Baby Shots

        "Doctor, describe to me how you would diagnose tetanus in a newborn."  The examiner was putting me through my three-day certification tests for a license to practice medicine in Thailand. 

        I can ace this one, I thought.  "You can make the diagnosis before the baby is even brought into the room," I said confidently, giving an imitation of the characteristic cry through clenched teeth., characteristic of the muscle spasms of "lockjaw."      

        "When I practiced medicine in Burma a few years ago," I told the examiner, "there was an epidemic of newborn tetanus in one village not far away.  The village midwife there never cleaned the scissors she used to cut the baby's umbilical cord after birth, and for a while all the newborns became infected  The babies start to show the signs when they are about a week old.  I saw eight cases and was able to save only one or two. The others all died of constant muscle spasms from the toxin produced by the tetanus bacteria."  (Even though we gave anti-toxin immediately, it does not counteract the toxin already attached to the child's nerves.)  "Once you see it," I said, "You never forget it."  The examiner went on to other questions, and finally told me I passed.

       Diphtheria, pertussis, and tetanus, three entirely preventable infections of childhood, are the reasons for giving "DPT" shots to American babies.  I have seen children die of each of the three diseases in Burma, and I am a firm believer in immunization. 

       Not all cases ended as unhappily as the tetanus victims, however.  A Burmese soldier in Kengtung came into the dispensary one day, carrying his three-year-old daughter in his arms, her lips blue, head thrown back, gasping for each breath.  I quickly took a swab of the grayish-white membrane that was coating her throat and tonsils, smeared it on a glass slide, and stained it with methylene blue. As I looked at it under the microscope, all the doubts of an inexperienced young doctor swept over me.  Are those really diphtheria bacilli I see, or something less dangerous?  Can I get by with a steam tent, or must I open her windpipe to bypass the rapidly closing throat?  The only other time I tried that, the child had died anyway.  Whatever I decided, there would be no time for a second chance.

        After a moment, and with her parent's consent, I carried her to the operating room.  General anesthesia is too dangerous in these circumstances (we had only an ether mask in those days.)  Injection of local anesthetic must be enough, plus a towel over her eyes so she won't have to watch.  Left thumb and middle finger push the neck veins to each side; her lips turn a little bluer with the pressure.  I pray silently as I cut, "God, at least keep me from doing her harm."  Left forefinger finds the trachea; one more cut and air hisses sharply in and out of the opening in her neck.  A metal trachea tube is inserted into her windpipe, and her gasping changes to a spasmodic cough.  I lift the tube slightly and for the first time her breathing is quiet and regular.  I tie the tube's tapes around her neck so she can't pull out the tube.

        An hour later she is sitting up in her crib trying to tell her father about the steam kettle by the bed, but no sound comes from her mouth, only the sighing of air through the tube in her neck.  It took a week of medical treatment and wound care before the tube could be removed and she could howl at the doctor properly, but she went home cured.

        Pertussis, the "P" in DPT vaccine, is an illness that lasts six weeks or more, with forceful coughing followed by a massive effort to breathe in through the narrowed airway.   The sound of this intake gives the disease its name, "whooping cough."  You'd think no one would die from coughing, but a month of this can be extremely exhausting, not to mention the pneumonia, ear infections, convulsions and other complications that sometimes follow.  Ordinary cough remedies have little effect.

        The seven-year-old daughter of the hospital laundress had been a patient for many days with various complications of whooping cough, and she finally died.  It's a social error in Kengtung to not accept an invitation to a funeral.  It got depressing, knowing as many dead people as I did in those days of epidemics, and I tried to gracefully decline whenever I could (hospital emergencies, for example) but in this case the family were personal friends.

        Among the Shan people in Burma, you don't bring food to the bereaved family.  Instead, they feed the guests a full meal, offsetting the cost by the offerings of money the guests bring.  The noise of fifty or sixty neighbors eating and visiting is mingled with the wailing of several female relatives.  Each family has one or two women who cultivate the art of wailing as a social grace, and they greet each arriving group of guests this way.  Artificial, perhaps, but no more so than the facial expression a western funeral director might wear.

        What struck me as most unusual at that child's funeral was the graveside ceremony.  Her teacher and schoolmates recited a few lines absolving her spirit from all further responsibility at school and telling it not to come back.  (Belief in haunting spirits is not confined to non-Christians in Burma, I might add.  A university-level divinity school graduate told me he used to be afraid to go near the hospital at night because of all the spirits there.  He was now no longer afraid, he said, because even though he believes the spirits are still there, God is with him, and is more powerful.)

        We still see diphtheria, tetanus, and pertussis even here in America nowadays, among children or adults who were never immunized, and even some elderly adults who were immunized many years ago.   Some American parents refuse to get their children the routine childhood immunizations, citing the very few each year who develop meningitis or other adverse reactions to the vaccine.  Aside from the danger of decreasing the overall immunity of the public, I offer my personal opinion: the one-in-a-million chance of death or disability from vaccine is not nearly so bad as watching your child die from a disease you could have prevented.  That's why kids get their shots.

Keith Dahlberg, M.D.