Long day’s journey of the Saturday

At the beginning of this Easter weekend, I will leave my readers the thoughts of George Steiner from the concluding chapter of his book, Real Presences:

“There is one particular day in Western history about which neither historical record nor myth nor Scripture make report. It is a Saturday. And it has become the longest of days. We know of the Good Friday which Christianity holds to have been that of the Cross. But the non-Christian, the atheist, knows of it as well. This is to say that he knows of the injustice, of the interminable suffering, of the waste, of the brute enigma of ending, which so largely make up not only the historical dimension of the human condition, but the everyday fabric of our personal lives. We know, ineluctably, of the pain, of the failure of love, of the solitude which are our history and private fate. We know also about Sunday. To the Christian, the day signifies an intimation, both assured and precarious, both evident and beyond comprehension, of resurrection, of a justice and a love that have conquered death. If we are non-Christians or non-believers, we know of that Sunday in precisely analogous terms. We conceive of it as the day of liberation from inhumanity and servitude. We look to resolutions, be they therapeutic or political, be they social or messianic. The lineaments of that Sunday carry the name of hope (there is no word less deconstructible).

“But ours is the long day’s journey of the Saturday. Between suffering, aloneness, unutterable waste on the one hand and the dream of liberation, of rebirth on the other. In the face of the torture of a child, of the death of love which is Friday, even the greatest art and poetry are almost helpless. In the Utopia of the Sunday, the aesthetic will, presumably, no longer have logic or necessity. The apprehensions and figurations in the play of metaphysical imagining, in the poem and the music, which tell of pain and of hope, of the flesh which is said to taste of ash and of the spirit which is said to have the savour of fire, are always Sabbatarian. They have risen out of an immensity of waiting which is that of man. Without them, how could we be patient?”

In the wee small hours

My daughter telephoned me at work to let me know that the elderly woman she had been caring for had died in the night.

She was staying with the woman and her husband in their home. The woman had liver cancer; the man suffers from dementia. My daughter cooked them breakfast, helped them bathe and dress, drove them to medical appointments, made sure they got their medications on time, kept the larder stocked.

She heard the woman moan in the night, turned her over on her side, heard the rattle in her throat. She called the hospice nurse first thing in the morning. The nurse came to the house, pronounced the patient, and signed the death certificate. Then she and my daughter bathed and dressed the body.

I could hear the exhaustion in my daughter’s voice as she related these incidents over the phone. I was certain that she had learned quite a lot while taking care of this couple, much more than she would have learned sitting in class at nursing school.

These thoughts ran through my head as I sat listening to an old Frank Sinatra LP recording after dinner. The album belongs to our next door nonagenarian neighbor; the old turntable was a gift from the elderly woman who died.

I sipped my coffee as Sinatra belted out the words to “All the Way” and softly crooned “In the wee small hours of the morning.”

In the wee small hours of the morning
While the whole wide world is fast asleep
You lie awake and think about the girl
And never ever think of counting sheep.

When your lonely heart has learned its lesson
You’d be hers if only she would call
In the wee small hours of the morning
That’s the time you miss her most of all.

Literary critic George Steiner opines that “Death is closely related to what I call real music: a certain sense of the end of time and of personal life.”

“When somebody asks how one can have an intense meaning which one doesn’t understand, music is the one place to turn for an answer.”

Right now those words seem to make infinite sense.

A tapestry of song

My life has been a tapestry of rich and royal hue
An everlasting vision of the ever-changing view
A wondrous woven magic in bits of blue and gold
A tapestry to feel and see, impossible to hold.

—Carole King, Tapestry

When we arrived home from the Tapestry Singers annual Valentine’s Day cabaret concert, I counted up the musical numbers listed in the program. There were exactly twenty — a full musical score.

The songs ranged from Broadway hits to country ballads, patriotic medleys to spiritual worship songs. For two hours we were treated to poignant arrangements of pieces like Leonard Cohen’s “Hallelujah” and Enya’s “Only Time,” Jerry Herman’s “Ribbons Down My Back” and Irving Berlin’s “Anything You Can Do, I Can Do Better,” Mark Hayes’ “Consecration” and Marie Barnett’s “Breathe.” For the grand finale there was a special rendition of “Over the Rainbow.”

This annual event was the brainchild of Jana Pivácek-Cole, a talented vocalist and voice teacher, who succumbed to cancer at the close of last year. Since 1998, Jana’s Tapestry Singers, composed of former voice students of all ages,  has offered public performances to raise financial support for the Kateri Medical Clinic in the Kaduna province of northern Nigeria.

Without the benefit of Kateri Medical Clinic, thousands of Nigerians who reside in the region would have no access to medical care. Last year over 14,000 people received care at Kateri for the amazingly low cost of $5 per encounter.

As I sat through this moving musical repertoire, I reflected on our medical mission to Nigeria last summer. We saw nearly 6,000 patients in a 2-week stretch. Many more were unable to access care during our stay; although the needs were great, the workers were relatively few.

When my eyes began to water, I wasn’t entirely certain why. It might have been the poignant pieces of music I heard — or perhaps the memories of those Nigerian patients I had seen. Both sets of voices were certainly present, and together they sounded sweet and low in my ear.

In a Paris Review interview literary critic George Steiner opined:

The next Copernicus may have something to tell us about what music does inside us and how it is created. Above all, music illustrates for me that order of meaning that you can’t translate, can’t paraphrase, can’t put in any other terms, and yet which is intensely meaningful.

Some say that music can heal the heart; I know it can heal the soul. Perhaps it is even capable of moving beyond the borders of space and time to touch the lives of others in need, continents away.

Night and day with three musicians

"Three Musicians" by Pablo Picasso

“Expression was the need of their souls.” —E.B. White, Introduction, Onward and Upward in the Garden

No sooner had we arrived at the cottage secluded by the lake; no sooner had we unpacked the van, trucking in the duffle and the newly purchased provisions; no sooner had I slid open the screen door to step out onto the deck to peer down at the lake through the towering pines, than the musicians cracked open the latches on the cases of their guitars, tuned their instruments and began to play.

For an hour or more they strummed and sang. We put the kabobs and corn on the grill, and still they played. When the food was ready, we ate; and afterwards they picked up their instruments and played some more.

They played into the early evening and then into the twilight. A brother-in-law appeared, bearing a cache of blues harps and a drum and cymbals with sticks and brushes.

They began to jam, playing off one another’s riffs, improvising a tune, until some song burst into being. Three guitars, one bass, harp and drums: a litany of songs sung through the evening hours late into the night, notes strung together without pause, one rendition rolling into the next, and the next, and the next. Sonora’s Death Row, Sound as a Pound, Heart of Gold, The Night They Drove Old Dixie Down.

Like the band that played on while Casey waltzed with the strawberry blonde, they moved from one number to the next, without pause, without missing a beat.

Sometime after midnight the brother-in-law left, leaving the drum and cymbals behind. We bedded down beside a warm fire in the woodstove, drifting off into our own individual nocturnal reveries.

Hours later I awoke, threw back the blanket and made coffee. The musicians sat up, rubbed their eyes, retuned their instruments and jammed for another hour before breakfast. That’s how musicians talk, making morning conversation over coffee and finger-plucked guitar chords.

Base clefts in the rock, R & B, fish scales and folk, cowboy country ballads and bar songs, a few noteworthy bars; Joycean tunes, I say again, rejoice; play it again, Sam; you must remember this, a kiss is still a kiss, remember who wrote this? Improvise, resize, economize; Tommie and the Who, doo-whap, doo, jug band blues; crazy momma, crazy MoMA, art beat, the beat; beat-beat-beat-beat, brush and beat; freight train, freight train, going so fast, I don’t care what train I’m on, just as long as I’m moving, moving along.

Three Musicians on the Rocks, Big Clear Lake

The Grace of Gratitude

In her book The Gift of Thanks:  The Roots and Rituals of Gratitude, Margaret Visser examines what gratitude is and how it functions in our lives.  “Gratitude is always a matter of paying attention,” Ms. Visser observes, “deliberately beholding and appreciating the other.”

Humility is a prerequisite to being genuinely grateful.  If we are to become humble, we must learn to esteem others more highly than ourselves.

One afternoon this past week three patients appeared on my schedule for physical examinations.  The first was a 10-year-old boy.  His father suffers from paragangliomatosis, a genetic condition in which tumors arise from neuroendocrine tissue in the body.  The father has already had several tumors surgically resected and has undergone extensive treatment with chemotherapy.

This boy—Norman is his name—and his two brothers underwent screening for the defective gene; Norman tested positive.  This past summer markers suggesting a developing tumor appeared in his urine and blood.  A scan demonstrated a pheochromocytoma in one of his adrenal glands.  The tumor was resected successfully.  His oncologist continues to watch him closely with periodic tests every three months.

Norman is a happy boy.  He’s put on some weight this fall.  His mother tells me that she didn’t sign him up for soccer this year.  “We’ve had too much going on at home.  My husband had a relapse and had to go on more medicine.  I’ve been sick with a cough for four weeks—they just can’t seem to find out what the problem is.  I’ve been through three courses of antibiotics, prednisone, other medicines—nothing seems to work.”

“You’ve had a lot on your plate,” I say as I begin to examine Norman.

“Well, what can you do?” she says.  “We just take it as it comes.  No sense worrying about the future—that will take care of itself.”

In the adjacent room a 6-month-old girl greets me with a huge smile.  Her mother holds her up so the baby can bounce on the exam table.  “Somebody seems happy today,” I remark.  “How’s she been doing?”

“Terrific!” her mother says.  “She’s been eating like a champ and putting on weight since you recommended she start cereal.  My breast milk just wasn’t enough to satisfy her.  And she’s doing all sorts of things now:  rolling over, sitting up, holding toys, drooling from a new tooth—she’s a great baby.”

I proceed with the exam, point out the child’s robust percentiles on the growth chart, share some anticipatory guidance and administer the shots.  Afterwards, the girl quickly quiets in her mother’s arms, returning to her happy disposition.

“We should see her back in three months,” I tell the mother.  Then I remember to ask:  “How is your housing situation working out?”

“We finally got the trailer.  It’s a little cramped for me and the four kids, but we manage.  They say our house won’t be rebuilt until next June.”

“Another eight months,” I say.

She shrugs her shoulders.  “I’m not complaining.  We’ve got a roof over our heads and food to eat.  More important than that—we’ve got our lives.  Sometimes I can’t believe that we all escaped from that fire without a scratch.  Every day I’m thankful that my kids are okay.”

At 18 years of age, my next patient is technically an adult.  At least, he is classified as such according to the ICD-9 codes.  Although he’s been coming to our group practice for regular exams over the past four years, this is the first time I’ve seen him.  He’s here with his father.  Wes is a soft-spoken boy with a pleasant disposition; he’s got a light growth of downy hair on his chin.  When I introduce myself and offer my hand in greeting, Wes can barely lift his hand from the arm rest of the wheelchair in which he is confined.

The chart tells me that Wes was diagnosed with Duchenne muscular dystrophy at age 5.  He has gotten progressively worse over the past six years.  He has no strength to speak of in his proximal muscles; he is unable to straighten his legs due to contractures.  He has had spinal fusion surgery, and recently a pacemaker defibrillator was implanted in his chest.  His respiratory status is compromised:  due to extensive muscular atrophy, Wes is unable to use his accessory muscles to take a deep breath.

I ask Wes how he spends his days.  He tells me he likes to listen to music.  “What kind?” I ask him.

“Any kind,” he says, “classical, rock, country—heavy metal.”

His father rolls his eyes.

“What else do you do?”

“I play video games, read books, watch some TV, spend time with my family,” he tells me.

“Any plans for the future?” I ask him.

Wes looks at his father.  His father tells me that right now Wes is residing at home.  “My wife is a stay-at-home mom,” he says.  “Wes has talked about going to college, but right now he’s taking a break from his studies.  He just graduated high school last spring—cum laude.”

I examine Wes as best I can, given the constraints of the wheelchair.  Afterwards I comment that the physical exam is normal—normal apart from the obvious muscle wasting, contractures and inability to move his limbs.  “He’s due for two shots today,” I explain to his father.

“I’m good with that,” Wes says.

I administer the shots, and Wes thanks me for taking care of him.  I take a deep breath and say:  “You know, Wes, I think it is I who should be thanking you.  I’ve learned a lot from you during our time together today.”

Wes regards my face with silent eyes of innocence.

“Wes has taught us a lot—quite a lot—over the years,” his father says.

“I’ll bet he has,” I say.

Wes smiles.  “I’m no one special,” he says.  “I just try to do the best I can with what I’ve got—you know, take it one day at a time.”

That’s the grace of gratitude for you—lived out better than even the best author is capable of putting into words.

Streets of Philadelphia

I walked the avenue till my legs felt like stone
I heard the voices of friends vanished and gone
At night I could hear the blood in my veins
Black and whispering as the rain
On the streets of Philadelphia.

—Bruce Springsteen

This past weekend I did something I hadn’t done in thirty years:  I took the train to Philadelphia.

The occasion for my excursion was an editorial board meeting for a national medical journal.  Such meetings are held twice a year.  Six months ago I flew out to San Diego for the previous one.  This time round I took the train.

Friday morning I boarded a two-car commuter rail just north of Hartford, rode it to New Haven, and connected with the northeast regional to Philadelphia.  In thirty years I had forgotten that trains in the northeast corridor pass through rough stretches of country—past litter strewn ravines, boarded up brick buildings, scrap yards filled with piles of junked cars, graveyards populated by the dead.

Those of us on the train—the living—sit by the windows and watch graffiti covered walls stream by or read the morning paper, listen to an iPod shuffle or text message a friend.  Occasionally we rise to our feet and stagger down the central aisle to the john before picking up a coffee or a bottle of water in the café car and return to our seats.

I arrived at 30th Street station in Philadelphia that afternoon and walked thirteen blocks to the Westin Hotel on 17th Street and checked in.  The remainder of the afternoon I spent exploring the city on foot.  I sauntered down Chestnut Street to Independence Hall, glimpsed the Liberty Bell through the massive window, paused at the memorial in Washington Square and picked up Walnut Street on the return leg.  Near Jefferson Hospital I cut up to Chestnut again and stopped at a medical bookstore to browse the titles.

My first medical mentor had attended Jefferson Medical College in the 1960s.  Shortly after I got to know him in the late 1970s, he developed Hodgkin’s lymphoma.

I in turn took my medical studies at Hahnemann at Vine and Broad Streets, where I cemented a life-long friendship with another student who now practices family medicine in Arizona.  At the time we both roomed on north 15th Street, although he and his wife later took another apartment ten blocks south near Spruce.  My wife and I sublet from them when they were out of town for a month that second summer.

I exited the bookstore with my hands thrust deep into the pockets of my trench coat.  It had started to rain; the wind was whipping up in cold wet gusts.  I passed by two musicians huddled in a stone archway playing a Michael Jackson tune on their saxophones.  I’ll be there, one horn soothed reassuringly, while shortly afterward its companion echoed the same soulful sentiment.  I tightened the collar of my trench coat against the wind and pulled the brim of my cap down tight.

That evening I met up with my fellow editorial board members for dinner at Upstares & Sotto Varalli on South Broad.  The remainder of the weekend flew by:  an all day meeting in the Director’s Room at the hotel on Saturday, dinner at the Raw sushi bar on Sansom Street, a late evening demitasse of melted chocolate at the Naked Chocolate Café on Walnut.

Back in my room on the 14th floor of the hotel I stood at the window and looked down on the gleaming streets of the city.  I thought about the man I had seen slumped over a makeshift cardboard sign on which was scrawled one word:  “Hungry.”  A tangled mass of black hair emanated from the back of his stocking cap, his coat was marred with grease stains, his ankles showed white between the tattered cuffs of his trousers and the tops of his dirty sneakers.  When I dropped a few coins into the plastic bowl in his lap, he barely stirred.  In thirty years the streets of Philadelphia haven’t changed much.

The cabbie I hired Sunday morning chatted in Arabic on his cell phone all the way down JFK Boulevard to 30th Street station.  I tipped him a dollar and stepped out onto the wet pavement in the early morning darkness.

As we gathered at Gate 3 to make our descent to the waiting train, I noticed a young couple standing off to the side, holding hands with their foreheads touching.  There are always young couples standing on station platforms, it seems; huddled together, oblivious to the rest of humanity.

Shortly after pulling out of the station we passed over the Schuylkill River.  I caught a glimpse of the macadam path that runs along the bank by the boat houses.  Another good friend and I attempted the Philadelphia marathon there when we were undergraduate students.  I logged 18 miles before I cramped up from dehydration and dropped out of the race.  Some things in life you never complete.

My mentor finally succumbed to his lymphoma this past year.  I still correspond regularly with my doctor friend in Arizona.  Once a year we get together for an afternoon saunter through another Pennsylvania town and catch up on our lives—far from the streets of Philadelphia.

Spring Peepers

Late last Friday afternoon I was still at work in the office, waiting for the 5 o’clock whistle to sound.


It turned out to be a lovely spring day.  Over lunch I had managed to slip out for a short visit to a local book store.


One of my patients had given me a voucher for a reading program that his school was sponsoring.  Over a three-day period the Barnes & Noble book store had agreed to contribute 10% of each purchase to this special program to send books to students in Uganda.  I ended up buying The Shack and Three Cups of Tea, both of which I’d been meaning to read for quite some time; and so contributed $3.20 toward the Uganda project.


As I sat in the back office by an open window, looking out over the expanse of wetland cloaked in bare white birches and young maples, a cacophony of spring peepers erupted.  Trebles from spring song birds periodically punctuated the frenzied crescendo.


Overhead, the sky provided a faultless blue canopy for the performance.  Although lingering patches of snow had disappeared over the course of the past two weeks, the woods still seemed to be wintering over:  bare trunks and grey branches, brown leaves, cinnamon sand.


Momentarily, the peepers died down to a few isolated chirps, then once again welled up into a feverish frenzy.  I sat back and closed my eyes, meditating on their orchestral orations.


I look forward to the appearance of these little frogs each year.  Their song ignites in me a certain undefined hope that heralds the coming of spring.