. It is, also, a need, strongly reinforced by a snug squeeze through the birth canal. It seems shameful to spank its new-born bottom the moment the baby enters the outside world. A brisk rub up and down the spine does the trick just as well.

I was not a total novice on my first day of internship, however. I had already delivered twenty-five babies while on hospital obstetrical service in medical school. Things were different as an intern, though. I was intimately and intensely involved in the birth process, more on my own, with a higher degree of responsibility. It would have been the worst possible place to make a mistake.

Easing the baby out of the birth canal as soon as the tip of its head appeared was priority number one. At delivery number ninety-eight, it was still as important as it had been with the first.

Priority number two was to minimize the tearing of the mother's surrounding tissue, since a baby's head often seems to be about five times larger than its exit. Despite the most careful attention to massaging the vaginal rim around an increasingly-protruding baby, it was sometimes necessary to make an incision. In certain cases it was imperative to prevent uncontrollable tearing which could cause serious injury to the mother's rectum and bladder.

As soon as the baby was born, breathing, and freed of its umbilical cord, priority number three was to carefully suture the mother's wound so that excessive scarring would not result in future discomfort and difficult child births. Depending on the needs of the baby and the necessity to minimize tissue tearing, the size of the incisions varied. At times, they had to be deep and long.

It took another half hour to put things back together. During the process, I often wondered how Dr. Eberhart, of some 35 years ago, had been able to perform such a miracle in my mother's bedroom. Of course, I knew that the process had become quicker and easier after Mother had delivered several of my siblings. By the time the ninth one came, she was able to do it herself with only the help of a neighbor.

A few years later, it was unheard of for a baby to be born at home. Except for those few who had to be delivered by distraught fathers, taxi drivers, and firemen along the way, they all went to the hospital whether they needed to or not. Hospital deliveries were said to be safer for both mother and child. They were definitely more convenient for the doctor. And, they became increasingly more expensive.

It wasn't until some thirty years later that the pendulum began its swing in the opposite direction. Baby-boomer parents of the 60's and 70's became increasingly interested in the options of natural childbirth and home delivery.

As expected, the conservative colleagues in my medical community would not hear of anything so unconventional. It took one obstetrician and myself to promote the idea. After our first several deliveries--all successful because of our own careful selectiveness and diligent attention--the movement was underway. Parents continued to exert mounting pressure on the medical establishment. It was an issue that was not about to be ignored.

The medical community compromised by developing the birthing room at hospitals. A woman in labor could be admitted just in time for hospitalized delivery in the most natural way possible. The father was no longer excluded or expected to pace the corridor. Instead he was right there by the delivery table along with the pediatrician. When everything went well, the proud parents and the newborn child could leave the hospital for home after a few hours or so. My friend and I had opened the Birthing Room delivery door.

It was fitting that my pediatric service rotation followed obstetrics and gynecology. I became intimately acquainted with infants and children, both healthy and diseased. I was able to watch the growth of babies I had delivered just two months before. Occasionally, I helped feed the young ones and sometimes rocked them to sleep after finishing my intern duties for the day. It was easy to fall in love with them. It was, also, easy to fall asleep with them still in my arms after I would sing my own version of:

Rock-a-bye baby, in the treetop.

When the wind blows, the cradle will rock.

And if the bough breaks, sweet baby will fall

Into my arms, safe and sound after all.

With increasing mellowness in my own mind and heart, I decided the fairy tales and nursery rhymes of elder days were terrible for babies and young children. During their most impressionable years, they were rocked to sleep and put to bed with visions of wolves eating young girls, pigs boiling wolves to death, and stepmothers poisoning pretty little girls with bright red apples. I've often wanted to rewrite them all.

On the other hand, in today's world of violence, wickedness, and greed, and with an overload of low moral psychosocial behavior in all people "great" and "small," could it be that the authors of fairy tales and nursery rhymes back then knew what they were doing after all? Perhaps they had the foresight to desensitize and prepare us for the crazy present.

The moment I met Becky, she became one of my favorite patients and persons. Becky first entered the hospital while I was still on the pediatric service. She was very sick with what turned out to be a case of nephrosis of the kidneys. Only vaguely did I realize or want to think about the gravity of her disease back then in the 1950's.

That ideally beautiful four-year-old child, blessed with an equally captivating personality, was plagued with

the immense problem of repeated attacks of kidney failure. Her sweetly innocent life was doomed to an early end.

Becky entered the back pages of my mind over the following six months as I rotated through internal medicine, surgery, neurology, and other specialty fields.

She returned in stark reality during the last month of my internship on the pathology service. I entered the autopsy room one day to see her precious little body on the cold stone autopsy table, awaiting my help with her postmortem examination. In all the years since, she has never left my mind.

At that moment, I didn't feel all that fortunate. I began my internship bringing life into the world and ended it by seeing some of those lives leaving.

A twin birth is an infant replay.

Interlude 3

Insomnia

It has been said by "the experts" that some thirty million people in the United States have trouble sleeping each night. That figure includes those who have difficulty falling to sleep, those who awaken frequently, those plagued by nightmares, and those who sleep so lightly that the drop of an eyelash would awaken them.

Decide for yourself whether or not you have insomnia. Don't take it from someone else who wants to sell you a sleeping pill or a new mattress or advise you to replace your sleeping partner with one who does not snore.

If you feel reasonably well rested during the day and you're reasonably able to accomplish all that you choose to do, physically and mentally, you are getting enough rest.

Chapter 4

Big George

Be careful about following directions,
you might just end up where you're not going.

"Who is this?" I asked, a little surprised to hear a young boy's voice at the other end of the line in the middle of a school day. "Is your Mom home?"

"It's Little George," he answered. "I'll get her."

Wednesday afternoons have become a time for my regular four-hour, eighty-mile, house-call rounds. The trip includes several calls in Susquehoning and other stops in the surrounding countryside, in all directions, as far away as twenty miles.

The dozen or so patients I see are all homebound because of advanced illness or age. Some of them suffer from terminal cancer, stroke, heart disease, cerebral palsy, or Alzheimer's disease. Their ages range up to ninety-seven years.

Jane got on the line and explained, "It's George, Doc. He just got back in from a milk association meeting in Denver, and he's really sick. He can't get out of bed. Can you come out?"

The image of Big George was taking shape in my mind as I listened to Jane. George was a man with a laugh as big as his frame, and he could fill a doorway with no trouble at all. It would have taken an ambulance with a full crew to get him in to me or to the hospital, 35 miles away.

"I'll be out that way on calls this afternoon. You can expect me then," I promised.

By early afternoon, I manipulated my old, four-wheel-drive pickup, Chunker, off the asphalt secondary onto a muddy road that sloped down into a shallow valley just outside the village of Goosetown.

Vehicles of the vintage of my old truck are called clunkers, but not mine. Mine is built with a broad wheel base, slung low to the road, with tires that grab the ground and hang on for dear life. It refuses to be turned over. Yet, under the right combination of circumstances, it is willing enough to get stuck in the mud or snow. More than a few times we have been towed out of drifts and ditches and fields by the closest farm tractor or plow horse.

My truck chugs along the road at pretty much its own pace, regardless of the gearage, eating up the miles one chunk at a time. There are a lot of clunkers out there, but mine is the only Chunker I know.

As I drove down the winding road to the Williams Farm, I once again appreciated the wonderful Allegheny Mountains. Surrounding me was the most beautiful deciduous mountain country, a year-round sporting arena for hunting and fishing, and a treasure chest for the nature photographer, writer, and outdoor person.

Hills and valleys and fields and streams have become the picture frames of my reference, wildflowers and wildlife my companions. At any time of the year, my senses are filled with the magic and mystery of the mountains and its people.

I dodged some white-tailed deer on my journey, and one wayward cow. All the while, the slopes of the mountains reinforced my sense of everlasting at-home-ness.

"Our road is exactly one mile past the village general store," Jane had told me. "Look for a wooden shelter on the left at the top of the hill where the boys wait for the school bus. Turn right, onto our road, and come down the slope exactly one-half mile. Look for a white frame house on the left with a red barn right across the way. There is a sign right there that has our name on it."

Now, I have become very careful about directions to country places over the years, especially when the word "exactly" is used before the number of miles. Many times, both day and night, I have found myself lost. Country nights can be very dark, and the back roads are lightly traveled. The distance between me and a dusk-to-dawn light can be a lot of miles to go.

As Jane finished her directions with a confident, "You can't miss it," I found myself thinking about my first house call several years ago to Clara Piper's place.

"Turn right by the green Esso service station. You can't miss it, Doc." What Clara hadn't told me was that the service station had recently changed hands to Sunoco. Also, the station's color had changed from green to white. Sure enough, I missed it.

With Jane's directions fresh in my mind, I drove off the ridge down into a shallow, windswept valley that resembled of the lower half of a wind tunnel. The directions were scribbled on my prescription pad so I wouldn't forget a turn or a landmark. Most of the time, I remember to bring the pad.

The Chunker and I slid down the wet, muddy surface aided by a strong gust of wind. With careful aim, I managed to stay on the road until it leveled off a bit. Slowly and cautiously, I accelerated onward, grateful that it was not an icy road of winter. Three miles passed and I had yet to see "The Williams Farm" sign, although I did see several white houses with red barns across the way.

As I turned around to try it from the other direction, I was certain I heard the Chunker chuckling. So many times the grill of my old friend takes on the appearance of a laughing face with its bumper twisted into a smirk.

Two and a half miles back up the road, I stopped at one of the many red barns. Stepping out of the Chunker, I yelled over the roar of the farmer's tractor motor and asked directions to the Williams Farm.

"You're on it!" he shouted back.

The sign was nowhere to be seen as I felt the icy sting of the wind strip away what little warmth my clothing gave me. I looked down to see my shoes buried in mud to the shoe strings and said, "Yep, and it looks like I am in it, too. Where do I find Big George?"

He pointed to the back door of the house across the way.

I had to hold onto my hat to keep it on my head. I was thankful for the black bag in my other hand, for its weight kept me from blowing away like the Williams Farm sign.

Inside the Williams' home, the wind whistled in and around the windows with a musical note I had not heard since the summers I had spent on my grandfather's farm long ago and far away among the Pennsylvania hills of Clinton County. I was momentarily overwhelmed by the pleasant ghostliness of a nostalgic past.

I imagined I was back in the kitchen of that old farmhouse. It was dark outside. My older brother and I sat with my grandmother and grandfather, talking together by the light of a kerosene lamp. At age six years, I was homesick for my family a hundred miles away.

During the day, Chuck and I helped mow hay with a pair of horses. There was no such thing as a tractor. Wheat and oats were cut to the ground with a scythe, something I was not big enough to use. I did help make sheaves after the cutting, though.

The trick was to gather up an armful and then tie it together with a half dozen or so strands of stalk. A dozen of these bundles were then stacked together until the whole field was harvested. Horses and wagons were driven through the rows to load the shocks destined for the barn. There, on the main floor, each bundle was threshed by hand to separate the grain from the stem. Grain ended up in a bin for later use as food for livestock and flour for the kitchen. Stems became straw bedding for cows, horses, and chickens.

I decided that farmhouses such as those would have made great little sanitariums for tuberculosis patients of earlier days when fresh air and sunshine in season were the only treatment around. It was a pleasant country environment, and Jane told me how nice and cool it was in the summertime.

I found Big George in his country-cool bedroom buried under an even bigger mountain of country quilts. I knew he was in there somewhere from the clouds of water vapor that hovered over an opening near the topmost blanket. Ordinarily he would not have consented to a house call. In fact, he likely would not admit that he needed medical care at all. I was there only because Jane had summoned me and because he was truly sick with the fever and cough and the aches and pains of a severe case of bronchitis.

There are many rugged individuals like Big George here in my part of the world. Nine times out of ten they are men. They are not at all unlike those of older times and similar places. Today's breed may be more educated, more successful, and more affluent. Yet deep inside their soul, that old trait of imaginary indestructibility still glimmers through.

Big George was happy enough to see me that day after all. He was too weak to complain and unable to resist the penicillin shot destined for his bare backside. He even agreed to stay in the house and take it easy for the following three days, giving up a business trip to New England and his work in the barn and fields. It would be very unlike George, but he decided he was sick enough to cooperate with Jane and me at the moment.

"You know this all started out as the flu, George," I reminded him. "When fall comes, you should think about getting the vaccine. We have had the flu vaccine for quite a few years," I said, "and it's one of the best we've ever had."

"Does it work?" Jane asked.

"It can prevent the flu that occurs from mid-December to the first part of March for about eighty-five percent of those who take it," I replied, "and for the other fifteen percent, the symptoms will be mild. Another good reason for taking it is to prevent complications such as bronchitis and pneumonia."

Looking like a big black bear settling in for hibernation, Big George grumbled and moaned under his breath as he slid back under the quilts; I was not at all sure he would consent to a shot come October or November. But I did know, at that moment, he wished he had taken the vaccine the previous year.

As I descended the creaky steps of that simple, yet solid, hundred-year-old farmhouse, I realized how typical it was of its place in time, occupied with only the necessary furnishings and furniture.

"This house has character," I reflected, "a personality. It feels like an old friend." I walked away from the Williams Farm, not all that anxious to leave.

My Chunker's climb to the top of the ridge took longer than its slippery descent of an hour before. We stopped there for a while looking down over the valley--the white house, the red barn, the cows in the meadows, and the fields that were ready for corn and wheat. The scene was frame-worked by fence rows and woodlands. Days of youth flashed before me and filled me with sweet nostalgia.

I reminisced for a while about boyhood summertimes in the month of June when huckleberries were at the peak of tasty-blue ripeness. Early morning hikes to the berry patches, sometimes several miles away, took my brothers and me into the hills with pails in hand and lunch in pocket, eager to fill the buckets--but not for the love of picking berries. The joy of swimming in the pristine water of a cool mountain stream was our inspiration. It seemed uncanny that berry patches were always located near the ol' swimming holes and that the pails were filled at the time of the day's greatest heat and humidity.

Country boys did not know of tractors back then. We, also, did not own swim suits. Skinny-dipping was the only way to go. In the heat and humidity of a berry-picking day, there was no greater pleasure. Picking was quick, swimming was long, and summers were all too short. No wonder they went so fast; like dream fragments of so much more that is remembered less and less.

I would have come to see you last week, Doctor,
but I wasn't well enough.

Interlude 4

Whatisitis?

Whatisitis is not a disease. It is a question: what is -itis?

The answer is that -itis is a suffix found at the end of many medical words. For example, there is appendicitis, sinusitis, and bursitis.

It means inflammation of the kind of tissue that precedes it in the word. Therefore, tendinitis means inflammation of the tendon.

Inflammation comes about because of some kind of irritation. Irritation may be brought about by bumps, cuts, scrapes, over-stretching or overuse of muscles and tendons, or by tearing a ligament. Hence, there are words such as fibrositis, myositis, and epicondylitis.

Irritation can, also, come about because of some disease in the body that focuses on certain types of parts and organs. In this group of conditions are such things as arthritis, arteritis, and thyroiditis.

Viruses and bacteria, too, can cause irritation of certain parts of the body such as the mucous membranes of the respiratory tract, so that we speak of rhinitis, laryngitis, and bronchitis.

Chemicals in foods can cause irritation. Thus, there are conditions called gastritis, colitis, and cystitis.

The symptoms of -itis are swelling, pain, tenderness, and heat. The latter explains why an arthritic joint may feel hot to the touch and why we experience fever with a cold or sore throat.

When an -itis condition is mild and you know with certainty what it is, it can be treated by resting, by not moving or using that part of the body. Many of them can also be helped by cold compresses. Additional relief can be achieved by taking a medication, such as acetaminophen and ibuprofen, to counteract the inflammation.

When conditions are more painful than you can tolerate or treat by yourself, it is time to see your doctor. The doctor will diagnose the condition and, if required, treat you for inflammation, pain, and the underlying cause. What is used will depend on the cause and severity of your own particular -itis.

And that's what -itis is.

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