She is a “designer breed”, a purposely mixed mating between a teacup Maltese and a Pomeranian. My stepdaughter acquired a Yorki-poo at the same time and they often play together. How wonderful to have a puppy who is gentle, quiet yet full of spirit, and hypoallergenic! She is in my office most days and many of you know her personally.

She was born three days after my latest grandchild, my seventh, but unlike them she isn’t hours away by car or plane but here in my life, my space, my heart. I’ve had to re-learn what new parents all experience: the unconditional love and hard work, the reading of subtle sounds and body language, the moments of pure joy and the anxiety of vaccinations, injuries (one trip to the emergency room already), the challenge of toilet-training, vet’s bills, and above all the responsibility of caring for a little package of life so totally dependent on you. A friend said recently after meeting her that a dog is the only animal that prefers the company of another species to its own.

Parents often ask about dogs and children. Generally it’s best to wait until all the kids are 6 or more. That’s because younger children may abuse the dog, won’t help care for it, and you have enough to do already! However, these days people often have pets before kids and that’s manageable too. Cats are more of a problem because they cause more allergies and infections and tend to get jealous of babies whereas dogs usually are protective. It is true that a dog’s mouth is cleaner than a human’s; I’m glad because Gucci would have licked me to death by now.

George Will published a great column yesterday called “The Last Doughboy” in which he paid tribute to our last surviving WWI soldier, who is a spry 107 and not only served in France with over 4 million other Americans but spent most of WWII in a Japanese prison camp, having been a civilian contractor in Manila on December 7, 1941.

Our nation is at war but I wonder where we’d be without the thousands of young folks who volunteer to keep us free and safe. Our schools do such a poor job of teaching history, and the Blame-America-First crowd dominates our media and academia so thoroughly that patriotism has been on the defensive since the 60’s. In 2004 presidential candidate Jean-François Kerry famously warned that our kids better do well in school or they’d “wind up in Iraq”, thus insinuating that the military is for dummies. Au contraire the ranks of our military are better-educated than their peers who stay out of the service. General David Petraeus, the counterinsurgency expert now running our liberation efforts in Iraq and Afghanistan, has a masters and PhD from Princeton, for example, and could be making millions as a CEO.

Growing up during WWII, I saw a nation united. People did without; staples were rationed, everyone had a “victory garden” to grow vegetables, there were no new cars. People in coastal cities patrolled for submarines and aircraft (I still have my Aircraft-Spotters Handbook). Gold stars hung in so many windows, denoting lost sons. More Marines died in one day on Iwo Jima and Tarawa than all military deaths in over five years in Iraq.

America is great because America is good. We have conquered fascism and communism but have helped rebuild their breeding grounds into vibrant and free societies instead of seizing their lands. We have conquered slavery at home and built the most successful multicultural society ever known. The rows on rows of crosses and stars in military cemeteries across the world speak to the sacrifices that we honor today. I’ve been to Normandy, to Pointe du Hoc where the shattered guns and barbed wire remain, but it’s the sea of white row on row that I remember.

As I write this I’m wearing a T-shirt that says “Freedom Is Not Free.” Indeed.

Sibling Unit #1 tends to be the most successful, most pleasing to adults, most neurotic, and most cautious. I am an oldest child. If I ever get around to writing my long-planned book its title will be “Children Are Like Pancakes - You Should Be Able to Throw the First One Away.” New parents get their on-the-job training with Numero Uno, hovering over him or her, taking pictures all day and boring their friends with minute-by-minute play-by-play of every hiccup and poop. The first child’s universe is dominated by insecure, overprotective parents whose efforts at discipline are often inconsistent if not downright silly. When I’m on call at night I can usually guess within the first 30 seconds if the parent on the phone is new or not.

Sibling Unit #2’s very existence may be determined by #1. The first child who turns his or her parents into a puddle of tears may wind up an only child, a subspecies of human not always thought of as admirable. But for sake of this exposition let’s assume there is a second. Typically this bundle of joy will arrive when #1 is about two-and-a-half, the worst possible interval in terms of sibling rivalry. Just when Mom and Dad figure they’ve got this parent job down they learn that #2 is from another planet. This child’s universe is much different, being less controlled by parents but more by this irksome larger humanoid who has all the toys, all the privileges, and way too much attention and therefore must be challenged. Sibling Unit #2 tends to be independent, fearless, impulsive and rather indifferent to grownups. #1’s weapon of choice is passive-aggressiveness; #2 is far less subtle. Everything is “Mine!”. This child will spend much more time in the Emergency Room and much less posing for pictures.

Sibling Unit #3 is less often seen these days, what with $40,000 tuition bills (and that’s just for private kindergarten) and older parents, but the old saw tends to be true; #3 is a charm, and why not? This child’s universe is full of excitement and love from a family that’s survived the learning curve. On the other hand, #3 has turned #2’s world upside down, creating the dreaded middle child and sometimes causing regression to infantile behavior. It does have its advantages though, and they do get over it. Parents need to be aware that each child’s growing-up experience has its ups and downs, and giving up the treasured baby position in the family can be a major trauma.

After #3 subsequent children tend to be like #3 although each is unique. My S.U. #4 is probably my sweetest and least complicated even though he was just 13 when his parents divorced and by all odds should have become a drug-addicted criminal. Now he’s a father of two and a great one. I’ve cared for two families of ten each, plus a few fives and sixes, and it seems such children are exceptionally well-behaved and responsible. Perhaps you’ve seen the Duggers on cable TV with their 17 or 18 kids and marveled as I have at how happy and youthful they all are, including Mom and Dad.

Children often get a bad rap in our modern world. In earlier agricultural societies they were an economic asset, and a vulnerable one. People had many children because some died. Now we’ve come all the way to becoming the first culture in human history to have an entire class of young people whose major economic impact is to spend money buying gadgets and hanging out at the mall, or to spend years soaking up higher education (and lots of alcohol) at universities which are charging a lot and teaching less of relevance.

From the time of Malthus in the 18th century, experts have warned that the world’s population is too large. As recently as the 1970’s Ehrlich predicted that we’d run out of food and natural resources by the 80’s. He continues to ply his message of fear and doom despite the progress being made in agriculture and medicine. In truth the USA is one of the few developed countries having enough children. The “sustainability factor” is 2.1 children per woman, which is just where we are in our country. Other modern nations are far below that; even largely Catholic Italy’s rate is 1.1 and as people live longer there will be too few young people to work and sustain programs like social security. In China, years of forced abortions have created labor shortages in parts of that enormous country, and there are far more young men than women, a sure formula for more crime and social unrest.

So let’s hear it for our children, our future. And Steve, I was just kidding about the pancake thing.

Today’s doctors are a much different breed. Solo practitioners like me are becoming rare. It used to be said that organizing physicians was like herding cats, but that old-fashioned pioneer spirit is giving way as group practice becomes the norm. I say that without passing judgment. It is what it is. The new doctors are about 50% women, often working part-time in corporate settings and retiring in their prime. Priorities have changed.

When I began blogging I promised my wife I’d avoid politics, but in this year of presidential campaigning it’s chasing me. The profession is under attack from all sides and no one speaks for us. There is a “crisis”, a word politicians use as a pretext to empty your pockets.

In 1976 during the strike, and again in 1993 when Hillary Clinton’s secret task force was scheming to take over health care which represents 14% of our economy, I sent letters (how old-fashioned is that?) to my patients, and some of the phrases I used still ring true. Under a government-run system, your doctor will no longer be anyone special to you, and vice versa. You can expect the compassion of the Internal Revenue Service, the efficiency of the Post Office, and the interpersonal skills of the DMV.

Fifteen percent of our citizens are uninsured. That is not a crisis, it is a personal choice made mostly by healthy young people who have decided is not worth buying insurance at its current cost. Government cannot fix that any more than they did car insurance by making it mandatory. In fact it is because of government’s heavy hand in controlling so much of the system through its Medi-Care and Medic-Aid plans that costs are spiraling upward. We also are a free country, not likely to allow bureaucrats to tell us what care we may get. Our medical care is the envy of the world; thousands of foreigners come here for care. On the other hand it is the burden of caring for millions of illegals that threatens to overwhelm hospitals and emergency facilities.

Under the 1993 plan, it would have been illegal for patients to pay doctors for services they felt they needed; both would be subject to fines or prison. (Even Soviet Russia allowed some private practice of sorts). In England and other countries with socialized medicine, waiting lists are very long (40% of Canadians awaiting coronary by-pass die before their number comes up). Kidney dialysis is not allowed over 65. It takes months to get CT scans or MRIs.

These facts seem shocking to people of my generation, but I don’t sense much concern on the part of my younger colleagues. Insurance companies do such a terrible job of acting as intermediaries that most providers reflexively wish for government to take over because it would be “simple”.

There are constructive options available but time is not on our side. Making the system job-dependent was a ploy that made sense 70 years ago; health benefits were deductible to the employer and not taxable as income, and the labor unions went for that in a big way. In this global economy American companies are suffering competitively because of the weight of insurance and pension benefits. Employees also give up much freedom to change jobs or to choose other coverage.

Clearly we need a national market like that of car insurance, with customers calling the shots. Health savings accounts are a step in that direction. There must be national tort reform like that passed in California long ago. (Good luck getting the lawyers in Congress to let that get by them). I do not believe that electronic medical records or national guidelines help at all, and they are a real threat to your privacy.

Please remember when you hear the politicians demagoguing the issues that doctors don’t grow on trees, that they come out of training deeply in debt and often over 30, that they have skills few people possess and your lives may be in their hands. They deserve better than to be afterthoughts of political campaigns, to be swept up with the banners and placards.

Don’t forget to vote.

Some people would say he has no business being here. For one thing he came through two life-threatening heart surgeries very early in life. And then there’s that “extra” thing, a 47th chromosome that marks him as a Down’s Syndrome child with a distinctive appearance which makes children so afflicted look more like each other than like their siblings.

You don’t see as many people with Down’s nowadays because about 80% of them are aborted. They were often institutionalized in the old days and were expected to be weak and retarded. When chromosome analysis became available routinely, the rush was on to eliminate as many defective babies as possible; ergo amniocentesis, especially for pregnant women over 35.

In my early life there were 48 chromosomes and 48 states. I think it was an American assumption. But about the time Alaska and Hawaii made it fifty, the human cell was found to contain 46 chromosomes, which in biology is a rather peculiar number. There are the two sex chromosomes, X and Y, and 22 pairs of others - usually. Down’s Syndrome has an extra #21. Turner’s Syndrome occurs in females with one X only. There are other “trisomies” involving 17/18 and 13/15, generally recognizable at birth and incompatible with life (the only one I cared for actually lived over a year).

Ricky’s mother was 41 and her obstetrician insisted on an “amnio” but with the moral certitude of a woman unburdened by an Ivy League education she said no. She would play the cards she was dealt. As her pediatrician I had qualms because I knew the medical problems he’d likely face, starting with his most serious cardiac defect. But there was no moral hesitancy on my part any more than on the part of his parents.

This weekend I read an article on bioethics that reminded me of others I had read years ago, regarding Nazi Germany before World War II. For about 12 years in the 70’s and 80’s I edited and produced a newsletter for the medical staff of my hospital. My editorials were as provocative as I could make them. The doctors older than I usually loved them and the younger doctors called me all sorts of names, but they read them. My last one was about a psychiatrist from Boston who had been a Holocaust survivor and had described how the German medical community of the 1920’s often did Hitler’s work for him by justifying the isolation and extermination of individuals whose lives were “unworthy of life”, from deformed babies to homosexuals, elderly and insane, and later Jews, gypsies, communists, and anyone judged expendable. It was the awful “slippery slope” fueled by scientific zeal to purify the race. (Did you know that Margaret Sanger, founder of Planned Parenthood, was an ardent admirer of Hitler and his eugenics program?) That editorial was too much for the CEO of our hospital; he fired me because my editorial was “way too controversial”, even though I took most of it (with due credit) from the New England Journal of Medicine!

Ricky is a delight to his family, to me and my staff, to all the many medical people he has come across. He has a right to his life. I don’t know if he’ll be able to attend regular public school or be self-sufficient when he grows up, but I don’t know that about my other toddler patients with 46 chromosomes either! I am sure he’ll be a gentle soul whose family and community will be better off with him. We’ve also learned how heartless institutional care can destroy the emotional, physical and intellectual development of children born normal but deprived of love, as in Victorian English foundling homes or more recently in Romania and China.

Doctors have significant power over peoples’ lives, even in this age of the internet and “patients rights”. I’ve sat on Bioethics committees and heard an appalling lack of any moral compass from not only physicians but lawyers, social workers and executives and even clergy who confuse themselves with Him Who created us all equal and in His Own image.

Seven years ago President Bush was under fierce pressure to give a green light to federally funded embryonic stem cell research. Inevitably this would involve creating new human embryos for research (i.e. destruction). With the extensive involvement of his Bioethics Task Force chaired by Dr. Leon Kass of my alma mater, the University of Chicago, and Dr. Robert George of Princeton, he stood his ground, permitting only already existing lines to be used. Almost $2 billion in private funds later, embryonic stem-cell research looks more and more like a blind alley, whereas stem cells from much less controversial sources turn out to be far more promising. Even the New York Times begrudgingly admits that that was Mr. Bush’s finest hour.

A recent CDC bulletin shows the good news and the bad about this ancient scourge. An athletic competition in Pennsylvania drew 265,000 participants and spectators from eight foreign countries and all parts of the USA. A 12-year-old Japanese boy was incubating measles when he arrived in PA after several changes of planes. His team and the Taiwanese shared transportation.

The good news: only six more cases of measles could be documented after intense search by a team of epidemiologists. The attack rate for measles in a non-immune population would be over 90%. The bad news? It’s still around, and the victims were very sick. A 40-year-old sales rep developed a 105.7 F fever and seizures after contact with the index case, by which time he was home in Texas. A 53-year-old woman from Michigan got typical measles, which she had not had as a child, after sitting near the index case while flying into Detroit. (People born before 1957 are assumed to be immune). All recovered.

I took my new puppy Gucci to the vet yesterday (many of you have met her as she spends most days in the office) and we discussed vaccination. Distemper in dogs is caused by the same virus as human measles, and many younger vets think it’s no longer a threat because they’ve never seen it. Last year he saw an outbreak of 29 cases, all devastating.

Smallpox is gone except in laboratories, polio is almost gone, but measles and the other childhood diseases are lurking, and only continued efforts to vaccinate all children will save us from more surprises. In this age of international travel, that must include kids from all over the world. Despite a few loose cannons on the Internet, we are making progress.

Medical graduates must serve at least a year of training before being eligible to practice medicine. The internship no longer exists as such, perhaps because the memo about the Emancipation Proclamation finally got to the powers that be. As was typical of the time, I worked 90-plus-hour weeks for $100 a month. It had been $59 the year before but some interns’ wives marched to City Hall with a contingent of reporters and applied for welfare, embarrassing the mayor and his cronies enough to get us a 70% raise.

There were 90 of us from all over the country. It was an old-fashioned tour called a “rotating” internship, with thirteen 4-week assignments ruled over by faculty from Philadelphia’s five medical schools. Penn, right across the fence, was the best, and I lucked out in getting several of their best teachers.

Our only outlets were the baseball field and poker. Philly had its snowiest winter on record with three 18-inch blizzards, but during the warm months we had a league with several teams. The doctors had two and were usually no match for the orderlies, techs, kitchen crew, security, etc. but our guys were good. I had the honor of hitting the year’s most talked-about home run which broke a window on the fifth floor of the student nurses’ dorm (for the single guys the 500 future RN’s from the hills of Pennsylvania and West Virginia did constitute a third outlet, but I wouldn’t know about that).

Across the street was the Palestra, a popular venue for sports. To our dismay we discovered after a rainy spring night that a number of cars belonging to people attending a boxing match had parked illegally on our baseball field, leaving nasty ruts. Most were big black Cadillacs with New Jersey plates. The administration would not respond to our pleas, so next time our field was misused certain interns went out and flattened one tire on each car. There was a lot of cursing in Italian at about 11 PM, but the field was left alone for a few weeks. Next time they tried, each car got TWO flat tires. Now there is a major difference between having one flat and two. The last car didn’t leave the lot until almost dawn. But the field was ruined and our season ended early.

Our class showed its mettle early. We had been warned by the outgoing group that the administration was going to put a divider along the tray line in the cafeteria so that everyone had to pass through single-file. Our meals were free and time was precious so we’d grab our grub and head straight for a table. Soon after we started an ugly plastic barrier went up, preventing us from breaking out of line. It lasted a day. A furious administrator called an emergency meeting of our 90 rebels and demanded a confession, whereupon all 90 raised a hand and admitted fault.

The next week an even uglier partition was erected, this time anchored by a very sturdy pole through the floor and ceiling. One of the locals in our group had an uncle with a machine shop; this time the removal was challenging but by 2 a.m. the monstrosity was in pieces on the floor. The head honcho called a truce and we promised not to destroy any more city property.

The poker games were great fun and intense. About eight or nine of us were regulars, and what made the risk manageable was the presence of two Irani doctors on fellowship who seemed to have a limitless supply of the Shah’s money and no idea how to play good poker. Every time they’d fill an inside straight we’d tell them how brilliantly they played, assuring enough money at the end of the night for the rest of us paupers. Our best player was a 6′7″ rube from Louisiana named Travis Jeter Harrison. He’d win forty dollars or more every game. It was odd that in our last game he was nowhere to be found - that is until he strolled in wearing an outrageous green plaid suit and said, “Ah wanna thank you boys fo’ bahin’ me this-heah suit!”

One night the game was disrupted by a yell from the first floor - “Chicky the cops!!” By the time the fuzz had run up three flights, seven of us were sitting in chairs in the lounge reading sections of last Sunday’s NY Times. Cards and dollars were nowhere to be seen.

Twelve months of tension came to a head the last night. Someone started a bonfire on our baseball diamond and soon hundreds of medical text books were ablaze. The fire was at least three stories high and attracted the Philly PD and FD. As the fire was extinguished by hoses, turning the former ball field into a smoking swamp, a police officer mounted the bleachers with a bullhorn to give us a lecture on civics. At that moment the wildest intern in our group, a full-blooded Cherokee from Oklahoma, came storming out of the kitchen on a hand-pumped cart, whooping as if on horseback, beer bottle in his free hand, picked up speed down the ramp and crashed into the bleachers, sending the sergeant face-first into the mud. We felt lucky to finish the year without criminal records.

A year later while serving my stint in the Public Health Service, I picked up a local California paper and read that a “crazed mob” of young doctors had run amok in the streets of Philadelphia, turning over a trolley car. Now why didn’t we think of that?

The old hospital is no more, a victim of progress. For two hundred years the Blockley Medical Society, as the training staff was called, turned out future physicians who went out into the world knowing how it felt to deliver a baby in an unheated, rat-infested tenement, how to tend to dying patients with no family to care, how to save premature babies in a low-tech world (my son Danny among them). I believe medicine is not well-served by having young doctors go straight from school to specialty training, but I’m glad I had the opportunity. Last time I visited in 1976 the old place had lost its accreditation and was eerie in its silence, like an empty cathedral. And fittingly, the former baseball field was now a parking structure.

CDC in Atlanta, originally created to combat malaria, had by the early 50’s become the world’s top communicable disease command post. In order to put trained investigators at the scene of outbreaks and research facilities they came up with an elite group called the Epidemic Intelligence Service (EIS) which took about two dozen physicians, veterinarians and statisticians yearly, trained them and assigned them either to Atlanta or around the nation. EIS officers spearheaded the conquest of smallpox and polio, and its alums make up a major share of heads of health departments and professorships in the spheres of infectious and chronic diseases around and beyond our nation.

Doctors were subject to the draft when I graduated and finished the required internship in 1961. Were my number to come up then with no specialty training, I’d likely be assigned to a dispensary in Greenland. With a wife and two kids, that sounded grim. When one of my favorite teachers recruited me for the EIS, enabling me to satisfy my military obligation, I jumped at the chance.

The science of epidemiology (the study of epidemics) began about 1840 with Dr. John Snow of London and the Broad Street pump. A cholera epidemic was ravaging the city. Dr. Snow spotted cases on a street map and showed that the closer one lived to the infamous water pump, the more likely one was to get cholera. It must have been like a police station tracking a serial murderer.

Learning this exciting discipline from Dr. Alexander Langmuir and his staff was like learning astronomy from Galileo. “Alex” had come from Johns Hopkins to set up the program and treated us like princes. After training for a summer in pre-airconditioned Atlanta, we were encouraged to choose our assignments in a surprisingly open way. The requests for EIS officers far outnumbered us, so Alex took the five of us who were left unmatched because we lacked the years of residency and field experience that others had, and made sure we were all happy with our destinations. I had always wanted to live in California and could barely contain my glee when he suggested I take Berkeley and the California State Health Department (since moved to Sacramento).

My primary responsibilities were tracking influenza, hepatitis and other major diseases and reporting back to CDC. I had a lot of latitude to pursue whatever medical problems popped up around the state, and managed to get into all but three of its 58 counties. When I needed some R&R with the family I’d often find some potential calamity threatening the good people of San Diego or Santa Barbara. I also saw trachoma in the Coachella Valley and took part in the annual health fair for Alpine County, America’s least populated (800), in its county seat of Markleeville (pop. 300). Getting snowed in just added to the adventure of it all.

My biggest project in my two years was a hepatitis epidemic in the little town of Los Banos which occupied the better part of six weeks in my first summer. They speak of “shoe-leather epidemiology” and indeed my associate and I met most of the 7800 people living there. I eventually published a description of the peculiar outbreak in our state medical journal.

A 12-year-old nephew of a local rancher deplaned at SFO from Italy with a sickly yellow complexion. The town had no hospital but one of the four local doctors had a “clinic” with a few beds. The youngster was treated there but for some reason his sickness was not considered contagious. Infectious hepatitis (The A/B/C system was yet to be defined) has a long incubation period but eventually 19 of 21 clinic employees caught it. By strange coincidence some snake-oil salesman passed through town hawking a miracle cure for liver ailments. Since the four doctors were overwhelmed (and undertrained) the word went forth: leave a urine specimen by the back door and if it shows hepatitis we’ll call you in and give you shots for it. Blood tests weren’t done and of course there is no treatment, but we were able to determine through interviews that about 500 cases occurred.

A side issue is worth mentioning. During the six weeks of tooling about in the motor pool Studebaker Lark without air conditioning (choice 1: close windows and suffocate in the 105-degree heat or 2: open windows and inhale the pungent dust of the San Joaquin Valley) I expressed concern about catching Valley Fever (coccidioidomycosis), a fungal disease of the lungs, but I was reassured by my colleagues. That summer the state hired Dr. Bill Reynolds to come down from Seattle and organize medical surveillance of the migrant worker program. Bill contracted Valley Fever and spent almost a year in the hospital!

While assigned as I was to the state, I was a federal officer and CDC made sure its young pups got a taste of real-world epidemiology. My Mission Improbable was to fly to Ketchikan, Alaska (by Constellation and Grumman Goose) to investigate a diphtheria outbreak. The locals greeted me with a banner headline (”Top Epidemiologist Arrives From Alabama”) - not quite geographically accurate - and I got to give a speech at the Lincoln’s Birthday Toastmasters meeting. I spent five days touring the village’s 35 bars doing nasal swabs. The patrons knew of the outbreak and were more than helpful; no one objected to a poke in the nose but first I had to hear their life story!

I found one diphtheria carrier, and left in triumph. On my EIS diploma is a cartoon of a well-dressed fellow who looks a lot like Dr. Langmuir sliding downhill on the right side of a graph, the message being to arrive after the peak of the outbreak so as to add to one’s air of wisdom. I revisited Ketchikan to refuel in later years, and by then there was a real airport and a more prosperous town. That first arrival in the Goose in 1962 was memorable. No one announced that it was an amphibian because it seemed obvious, except to the poor older lady opposite me who screamed and about fainted when the plane splashed down in the bay.

Why do we cough? To clear our airway of bothersome stuff: pollen, bacteria, viruses, toxins and the cellular reaction to them, collectively known as mucus. If not for the cough reflex our lungs would be like vacuum-cleaner bags.

When do we cough? The timing can indicate the cause. Exercising, especially in dry windy weather triggers an asthmatic cough in many people. Breathing via the nose helps humidify and warm the air, but I can attest to how difficult it is to do that while running. Night coughs may signify the common “post-nasal drip” one gets with colds and allergies.

The lining of our respiratory tract consists of microscopic cells with cilia, tiny hair-like structures that sweep invaders away from the lungs; these in turn are interspersed with cells containing goblets of mucus. Some infections such as influenza can destroy this delicate lining, which is why it takes three weeks to recover while the new lining grows. Smokers lose this defensive layer and it is replaced by squamous epithelial cells similar to skin cells, not only ineffective but prone to cancer.

Cough is different in babies for many reasons. They spend a great deal of time on their back, their muscles are relatively weak and their immune systems are rather slow to respond especially if not breast-fed. Respiratory viruses tend to be nastier the first time a baby encounters them, whereas the same virus appearing in later years will cause a simple cold. Children’s coughs are so ineffective that cases of tuberculosis under age 10 are not considered contagious (although no one seems to haver told this to the folks who make 3-year-olds get TB tests before attending pre-school).

Treatment of cough has changed dramatically in recent months with the withdrawal of all over-the-counter cough and cold preparations for kids under 2 (perhaps soon to be followed by further restrictions). The evidence for efficacy in babies was never established, and the dizzying array of new multi-symptom preparations was leading to overdoses. So now what? It’s back to your great-grandma’s remedies: moisture, positioning, suctioning, herbal tea, chicken soup, and good old honey (except under one!!) People ask about Vicks Vaporub and I have no idea if the stuff works or is safe, so you’re on your own! Much of the help we get from cough medicines is the topical anesthetic action on the throat, which is why cough drops have enjoyed a new life. Cough syrups taste awful because they contain things like chloroform and phenol; if you wash them down with water right away they don’t do much good. The most common ingredient in cough preparations is “DM”, a synthetic codeine imitator which has never impressed much in controlled studies. There are prescription medicines for cough, mostly with codeine. I feel that they are overused. If I’ve examined the patient and feel the cough is “useless” and lack of sleep is becoming an issue (for the child, not the parents) I’ll give an Rx for nighttime use only, and almost never in an asthmatic.

The patient was a 14-year-old black boy. He had been brought to the Emergency Department by police ambulance. He was admitted because the ED doesn’t like to handle deaths. We had no history. His mother came along soon afterward, and when the cause of death was suggested to her she became outraged. “My boy didn’t do drugs; he was a good boy!” He had stayed home from school with mild symptoms of a viral infection.

The intern on the floor then did something I can never forget. He examined the boy thoroughly. Although no rash could be seen on his mahogany skin, the young doctor retracted an eyelid and on the inside fleshy part he saw what he was looking for - a petechia, a broken capillary, purple and star-shaped. He ordered the stunned nurse to bring him a large syringe and needle, which he plunged into the still heart, drawing a post-mortem blood culture which did indeed yield the dreaded Neisseria meningiditis.

The intern’s diligence did two things. It removed doubt that his death was the result of drugs, giving the family some peace. It also alerted all the personnel who were in contact with the victim to obtain preventive antibiotics, thereby averting further tragedy.

Meningococcal disease is the stuff of medical drama. It is one of the three major causes of spinal meningitis, all of which are now preventable with vaccines. In my one year at County I saw about 350 cases. When the first vaccine arrived in 1985 (against “H. flu”) I had treated about ten cases in my own practice. Thousands of American children died yearly; now a case is so rare that most young doctors have never seen one.

You may have seen the TV ads for Menactra, the newest of the three vaccines and one targeted especially at adolescents. Young people in dormitories or military barracks are at somewhat greater risk, although actual numbers are quite small (about 3 per 100,000) and the victims are often smokers and party-animal types. Whereas the other two types of meningitis are essentially always fatal without treatment, some 40% of meningococcal patients recovered in the pre-antibiotic era, many with severe disfigurement from loss of extremities. At the other extreme are patients like the youngster described above who die so quickly that meningitis has no time to develop.
The only other infections I can think of that kill so quickly are plague in its pneumonic form and Ebola virus. Yet the bacterium is commonly found in healthy people. It is analogous to being struck by lightning.

I’ve seen exactly one case in my practice. My first Labor Day on call in 1967 an alarmed grandmother phoned me. Her daughter had taken her 8-month-old baby girl to an urgent care but was sent home with reassurance. Grandma wasn’t buying it. She called one of the pediatricians she knew (she was an LVN) and I was on call and in the office (our hospital did not have an Emergency Room yet). The baby was there in 20 minutes and had the classic petechial rash of meningococcal disease. Many children develop these little spots after vomiting or coughing, and they also appear on the soft palate in strep throat, but these were not benign little red spots. They were purple and star-shaped, caused by plugs of bacteria and dead cells clogging up small blood vessels. I gave Baby Paula a shot of penicillin and followed her with Grandma to an ED 5 miles away where she was admitted. My spinal tap was diagnostic of bacterial meningitis (she needed no anesthetic, so lethargic was she by that time) and she recovered fully.