3/7/13 — Winding through the streets of east Yerevan, my host warns me, I might weep at the orphanage. Though I haven’t regretted the few times that I have broken down in front of a patient or family, Sir William Osler warned me, and generations of clinicians, to get their “medullary centres” a bit better controlled: Imperturbability is “largely a bodily endowment, I regret to say that there are those amongst you, who, owing to congenital defects, may never be able to acquire it … the physician or surgeon who … shows in his face the slightest alteration, expressive of anxiety or fear, has not his medullary centres under the highest control, and is liable to disaster at any moment … an inscrutable face may prove a fortune” No wonder they Knighted him. What a jerk.image We climb the eastern hillside, where the Urartu built their forts almost 3000 years ago, and come to the building entrance, which looks like that of any other 2 story building on this densely settled slope. But the sign on the door indicates that this is a project of the Order of Mother Theresa. Mother Theresa took a special interest in children. “No Photography” another sign says with a strike-through camera graphic. Sister Mikki greets us; she seems about 35, wears robes and a hair cover bearing the blue-on-white stripes of her Order, and has a brisk, joyful way about her. imageShe introduces us to two older residents, a 10 and an 8 year old boy sitting in newer (American) wheel chairs in an outer, 2nd floor “drawing room.” There’s a quiet, “Grandma’s house” feel to the place, with tiled floors, bas relief ceilings, wooden balustrades. We walk into sunny rooms, walls lined with knee-level seats, occupied by infants about 8 to 20 months old. Sister Mikki continually carries one or another of them, querying them, explaining things to them in her friendly way, eliciting magical, evanescent little smiles. As I walk in to the rooms I have the sense of having interrupted a conversation conducted in infant semaphore, as the alert residents face each other across the room. There is a luminous equanimity in their gaze, poised between expectation and curiosity. This isn’t the kind of equanimity that might come from following Osler’s advice “not to expect too much of the people amongst whom you dwell.” Here at the orphanage there seems to be enough love to go around. One or two infants have the persistent head-turned, “fencing” pose as a sign of their disability, or a flexed posture. About 15 infants in total, they all seem to have neurological problems, two thirds of these related to various forms of spina bifida with hydrocephalus (which typically go together). If one gets adopted, there’s a good chance it will be to an American home.

To stand within a circle of attentive orphans. One might expect the narrative behind the tears in this setting to be about shortage: tender, new, incapacitated human beings caught in an anonymous backwater. What moves me is the open-ness in these infants’ gaze, that seems to say “what next?” without a hint of anxiety or imprecation. My favorite image of equanimity (until now) was in the story about the Buddha, who upset his followers when his only response to a man who came, first to spit on him, then to throw himself down on the ground, was “what next?”image ( )

Sister has arrayed the paper charts of the children on a table in the adjoining infirmary room. The infirmary’s glass-walled medicine cabinet has the commonly used seizure medicines sitting next to boxes of band-aids, gauze, scissors, creams and ointments: carbamazepine, valproic acid, phenobarbital. But the largest bottle, at the back of the upper shelf, is labeled “Holy Water from Lourdes.” The Sisters here are apparently among the many who believe in the healing properties of water from this part of France. Osler had an encompassing contempt for this kind of integrative medicine: “restrain your indignation, when you … discover accidentally a case of Warner’s Safe Cure in the bedroom of your best patient. … Curious, odd compounds are these fellow-creatures, at whose mercy you will be full of fads and eccentricities, … .”

She winnows through the charts with my host to see who must be seen, especially focusing on one who has been fussier than usual–is there an impending shunt obstruction? An Italian pediatric neurosurgeon is visiting next week. Though today this resident was calm, feeding a bit better. (In the end the visiting surgeon operated on two orphans during his visit, when he also brought to Armenia its first neurosurgical endoscope for performing 3rd ventriculostomies.) Sister Mikki has to leave before we do–one of her orphans is in hospital.

We did not see the other cadre of residents, the children with Down Syndrome, who tend to undress, and who in general have less need for a pediatric neurologist. But I feel an inscrutable, gravitational pull of the place across the shallow valley of Yerevan through my high windows on Parpetsy street. I think I will return.


I Don’t Know Your Name


4 thoughts on “Aequanimitas

  1. thank you for your blogs peter, i have been following them with fine interest. this one
    opens a can of worms for me. it has taken me 35 years to come to some comfortable
    useful blend of honesty and humanness with patients that is not counterproductive
    to the end game of healing -i still dont have it right- but it doesnt follow an osler
    dictum or even teaching i received in the seventies. finding ones own way. always
    the most fun. hi to dana

  2. Hi Peter, just home from a dinner party in Stowe. Reading your thoughtful blog brought me back to the muddled world we live in. Your beautiful song expresses it all. Thank you! Hugs to Dana.


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