THE MYSTERY OF CLEAR VISION IN PEOPLE WHO WERE BLIND - THE CHARLES BONNET SYNDROME

I got a letter from my cousin Nirmala, about her mother. I reproduce it verbatim unchanged. I have only highlighted a few things. 

"Periodically she gets visions (hallucinations) with audio. About bhajans, gods and goddesses, patterns on the ceiling, monsters, and now insects big and small on her bed and clothes, plastics hanging from the ceiling, and the cupboards becoming buildings and falling on her. She tries to get off the bed on her own and go out of her room. She can barely walk with the walker and one attendant to the toilet. 

She is aghast that we cannot see these things. She also sees a child and a man standing in the corridor. She has lost orientation her room and is worried about how to go out of it and come back.

She is wheelchair driven and is taken to the to to see Animal Plant, Just for Laughs and Planets Funniest Animals without sound as she cannot hear and her semi dentures do not fit.

Is fairly lucid and clear while speaking to us and neighbors.

She has  back pain and knee pain off and on and not much strength in the legs. Cannot read or write legibly, cannot read. 

Poor hearing - hearing aid not satisfactory; Poor eyesight and eye doctor has said no more can be done for her macular degeneration. 

Please see if anythings can help her. I will talk to her physician here.

Best, Nirmala"
  Obviously, the lady is seeing things which others do not, because, they do not exist - a phenomenon called hallucinations. Hallucinations are reported in people with normal eyesight sometimes caused by some medications, drugs, alcohol withdrawal and some other events.This is a unique situation where a person with a poor eyesight starts seeing things very clearly and these are not visible to the others. This is known as Charles Bonnet syndrome. Charles Bonnet was a Swiss naturalist and a good observer. He was the first person to describe this unusual syndrome. This is commonly seen in elderly patients with a poor vision and appears and disappears without warning. These hallucinations can be common, mundane or funny and rarely threatening.  The images could be in black and white or in color and can even be clearer than normal! The person seeing them fully believes them to be real! Sometimes they seem to fulfill a unfulfilled desire - like a lady who repeatedly 'saw' her deceased husband and a childless lady who 'saw' a boy and a girl as her children (she was longing to have children). They are able to 'see' these people / events even while speaking to others (who obviously cannot see them)!Sometimes the images may be of animals and inanimate objects like boats, houses. They may even be in the form of spinning lights!One person could see cartoons in  his scotoma - a completely blind part of his visual field! 
     These therefore are like usual hallucinations - probably the patients are 'filling in' as they are blind! What is astonishingly different in these people is that the filling in is done by using high level stored memories - like pulling out an old album and seeing the images with great clarity and in a great detail! These stored internal images therefore make up for the otherwise lack of vision = but they can never substitute the real vision! To quote Shakespeare 'You cannot cloy the hungry edge of appetite by bare imagination of a feast". These perceptions are probably an end result of an dynamic interplay between sensory signals and high level stored information about the visual images from the past! The higher visual centres therefore probably substitute  the 'best fit' to the lower centres which have failed in their duty of enabling the person to see normally (for whatever reason, these persons always have a poor eye sight). 
     Why I am enamored by this syndrome is because I encountered it in my own father - a very intelligent and accomplished doctor know for his clarity of thought and judgement. During the final phase of his life, he experienced these images which I later realized were due to the Charles Bonnet syndrome . He was a very well read person. One day he was very excited - he called me to tell me that he is able to read the front page of the New York times very clearly and believed it to be a miracle! Only there was no New York Times and he was a;most totally blind! Only when you experience these in a close friend or a relative you understand how important to identify it in the first place. The lady mentioned above is my father's sister. 
     There is no need to treat this if the patient is able to rationalize. That was what was done successfully to both my father and his sister.
      Coming  back to the story of my aunt , my friend, Dr. Gurudutt Kamath opined thus 
with poor eye sight and description of vivid pictures it looks like Charles bonnet syndrome
      I reassured my cousin about her mother and wrote to her 

"Dear Nirmalakka

     My dad also had it. These are NOT hallucinations. They are OLD IMAGES STORED IN THE BRAIN released due to some unknown reason ( like seeing old albums). Unfortunately the patient thinks it is really happening! Patient counselling is the best way out of it. This even has a name - Charles Bonnet syndrome. It is otherwise harmless. It does not indicate stroke. It poses a challenge to the caregivers. 

      Raghu

      Both my aunt and my father improved. But the Charles Bonnet syndrome continues to exist and haunt people out of the blue!

MYSTERY OF THE HIGH MORTALITY FOLLOWING ROBERT LISTON'S SURGERY!

     Sometimes, a patient can die following a surgery. There are many reasons why this can happen. Most of the times, death comes with a warning - a seriously ill patient, an underlying organ failure, associated critical illness, old age , multiple coexisting conditions to name a few.In these situations, the death is somewhat expected though unpleasant. There are some situations where the death is unexpected. These include cardiac arrest due to vagus nerve over activity, severe allergic reactions to drugs or chemicals. These are the situations where the death is both unexpected and unpleasant and sometimes leads to litigation's and court battles. Usually the surgeon is taken to task and has to suffer infamy and also loss of money and reputation. Today's story is about a surgeon who became famous (or rather infamous?) with an unexpected unusual mortality!
     Robert Liston was a Scottish surgeon. He was known for  speedy  surgeries he used to conduct. He lived at an era (1794 - 1847) when there was not much effective anesthesia was available. Therefore speed was a required faculty for a surgeon to be successful.  A noted surgeon, Richard Gordon, in his book written in 1983 describes some cases which made Liston famous.
     There was a patient with a huge scrotal swelling. After removal, this weighed 45 kilo grams and had to be taken away using a wheel barrow!
     Then  there was a young boy with a red, pulsating' tumor' in the neck. Liston diagnosed it as an abscess and was ready to drain it immediately.  A young but sensible house surgeon suggested that the 'tumor' could be an aneurysm as it was pulsatile. Impatient and irritated, Liston argued saying that aneurysm was highly unlikely in such a young patient. "Whoever heard of an aneurysm in one  so young?" were his exact words. He promptly pulled out a knife from the pocket of his waist coat and lanced it . The disaster that followed has been promptly recorded by the house surgeon "Out leaped the arterial blood and the boy fell!" The patient promptly died. The aneurysmal artery still lives on as specimen no 1256 at the Pathology museum of the university college hospital!
     Amputation of the limbs required both speed and efficiency and therefore a special skill required by the surgeon intending to do it. Usually these operations were witnessed by doctors, medical students and some distinguished spectators who would be surprised and enamored by the spectacle! One day Liston was amputating a limb. He completed the swift amputatoin in less than 2 and a half minutes! Then a most unexpected event took place - the knife not only amputated the intended  limb but also his testicles which was unintentional but disastrous!
     The cake is taken by the mother of all disastrous case wherein Liston wherein Liston swiftly amputated the leg in under 2 1/2 minutes. The patient died from gangrene due to hospital acquired infection ( after all it was in the pre - Listerian era). This was no big deal. though the mortality was 100%, it was acceptable. This story has an incredible ending - a 300% mortality! Wondering how it happened? Liston accidentally amputated the fingers of his young assistant who also succumbed to gangrene following gangrene due to hospital acquired infection. If that leaves you wondering how did a third person die in this unique episode, I will gladly explain. One of the invited distinguished spectators was intently watching the event. The tip of the swinging knife slashed his coat tails so close to his 'vitals' that he thought that his 'vitals' have also been amputated and died in sheer fright! Therefore this surgery had a 300% mortality! Incredible story - very strange but true!

WHO BENEFITS WHEN I UNDERGO STENTING FOR MY HEART ATTACK?

     Indeed the question is who benefits when I undergo stenting for my heart attack? I thought the answer is obvious - Me! If the answer is so obvious, I would not have posed this question in the first place.
     To the uninitiated, STENT is a way of making sure that blood flows once again in the vessel (coronary artery supplying blood to a portion of the heart in this instance). This is based on a sound principle that the heart attack is indeed caused by the sudden stoppage of the blood supply to the heart muscle in the first place. (A reduction usually happening slowly not amounting to a sudden block would result in a less dangerous 'warning signal'of  ( the possibly oncoming) heart attack - known as 'Angina pectoris (meaning 'chest pain'). The process of removing the block and preventing a further block is done using 'clot busters' - chemicals that dissolve the clot. However these on their own cannot prevent this from happening again. It is precisely for this purpose permanent measures are undertaken to make sure that  that enough blood flows through the arteries of the heart once again - these procedures are called 'revascularisation' procedures. An angiogram ( dye injection to visualize the arterial tree oft he heart ) is done first. This helps in making sure that there is a block ( or many blocks) in the first place and the size and location of these blocks. Depending on the feasibility, the patients are taken up for the medical procedure of Angioplasty (by which the blocks are removed) and stenting is done  to make sure the vessels which have been opened up are prevented from getting blocked again.There are many  types of shunts available - the ordinary ones wich keep the artery open ; the drug eluting ones  which hopefully prevent the blockade from happening once again by having a small dose of anticancer drugs which are known to slow down the cell multiplication ( the basic principle of treating cancer anyway). These are many times more expensive than the ordinary stents. Then there are the so called 'vanishing stents' which are supposed to merge with the arteries and keep them open longest. These are priced highest - in fact, many times more than the ordinary ones.
     Now we come to the basic point - HOW ARE THE STENTS PRICED? Basically there are 2 priciples of pricing anything - 1. The costs incurred. 2. The exclusivity. It is the neighbour's selling price that often determines the cost of the item most of the times. Thus a logical balance is struck - depending on the demand and supply position. This delicate balance is sometimes offset by EXCLUSIVITY of the product and the SERIOUSNESS OF THE SITUATION. In the case of stents BOTH these factors operate. This gives a free hand for the manufacturers to grossly overprice the product. This is what exactly happened to the 'Vanishing stents' sold by Abbot in India. The customers were royally fleeced to the core because there were no rivals. The worse news is that it has been found that even the so called vanishing stents get blocked many times defeating the basic purpose. Now we come to the point - the unsuspecting client is made to pay for the CONCEPT which has NOT been proved! You might ask me the question how on earth is this possible because even the drugs undergo extensive trials and attempts are made to obtain adequate proof before these are used on the patients. How then the stents get away? Brings us to a glaring fact that there is NO NEED to conduct trials before the DEVICES are used on human beings - and believe me, stent is one such device. How then can we remedy this seemingly iremediable problem where the ABBOT COMPANY MAKES HUGE PROFITS WHETHER THE END USER ( THE PATIENT WHO SUFFERED A HEART ATTACK) LIVES OR DIES OR BENEFITS OR NOT.The Abbott company DOES NOT EVEN MENTION THE MRP which has to be compulsorily mentioned by even products like toothpaste! I discussed this issue with legal authorities and patients who had suffered. I felt very sad after I was made to know that there is NO LIMIT ON THE MRP OF PRODUCTS CREATED BY ESEARCH for which there are no alternatives. I then understood that the ball is in the court of the consumer - the patient and addresssed may fora on this and related topics. No one saw the urgency in the issue till a kit or kin of theirs developed a heart attack and there was no time for these discussions.
     When I almost gave up, I found a good news on the newspapers today that the MRP OF THE DEVICES HAS TO BE COMPULSORILY MENTIONED. Now there is some kind of a hold on the companies like Abbott. I am not for a moment saying that they are the only ones in this dirty game. There are many other devices like pacemakers, intra cardiac defibrillators, artificial joints, ocular implants, heart valves, disposable syringes and many more items manufactured  by many companies. Now some sort of regulations will come int place. It has been also mentioned that attempts are being done to notify these products as drugs and compulsorily bring them under the Drugs and Cosmetics act1940. If this happens, their prices will be monitored and regulated making the whole process fair to all concerned including the stake holder - the patient. Therefore with this single act of the government, there will be more people benefitting fairly when a person undergoes stenting!

THE IMPORTANCE OF "COUGH!"

     You may wonder what is this all about! After all, what is the importance of cough, such a common happening? Is there anyone who has not had cough sometime or the other? None, I am sure. Then what is this about?
     I am not referring to the 'cough' you are thinking of - cough as a mark of disease. Cough is called a 'symptom' if the patient complains of it and a 'sign' if the doctors discovers that the patient is coughing too much. This happens in various situations some acute like acute bronchitis and pneumonia. and some chronic like tuberculosis or occupational lung disorders. Pneumonia has replaced tuberculosis as the 2nd most important killer!
     The cough I am referring to is a special cough - for example a cough by a girlfriend is a means of attracting the attention of her boyfriend particularly when she is forgotten in the company of his friends!  The cough by  a wife is a even more serious event - it is brake - a remote control even before actual remote control was even thought of - an effective means of telling her spouse "You are talking too much - Stop!". Most of the times, it has a magical effect!
     One of my patients once told me of an event where a patient had a bout of violent cough and fell down clutching his chest - he was taken to a hospital immediately - In all probability, the violent cough had ruptured his lung resulting in the escape of air outside his lung into the surrounding pleural space - a very serious condition called "tension pneumothorax" - a killer. He survived only because of a good medical attention!
     Cough may sometime  be the end point of a crisis! When someone is choked on something - say, a morsel of food, one can try a life saver called Heimlich maneuver - a type of a squeeze below the middle of the chest - which can effectively dislodge the substance blocking the critical airways and throw it out with a cough - a life is saved following that cough!
     Some coughs are telling - Bovine cough a cough resembling a cow's cough is said to suggest pressure on the recurrent laryngeal nerve deep inside the chest - an ominous sign indicating possible cancer. Our generation I am sure, has not forgotten the Whooping cough a dramatic event where a series of coughs in quick  succession  is  is followed by a distinct unforgettable sound of air rushing in - a whoop!This potential killer seen particularly in children has  become a lesser offender now due to vaccination though it is trying to raise its ugly head again!
     There is an interesting neurological condition called Pseudobulbar palsy which results from damage to the higher centres of the brain where the patient cannot cough to order but the reflex cough is preserved!
     Once one of my friends claimed that the best medicine for cough was brandy! In fact he was trying to justify his daily dose of brandy with a plausible medical reason!

" '"DOCTOR IN TROUBLE! "

     Gone are the days when a doctor was considered as God. Later he was revered and adored  though not treated as divinity. He formed a part of the family and was invited for all festivals and functions and consulted for all medical and even social problems. I remember distinctly an occasion when a patient died at home. He was regularly being treated by my father as his family doctor. It was a Sunday and my father had taken all of us to the beach at the evening. All of a sudden there was chaos on the beach. Two people were running, who we later realised, were desperately looking for my father. I was really surprised when I realised that they were looking for my father after the patient  had died! My father explained this phenomenon  to me describing it as a 'bond' between the doctor and the patient. It was imperative that the doctor who has treated the patient must see the patient after death so that 'soul rests in peace'. This was in the mid 60s when I was a primary school student. I was really overwhelmed!
     Later I completed my MBBS and went in for Post graduate studies in Medicine. I saw and treated patients at the Government Wenlock Hospital. It was a very heartening and a satisfying experience. The patients selected the government system knowing full well that it was far from perfect. The doctors knowing this, went out of the way to compensate with compassion and the nurses and the other paramedical staff also did their best. The team work seemed to satisfy the patients who came from far and wide. Of course, some were unhappy, they shifted their patients out to other hospitals. Some patients died - often this event was predictable. Sometimes death was unexpected but doctors were around at the time and shared the sorrow of the patients. The trainee doctors acted as a buffer between the patients and the treating doctors never letting down their teachers whom they held in high esteem.
     Now there is a complete change of the scenario. The patients do not respect the doctors in the same set up. Doctors are 'uncomfortable ,. Patients demand more. Even when they are aware of the limitations, their demands are unrealistic. They expect the senior doctors to be around all the time. It is unreasonable. The doctors belong to a cadre known as Honorary doctors who are not paid anything by the Government for teir services lent to the Government system. On the other hand the they are 'part time employees' of the teaching institution which limited responsibilities and limited emoluments. Obviously they have look elsewhere to make a comfortable living - which is the basic expectation of any professional with 15 years input into training (leave alone the cost). They do some private practice. In any professional system, there is a hierarchy and the system is closely followed. This happens in all government offices including the DC office, RTO, etc.
     Not only the doctors are expected to be present all the  time, they are also expected to solve all problems
medical and otherwise. One cannot expect a 5 star treatment at no cost. Shortage of medicines, non availability of space in the ICU, shortage of beds cannot be addressed to by the doctors. A road traffic accident is a case in point - Death or injury results from an accident. Such a patient is brought to the hospital and the relatives are naturally emotionally upset  Doctors become the target of any shortcomings of the hospital or the system and any adverse outcome of the event. First of all take the larger picture - why did the accident happen at all? Because an unscrupulous person bought a non roadworhty painted up bus and got it certified fit for use by a corrupt officer of the RTO. City corporation officials made a road out of what was left after sharing most of the sanctioned money at various levels. The so called road is a true mutant with many holes. An unsuspecting two wheeler rider who is innocently trying to avoid a pothole and find the road or what is left of it is mercilessly hit and knocked down by a speeding bus often from the wrong side. He is rushed to the hospital and the relatives are not prepared for the event, outcome, or the expenses. In this emotionally charged condition they try to vent the anger on the easily available person  - the doctor! Naturally the doctor who is trying to do his best against all odds gets naturally emotionally upset - after all, he is also a human being and an accidental easy target in the whole show!  Every one is unhappy and the real corrupt antisocial culprits have got scot free! Nothing ever has happened to the bus owner, bus driver, RTO official, corporation road contractor, or road tax collector, DC ever! Only the doctor is targeted. All these culprits should be made accountable - at least they must be given the responsibility of transportation of the patient and must be made to bear the expenses of all the expensive treatment modalities, diagnostic tests and costly medicines and also the cost of treatment in a higher, greater equipped center  if the need arises!
     This is my personal opinion. A beautiful honorary system will die down if the steps are not taken at the right time which is now!
   
     

THIS IS NO MONKEY "BUSINESS"

     We (my wife Shobha and me) are just back from a trip to Malaysia and Bali. We were specifically told to watch sunset aat Uluwatu at Bali. On the last day of our trip to Bali we planned this after checking out of the hotel before reaching the airport.
     There are 2 things to see at Uluwatu - an old Shiva temple for which the entry is highly restricted. There is a specific dress code which  we were not aware of and so we could not enter the temple as such. Then however, there was the sunset to watch and it can be watched from many points. You get a good view of the ocean too.
     There are many monkeys at Uluwatu. In fact they are encouraged and pampered. There is an exclusive swimming pool for the monkeys - something I have not seen anywhere. And there are very many monkeys. One an sit and relax in the benches provided from where the sunset is not visible. One could watch from the edge of the wall but it is not possible to sit there. We were sitting on one of the open benches when we net a family of 3 French ladies 2 sisters and their mother. The mother had a bandage on her little finger. On inquiry, she revealed that the injury was due to the monkey attempting successfully to snatch a banana in her hand. In the process he scratched and bit the little finger. She had to visit a hospital meant for the foreign tourists and and was given a shot of tetanus toxoid and one of ARV. The whole thing cost her a whopping 100 $! The monkey's prank turned out to be expensive indeed!
     As the sun set was approaching, I called my wife to stand near the wall so that the sunset can be viewed better. She did so. She was busy talking to me and the people around us. Then she moved back to the open benches saying that there is still more time. 2 guides belonging to 2 other groups were sitting beside her on both sides. Just then in one swift move she felt her glasses being snatched from her face suddenly. Before she could realize it was a monkey, he fled with the glasses and sat above the wall  near which I was standing. On the other side of the wall below the spot where the monkey was sitting, there was the ocean in full glory. There was a patch of grass just beside the wall where I was standing.
     The monkey carrying the Cartier glasses which  indeed was an expensive gift, jumped up and sat exactly above me and started to examine the glasses. My wife was desperate as there was no way we could reach the monkey and get the glasses back. There was very little time and little we could do. I wa about to shout at the monkey when a local man advised me to remain calm. He gave the monkey a small chocolate in his right hand. The monkey gladly took the chocolate, for a while held the chocolate in his roght hand and the glasses in the left hand and examine both. He must have found the chocolate more interesting and therefore threw the glasses down and was busy eating the chocolate. Now came the second hurdle. The glasses fell down into the patch of grass behind which was a cliff leading to the ocean. There was no way we could reach the spot where the glasses lay. The same man helped again. He jumped the wall  and in one swift move retrieved the glasses and jumped back to safety and returned the glasses to us. The whole thing was so sudden that we were stunned. Even before we could recover and thank him or offer him a gift, the man had vanished. All along, a Chinese tourist was video recording the whole thing and he had his dark glasses on his forehead. The monkey came back and in one swift move removed his dark glasses, jumped up to the same high spot, turned round the gasses, had a good look  cut it into 2 parts and sincerely gave one part back to the gentleman and threw the other part into the ocean. The glasses were destroyed forever.
     I shudder to think what would have happened if that fate had befallen my wife's glasses. In fact, my heart was beating in my mouth when the monkey was examining the glasses. It was a stroke of good luck that the unknown gentleman came along and helped us. My only regret was that we could not thank him properly.
     Need I say that we immediately proceeded to the airport without caring to watch the sunset. We proceeded to the airport in a taxi driven by Made Yasa who by then had become our friend. I made fun of my wife all along the way. We reached the airport, completed the security formalities and I found a newspaper and settled down to read it as there was time for departure. That is when  I realized that my gasses with the case were missing. Obviously, the monkey had taken it even without my knowledge! I am not too sure who had the last laugh - my wife or the monkey!

THE SWEET MEMORIES OF VISIT TO A MOVIE THEATRE

     The day on which all of us were taken to a movie in a theater was a big day. It was a family outing much looked forward to. It was a rare occasion and had its own special appeal. As a young boy maybe in the early primary school, I remember accompanying my dad to a classic - "Benhur". I was awed by the war scenes and the seriousness of the movie what if I understood nothing! The settings were great and I thought that the war scene was real!I also remember going to some Hindi movies with my mother and aunt. The dressed worn by the actress were displayed in the theater. I understood nothing of the hindi movies but felt very bad when almost every one cried in the theater! The movies I really enjoyed were the Kannda movies with Narasimha Raju a comedian playing some role usually with Raj Kumar. I was so fond of him that on a trip to Bangalore when my aunt, a doctor at Bowring Hospital asked me what I would like to visit most in Bangalore I replied "Of course, Narasimha Raju!" She politely told me she did not even know where he stayed and I tried to convince her that maybe he lived on the road they had just named after him! This was during my 7 th standard vacations. Any movie would begin with a "News Reel" a black and white depiction of news. One of the news surely would be about "Rashtrapathi Radhakrishnan". For some reason the black and white news played much faster than natural. I was really impressed by the 'speed' of the old polititians till I later understood that it is a technical problem!
     In the school they would rarely show us some excellent black and white movies. Usually they were about some scientific discoveries or about rockets, space travel etc. I would eagerly wait for that rare day. I still remember some scenes from those movies clearly. My beloved uncle would take us ( my cousin and myself) to some English movies at the New Chitra talkies. Usually they were spy movies. Enemy was always more intelligent than what the hero assumed him to be. However after all the action (usually mindless - ending in a large factory which produced God knows what) the hero always won convinsingly! This was during the high school, PUC and MBBS days. During the Post Graduation I would go to movies with my friend Gurudutt who was studying to be an Ophthalmologist. We would see an English movie on most Fridays. It would cost us Rs. 3.50 each for the balcony ticket (in the front portion). Reaching the theater from the hospital would cost less than a rupee. One packet of Masala ground nut and a cold drink each would be around Rs 2. So Rs. 10 in all saw us through a movie session. We walked home after the movie which was healthy and free.
     I just cannot come to terms with the present day scenario of going to a movie theater. Gone are the days of cheap tickets and simple eats. You are forced to take a huge packet of popcorn and a big coke. Some times one wonders whether people go there to eat or t watch the movie. Movies themselves are insipid. They are made by the people with questionable IQ s for people with even lower IQ s. Rarely we find gems among the muck. 100 crore club probably is another social club like Rotary or Lions nothing to do with the actual collections! However there are no superstars any more. No wonder people do not take the trouble of visiting movie theaters regularly. Any 3 Hindi movies seen in the course of 1 year will give you material and ideas sufficient for that year's releases. Once in a way however, a Lunch Box , a Dirty Movie, a Kahani will surface keeping the hope alive and faith intact. No wonder we hardly remember recent movies and never forget the movies like Lawrence of Arabia, Titanic, Inferno, and the like!

THE EPISODE OF THE MAN WHO SWOONED

     I reach the HOD office of Medicine department at 9 AM. today as usual. After meeting the people, signing documents and dictating a few letters and communicating digitally with some people I was driving to the teaching hospital .
A narrow road leads to the hospital. Usually vehicles are parked on the left side of the road and that makes the road even narrower. To make the matters worse, some two wheelers come on this narrow one way road from the opposite side. This forces the pedestrian to walk virtually in the middle of the road  exposing himself to all the vehicles. A car stopped. An elderly man got out of the car and even before closed  the door, swooned and fell. Another car passed him and possibly grazed his head. I was 2 cars behind this and saw it happen. As it was an unexpected event and there were people around, I was not too sure whether the man's head was hit by the door or the car that passed. The man who fell down started to bleed from his forehead just above the right eye. I was in 2 minds. I parked the car on the side of the road, got down came to that car and watched. The man driving that car also was an elderly man. He was shaken by the episode. People gathered around and started to ask questions. "What is the color and make of the car that passed by?" asked one person. Her blamed the driver for not noting the number. The driver was trying to put the man inside the car into the back seat and was struggling to do so. No one of the 50 or so people gathered around helped. One scooterist came from the opposite direction and blocked the door to ask some stupid questions of gossip value. He had to be shooed away to make way for the patient to be put inside the car. I helped the old man to do this. Then I volunteered to accompany them to a hospital leaving my car behind. I left the hospital only after making sure that the person was stable and his daughter arrived.
     Whatever happened to our civic sense? Why do we hesitate to help people in distress? Is it the reflection of "me" attitude rather that "we"? Maybe like the nuclear family. We are distancing ourselves from serious problems - "As long as it is not me why should I bother" is one reason. "Why should I get involved in a police case?" is the other one. How on earth do we expect these people to help us in our crisis?
     By helping them I got delayed elsewhere. I do not know whether I am right or the other 'wise' people are right. I am sure there ate more questions than there are answers. Sometimes the answers may be obvious and some times the answers may not come at all.
     I suddenly remembered my childhood days when we were a big homogeneous group unconditionally helping each other. If a boy fell from a tree and got injured, we would stop playing, attend to him, give him water, take him to the nearest doctor who usually did not charge, get medicines take him home and tell only the mother (underplaying the seriousness) and avoid the father and disappear. We pledged to remain so for all time to come and help each other and other people also. I wonder whatever happened to the pledge!

THE CASE OF THE "WRONG CALL"

     It was a very tiring day. I went to bed at about 11 45 and slept off immediately. I had to get up at 4 45 next day to be able to go to the gym. At about 12 15 I was woken up by the shrill ringing of my mobile phone. I picked up the call almost immediately
     The caller, obviously a lady was inconsolably crying. I was surprised but all the same decided to continue the call as the caller was obviously in distress. After a while of sobbing and actual crying, the caller introduced herself as a PG in Pediatrics. A baby had died in the ICU of her institution and the relatives were threatening to manhandle her and her co PG both ladies in the first year of training. Obviously it was the wrong call. I am heading the department of Medicine at a different  institution. The first thought was to say so and softly encourage her to call her HOD. I asked her whether the higher authorities have been informed. She replied saying that she tried to but they refused to take any responsibility saying that only imparting education was their responsibility. I immediately understood the seriousness of the situation. I surmised that the person must have saved the number as HOD and dialed  it. Still it beat me why she dialed me! By the time she realized that I was not the person she wanted to speak to and promptly disconnected. I tried calling her back and she did not pick the call.
     I like mysteries - I always liked to read the novels based on mystery. I always thought that the problem can be solved by logical thinking and action. Now I got an opportunity to put these into action. The number, named of the caller and the institution were the only leads available. Were they enough to solve the puzzle at the dead of the night? Was I justified in helping a PG from another institution? I have 2 daughters who are doing their higher medical training at different institutes. I would have appreciated someone going out of the way to help them. Then I should also do the same!
     I had to some quick thinking. Maximum number of the seats this time went to PG s from Andhra. So, logically no harm thinking that this girl is also from Andhra. I have always found PG s from Andhra quite resourceful and closely knit. So I decided t wake up an Andhra PG and gave him the number and name of the PG and the institution. To the credit of all Andhra boys, they tracked the identity of the person in next 15 minutes! The phone belonged to one of the PG s from our institutes who had stored my number as HOD. He gave the phone to his wife who was working in that institution and in turn, she had lent it to her friend during the hours of duty. This solved the mystery why she had called me.
     Then came the appropriate action. The PG whose wife was having the mobile went to the spot. He was surprised by what he saw. The ladies were hiding inside a small room in ICU. There was a commotion outside the ICU. It was pathetic to see that the management security or the police did not take it seriously. The doctor who went successfully escorted the lady PG s out of the ICU  and took them to a safe place.
     This case is another eye opener. Do we have to wait for something to happen before helping the ladies in distress? Where is the chivalry? It is nauseating to see the people not even doing their own duty for which they are regularly paid. I feel only making people liable for their inaction will be a good answer. There should be stiff fines based on the duration of inaction. Repeated offences should lead to successive demotions and dismissal altogether after the last possible demotion.

THE LAST WORD

     Way back in 1970, when my headmaster, Mr. Anantha Rama Rao Verkady summoned me to his room, I was surprised. It was to tell me that I was one of the reciepients of the National Merit Scholarship for having figured in the list of first 100 ranks in the state SSLC examination. My joy knew no bounds. He gave me a letter to that effect and another accompanying letter to be signed by my father, a physician,  and indicated where my father had to sign it. The scholarship was a prestigious one and would look after my education till my Phd if ever I chose to do it! When I proudly gave the letter to my father he was extremely happy. He went through the contents of the letter very carefully and appreciated my achievement but flatly refused to sign it. 

     He pointed out to me that an income limit was prescribed and that his income exceeded that limit marginally. I tried to convince him by saying that by signing this he would be absolved of all responsibilities of my entire education. I however failed miserably in my efforts.

     I then put forth my last argument saying that if he did not sign the letter for his son, the next in line would sign it for his own even if  his income exceeded the prescribed limit. To this my father coldly replied "hat is the difference between hid father and your father!"Needless to say I never received the said scholarship but rt only Rs. 100 as a token and a certificate instead. This action of his reflected his honesty, transparency and descipline. 

     The day before his demise, when he was unable to swallow, I politely suggested that he may be admitted into a hospital and be given intravenous fluids. I felt that I was doing what was best for him as he always did for me. But he refused the suggestion immediately. The speed of decision and the finality of his voice reminded me of the incidence  in school. 

     The voice however had become feeble, but the spirit had not diminished. Needless to add, as usual, he had the final say in the matter!

FOOTPATH IN MANGALORE - A MYTH OR REALITY? - IS THERE ANY FOOTPATH LEFT?

     Footpath is a self explanatory term - a passage specially created for the safety and convenience of the pedestrians. I vividly remember walking on quiet and the safe footpaths of Mangalore as a young boy accompanying my mother to the  market.
     What has happened now? Many roads just do not have footpath. The basics insist that when a road is created, road, drains and footpath have to be constructed as a unit. Earlier there was not much of technology - but there was robust common sense. Now there is modern technology and no sense common or uncommon!
     If by chance the road you chose to walk on does have a FOOTPATH what has happened to it? Food vendors occupy it in the plum places parking their carts - making it a FOODPATH. People crowd round it effectively blocking what is left of it!
     Many ladies walk on the road and therefore the flower vendors are sure to occupy a corner making it a FLOWERPATH .Many varieties will be available in a small space!
     Vendors of footwear are ubiquitous and there is no better place than the footpath to sell them - they convert  the footpath into the FOOTWEARPATH!
      Autos and 2 wheelers and sometimes 4 wheelers are parked on it as if the owners of these vehicles also own the footpath making it a FOOTPARK!
     Some self respecting people are upset and try to tell the vendors that they are blocking the path and being an obstacle. If looks they give could kill, these guys would surely be dead - making it a MURDERPATH!
     Come elections, or festivals the footpaths now will be occupied by the poles and banners - usually holes are dug into the footpath to stabilize the banners - a sure way to destroy it permanently!
     Once I remember reaching the venue at Bangalore late when I was an invited faculty for a lecture for a Post Graduate Medical Education Programme because the road was blocked for some drama festival!
     Is there any remedy for this problem? Probably the change has to come from within. Common sense and civic sense have to be rediscovered. After all the footpath is primarily meant for the pedestrians.
     I only hope that these people who usurp the footpath realize their fallacy and vacate the same it will again be a pleasure to walk safely on the footpath. Let us rediscover the joy of using the footpath properly

THE STORY OF ASCLEPIUS - THE MAN WHO COULD BRING THE DEAD MEN BACK TO LIFE - WHY WAS HE NOT IMMORTAL?

     According to the Greek mythology, Asclepius could bring the dead back to life! This was probably his undoing. What is known about his life history makes an incredible story.
     His birth was indeed controversial and interesting. His mother was Coronis from Trikala of Thessaly. She had a secret affair with Ischys. When Apollo learnt of this, he wanted to kill her. On his command, his sister Artemis killed her on the funeral pyre. While watching this, Apollo felt guilty of killing the unborn innocent baby and rescued it by splitting open the womb - probably the first recorded caesarean section in he history of mankind! He adopted this baby as his own and brought it up under the mentorship of half human half horse Chiron a famous for his medical skills. Thus Asclepius learnt his medical skills from Chiron. He bacme a very successful healer with exceptional medical skills. He mastered the art of surgery and the art of medicine including the use of drugs and aprodisiacs. He is supposed to have given Gorgon blood with magical properties to Athena. Gorgons were Gorgons had snakes for hair, bronze claws, wings and eyes that could turn humans into stones. The blood from left side of Gorgon would kill a man and that from the right side would bring back a man from death.
     Ascalpions were built in his honor and memory after his death. The famous Hippocrates  studied medicine from one such Asclepion on the Kos island and started his medical career there. One should also note that the original Hippocratic oath mentions the names of  Asclapius and his daughter Hygea (goddess of hygeine) and Panacea (goddess of universal remedies). His 2 sons were Machaon and Podalarius who were great surgeons. They healed a 10 year old wound of an archer Philoctetes who later raised the bow to kill Peris to end the decade long Trojan war.
     However, the Asclepion, a rod with a single serpent wound around it is more famous than Asclepius. This signifies his exceptional skills in treating snake bites. It became the symbol of doctors and modern medicine should not be confused with Caducius a staff with 2 snakes intertwined  which is more a symbol of occult art carried by Hermis when he carried the souls from the land of living to the land of the dead.
     Because of the indredible powers of Aesclepius, many who were supposed to die did not die. Hades, the god of dead complained to Zeus the god of skies  who in turn struck Asclepius with a thunderbolt and killed him. Asclepius, his staff and the serpent became a constellation in the sky.
     Even Bible mentions that Moses during the exodus out of Egypt wandering in wilderness in search ofthe Promised Land raised a serpent made of copper on his staff like the rod of Asclapius, called Nehushtan. Mere looking upon it was supposed to heal people with snakebite! Snakes were regarded to have great healing powers and non poisonous ones  were left free in the dormitories where the sick lived. The snakes were believed to rejuvinate themselves by shedding their skin and therefore were believed to cure the sick!

JEAN MARTIN CHARCOT - PIONEER IN NEUROLOGY- ALSO A PATHOLOGIST AND A RHEUMATOLOGIST- BEST KNOWN FOR HIS 18 EPONYMOUS CONTRIBUTIONS TO MEDICINE

     Jean Martin Charcot is considered the father of Neurology. But he was much more than that. He was also a trained Pathologist. He was also interested in Rheumatology. He is considered to be one of the most influential physicians of all times.
     He was born on 29 November 1825. His father was a cottage builder. Being better than his brothers, his father supported only him to persue the higher education in Medicine. A keen observer, a good painter, he had a good visual memory. He was good in German, Italian and English languages.
     He graduated from the medical school of Paris at the age of 23. He was an intern at Salpetriere hospital, Paris. He held various positions at that hospital  including Chef de Clinique(1853), Physician t the hospital of Paris (1856), Professor of Pathological Anatomy at the University of Paris (1872). A position of Professor of the diseases of the nervous system was specially created for him. He established the neurology clinic in 1882. Classical French Neurology was founded by him.
     He would work uninterruptedly into the night and was a prolific writer. He articles regularly appeared in Lancet and BMJ. He also authored many books. He was a popular teacher and his students came from all over Europe. He  adopted theatrical techniques and lectures to teach the students. His famous students included Babinski, Bechterew, Pierre Marie, Freud, and Bouchard, Bornville.
     Bouchard was one of his good students. Bouchard being egoistic felt that he should get equal glory if not more for their joint activities - Charcot- Bouchard aneurysms was an example of this. Bouchard felt very neglected because his name came after that of Charcot!
     He was the teacher of Babinski. Babinski was thought to succeed him. Unfortunately for the crucial selection examination, Charcot could not come and Bouchard replaced him as the chairman. Babinski was not selected and it cahnged his life completely. He became very famous but never became a teacher officially.
     His contribution to the understanding of Multiple Sclerosis and differentiating it from Paralysis Agitans was then considered outstanding. He was a clinical wizard and was variously nicknamed as the 'Napoleon of the Neurosis' and 'Caesar of Salpetriere'.
     His 18  eponymous contributions include - Charcot -Leyden crystals seen in the stools of patients with Amoebiasis and the sputum of patients with asthma; Charcot's (Neuropathic ) joint seen in leprosy, diabetes, Tabes dorsalis, syringomyelia - a non inflammatory hypermobile painless joint; Charcot - Neumann crystals in semen; Charcot's (cerebral ) triad - Nystagmus, Intention tremor, staccato speech seen in Multiple sclerosis; Charcot's( Biliary) triad - Right upper quadrant pain, Jaundice, intermittant fever in cholangitis. Charcot's artery of cerebral Haemorrhage - Lenticulo striate branch of MCA; Charcot - Buochard aneurysms - aneurysms of the perforating branches of MCA  which can result in cerebral haemorrhage.;
Charcot's edemma - a painful edema seen in hysterical paralysis; Charcot's disease or Charcot's sclerosis -Lou Gehrig's disease a rare disease from which the baseball player of that name died; Charcot - Marie - Tooth disease - Peroneal muscular atrophy;  Charcot's hysterogenic zones; Charcot - Wilbrand syndrome - Visual agnosia due to PCA occlusion; Erb - Charcot paralysis - a rare from of spinal syphilis; Charcot's angina cruris - Intermittent claudication; Charcot - Joffroy syndrome of epidural ascending spinal paralysis.
     His pastime was music and Beethoven was his favorite composer. In 1882, University of Wurzberg honored him with a doctorate. He started to get attacks of angina pectoris and his health deteriorated. He died in 1893 of pulmonary edema at Morvan in France.His famous quote inclded " symtoms then ,are in reality nothing but cry from suffering organs". and "to learn how to treat a disease one must learn how to recognize it. The diagnosis is the best trump in the scheme of treatment".  So true!

THE STORY OF HIPPOCRATES - DID HIPPOCRATES REALLY WRITE THE HIPPOCRATIC OATH?

     Hippocrates known as the Father of Medicine epitomizes the Greek Medicine. His teachings in philosophy and medicine have influenced the practice of medicine through the ages.
     He was born in 460 BC in the island of Cos. His father was Heraclides a physician, mother, Praxitela, daughter of Tizane. He had 2 sons - Thesallus and Draco and son in law Polybus. Polybus was his true successor. Hippocrates learnt medicine from his father and his grand father
     He is known well for some of his views. He was the first to say that the disease was due to natural causes and not due to God's wrath. The focus was on patient care and prognosis and not diagnosis which was general. Another concept in the treatment of the disease was "crisis" the point at which the disease would abate or the patient would succumb to it. His therapeutic principles were humble and passive based on the nature's ability to cure.
     He was known for his strict professionalism, discipline and rigorous practice He would always trim his fingernails and had a primitive operating room where he did splinting and minor surgery.
     He contributed many things to Medicine. He is supposed to have written 79 books and 52 treatises - no body is sure how many of these were really written by him. He was the first to describe clubbing of fingers - sometimes called Hippocratic fingers. He described Hippocratic facies He gave very good descriptions of various diseases but did not name any syndromes. He gave the first description of Empyema. He devised a primitive speculum to study piles which must have been the first application of endoscopy He emphasized the importance of diet and exercise. He had the concepts of acute and chronic; endemic and epidemic; exacerbation, resolution, relapse and crisis.
     The most famous contribution to medicine by him was the Hippocratic oath. which is a seminal document on ethics in medicine. It entails good medical practices and morals. It is controversial whether he wrote it at all!
     Soranus of Ephisus, a Greek Gynaecologist of the 2 nd century was his first biographer. After him the famous physician was Galen who lived between 129 to 200 AD Thomas Sydenham, William Heberden, Charcot, William Osler followed his methods.
     Hippocrates is also well known for some of his aphorisms - Gout never develops before puberty on men; before menopause in women and never seen in the eunuchs. - almost true even today. He probably described Behcet's disease and Crohn's disease without naming them  He never spoke of a disease resembling rheumatoid arthritis and so the disease must have been more recent!
     Coins bearing his name and his profile were unearthed from Cos. He is supposed to have died in Thessaly. A sculpted head was found in the cemetary of Ostia which bears a close resemblance to what is now accepted to be his appearance
     It is indeed unbelievable that a sigle person has contributed so much to Medicine. No wonder he is liked, loved, adored and admired. He definitely qualifies to be called the "father of Medicine"
     

WHAT IS MUNCHHUASEN SYNDROME? WHO WAS MUNCHHAUSEN?

Every doctor has experienced patients who create symptoms or exaggerate them mainly seeking attention. They hop from doctor to doctor, hospital to hospital, producing thick charts, undergoing unnecessary admissions and even surgeries supposedly from a mental illness. This disorder has a name - Munchhausen's syndrome
    Karl Frederic Munchhausen was a minor nobleman, a country gentleman with a large estate. He was born in 1720 and joined the Russian army and served there till 1750.
     He returned to his home in Badenwerder. He has an extraordinary skill of story telling. He would tell terrific stories about his pole in wars and his other adventures mostly from his fertile imagination. Most of the events never happened or were greatly exaggerated. Rudlf Raspe in 1771 collected some of these cleverly put stories and published a book.  He had to persue a series of lawsuits to protect  his name.
     The stories included some of these - An effect of storm in Ceylon; how he flogged a wolf( which had attacked him) till its skin turned inside out; Story of an extraordinary horse presented by Count Prozobossy with which he performs extraordinary feats and continues to do so even when the horse has been sevbered into 2 parts; A brass cannon travelling to the moon; building a bridge from Africa to Great Britain; How he sieged Seringapatam; His combat with Tippu Sultan and such other spooky tales
     This condition differs from hypochondriasis and other somatoform disorders in that the patient does not intentionally produce the somatic symptoms. Emotional trauma during childhood or adolescence may be the contributing factors. In Arrhythmogenic Munchhausen, the arrhythmias are simulated. Munchhausen syndrome  by proxy is a condition where the parent will ensure that the child will experience some medical affliction compelling the child to suffer the treatment and to spend a significant portion of the youth hospital hopping and doctor shopping. Some of them even undergo repeated surgeries simulating surgical illnesses.
     In 1951, Richard Ashner published a paper in Lancet and titled it as Munchhausen's syndrome after this person. This was to give medical attention to this condition.
     One has to suspect Munchhausen's syndrome when new symptoms keep cropping up every time a negative report comes. They are eager to undergo new tests, may have multiple surgical scars, history of visiting many doctors and many hospitals.
     Baron Munchhausen became very famous. Books were written about him. Plays, and movies were made about his life. Illustrated comics were produced about his exploits. A puzzle/ hidden object game was produced which was named after him in 2012. In Russia, there is a club named "Munchhausen's grandchildren". Germany has arranged international tourism including the places visited by him. A museum was opened in his name where he had stayed with his wife. A commemorative coin was released by Latvian Central bank. In 1994 a main belt asteroid was named 14014 Munchhausen in honor of the Baron. 

THE STORY OF ROBERT KOCH - HIS FACE OFF WITH PASTEUR - DID KOCH REALLY DESERVE TO BE FAMOUS?

     The disease Tuberculosis is as old as the mankind. It has been demonstrated in ancient Egyptian mummies (100 BC)  and has found a mention in very old literature. Hippocrates called it Pthisis. It was a great killer rightly called the "captain among these men f death".
     The possible infectious nature of the disease was speculated for many centuries. Hippocrates and Galen had suspected its contagious nature. Laennec was convinced that the tubercle was the common factor of all forms of tuberculosis. Schonlein gave it the name  "tuberculosis" in 1839. Pasteur's germ theory in 1862 gave impetus to the research. Jean Antonie Villermin in 1862 proved that animals can get the disease from man by inoculation. Only demonstration of the causative agent remained. There was virtually a race among researchers to do this and finally in 1882, Robert Koch won the race!
     On the 24 th day of March 1882, in the monthly meeting of the Berlin Physiological Society the formal announcement about the discovery of the tubercle bacillus was made.The meeting was chaired by DuBois Reymond and Helmholtz, Leoffler, Ehrlich and other medical luminaries were also present.  There was no applause for the presentation though the audience must have sensed that this was going to be an important invention in the history of Medicine.The reason why it was not announced in the meeting of the Pathological society was because of the poor vibes Robert Koch shared with Rudolf Virchow, (Professor of Pathology), then a dominant figure in the Berlin Medicine. Robert Koch went on to further research in the field. He believed that the Tuberculin was the treatment of tuberculosis. Though he was proved wrong later, it became an important as a diagnostic tool in the management of tuberculosis.
     Koch used Methylene blue as the stain. Culture proved to be difficult. Prof. John Tyndall of Londin used the term "Koch,s bacillus" which was widely accepted all over the world. Erlich developed a method of staining which proved to be superior. In 1887, Ehlich tested his own sputum and found it to be positive! In a paper in 1884, he described what was later came to be known as Koch's postulates. Much earlier, in 1876 he had already described very virulent, spore forming Anthrax bacillus. He visited India in 1883 and identified Vibrio cholerae. During the second visit at the behest of teh British government, he carried out important work on Bubonic Plague , proving that it was transmitted to the humans by the rat flea.
     Robert Koch married his childhood friend Emily Fraaz in 1876. It was a happy mariage in the beginning and they had a daughter in 1878. However after 20 years of he married life, the relationship broke down and ended in a divorce in 1897. 2 months after the divorce, at the age of 50, he married  a young actress Fraulein Freiburg who was only 21. The second marriage was followed by a social boycott and was forced to spend much time abroad.
     In 1883, a controversy arose when Pastuer, calling himself 'second Jenner' tried to use methods of inoculation with the hope of preventing certain diseases. He used nasal discharge from horses who had supposedly died from horse typhoid and inoculated the rabbits with it.  He used saliva from children with hydrophobia and inoculated the rabbits with it. When the findings were presented and discussed, Robert Koch took serious objections - the causative organism was not conclusively proved and the whole experiment was unsatisfactory. He claimed that the death of rabbits in both instances was due to septicemia. Despite all these shortcomings, Pasteur was considered a genuine "path breaker"
     For all his discoveries concerning tuberculosis, Robert Koch was considered the father of scientific study of tuberculosis. In 1905, he was awarded the Nobel Prize in Medicine. 

HEIMLICH MANEUVER - LIFE SAVER FOR THOSE WHO CHOKE - DID HENRY JAY HEIMLICH REALLY DISCOVER IT?

     Henry Jay Heimlich was born in 1920. He was a trained cardiothoracic surgeon He realized that choking was an important cause of death in the USA. He wanted t do something to save lives of those who had choked.
     He was a keen observer. He had observed that abdominal thrusts helped the dogs to get rid of the material on which they had choked - that would dislodge from the throat and come to the stomach. He therefore attempted to try the same thing in the human beings - apply pressure on the chest and see whether the material blocking the throat would come to the stomach. Soon he realized that it was the pressure to the diaphragm that was really needed.
     Heimlich suggested the use of a fist - placing the thumb against the patient's upper abdomen and grasping it with the other hand from the back with quick upward thrusts. He published the technique and its advantages in Emergency Medicine in June 1974. The article was titled "Pop goes the Cafe Coronary" Within weeks, he started receiving reports as to how the technique was saving lives. JAMA was so impressed with this technique that they renamed it as Heimlich Maneuver.
     From 1976 to 1985, the American Heart Association and the Red Cross recommended guidelines on choking nicknamed as "the five and five"- 5 back slaps and if that failed 5 Heimlich Maneuvers. However in 2006 the term Heimlich maneuver was replaced by 'abdominal thrusts'. The drowning rescue guidelines regarded it as not only not useless but also as potentially harmful because it could facilitate vomiting and choking on the vomit. There is no doubt that Heimlich Maneuver saved millions of lives.
     Heimlich was not a one trick pony. He has contributed many other inventions to Medicine. In 1960 s he devised a simple inexpensive unidirectional valve in the Vietnam war which helped to remove blood from the chest of injured soldiers and saved thousands of lives.
     In 1950 s he devised a surgery wherein he replaced the damaged part of the esophagus with a portion of the normal stomach in patients whose esophagus was damaged and resulted in the difficulty for the patient to swallow. He claimed that they were happy and could enjoy normal meals with the family.
     In 1980 s he devised a Micro-trach transtracheal catheter to deliver oxygen more efficiently
     Heimlich went on to claim that his technique would even help the patients with severe asthma. His adversaries however argued that though it helped remove blocked secretions, it did not help relief from the asthma in any other way.
     His unusual experiment in China where he tried to induce Malaria  -Malariotherapy- to therapeutically benefit patients with Lyme disease and AIDS by allegedly 'strengthening the immune system' was severely criticized and he was even labelled as a fraud by some .
     His worst critic was his own son  Philip Heimlich who later became the county commissioner of  Hamilton County, Ohio, always held the view that the real discoverer of the maneuver was a doctor by name Henry Patrick and Henry Jay Heimlih only stole the idea fro him!
     Whatever the controversy may be, there is no doubt that the maneuver saved millions of lives. In 2002, George Bush, then the President of USA survived choking. Tennessee William, a Pulitzer prize winner who choked on the cap if an eye drop bottle and Marshall Subrato Mukherjee , India's first chief Air Marshall who choked on fod in a Tokyo restaurant were not so lucky. Both died of choking!

THE CASE OF THE" FROZEN ADDICTS" - WHY DID THE ADDICTS FREEZE? WHAT HAPPENED TO THEM?

     Drug addiction is a serious thing. The extent to which an addict would go is decided by the desire, craving, knowledge and intelligence of the individual. He would go any length to procure the drug or even to manufacture it! This is the story of such 'committed ' addicts!
     Barry from Maryland spent some time in India with his family He initially bought the medicines from the street. One day in 1976, he took the drug manufactured by him intravenously. He felt severe burning at the site of injection and a sense of euphoria. Within three days he became immobile and mute. He was admitted to a hospital with a diagnosis of catatonic schizophrenia and was given phenothiazines to which he did not respond. He was promptly shifted to NIH where he was evaluated.Though the symptoms and signs closely mimicked Parkinson's disease,  the suddenness of symptoms made them suspect a toxic etiology. Their research showed that he had tried to synthesize a chemical called MPPP ( related to Meperidine). He inadvertently overheated the mixture and synthesizes MPTP instead. They had come very close to the answer. The next step was to try the hypothesis in the rats. They injected the rats with the same compound. Rats are not as susceptible to the toxic effects of MPTP and the catatonic phase seen was temporary. This resulted in a setback and the  further research did not get priority. The issue became dormant.
     In 1979, Barry's case was published. L Dopa was tried. He improved significantly and the speech returned. In 1978, he died of cocaine overdose. In 1982, George was found to have similar syndrome. He was also having extrapyramidal syndrome - Diphenhydramine did not work. He rapidly worsened and became stiff and immobile. He was later evaluated at Stanford.
     William Langston tried to find a connection. MPTP seemed to damage the mitochondria of dopaminergic neurons. Dopamine reuptake blockers could prevent this damage. L Dopa gave temporary relief . Drug holidays prolonged the response but eventually the drug stopped working. Eventually a steriotactic implantnation of fetal tissue was done in Lund, Sweden. This was tried in 2 patients George and Juanita and both did well.
     The research showed that the compound, MPTP was like a bullet to substantia nigra resulting in immediate and long lasting damage. This compound gave an insight into the the role of environmental causes in the genesis of Parkinson's disease.
     The addicts had a very bad outcome. They became immobile and mute - truly " frozen addicts". Only some fortunate ones recovered. Others remained so for long periods.
     The the case of the "frozen addicts" opened up a new chapter in the study of environmental  toxins in the causation of PD. It also gave an insight into the animal studies in PD which is otherwise almost impossible due to the insidious onset of the disease! Thus the "frozen addicts" came as invaluable research tools!

THE EPIDEMIC OF THE WITCHES' CURSE - WHY WERE HUNDREDS OF "WITCHES" IMPRISONED AND EXECUTED?

     The place was Salem. The date 1692. The event - a tragic community event leading to the death of 20 innocent Puritans
     In 1691, 8 teenage girls presented with altered behavior, gesturing, posturing, speech disorders, convulsive seizures - then known as "unknown distempers". A possibility of witch craft causing this was seriously considered. and this was even testified by the sufferers. 20 residents were tried and hanged for the offense. 150 more were incarcerated.
     Some sought alternative expanation for these phenomena - mass hysteria, fraud, politics, social devisiveness were considered. It was noticed that the symptoms started after cold winters. This phenomenon was observed to have 2 presentations - Acute neurologic presentation - hallucinations, convulsions,  paranoia, mania, sweating, spasms, jerks what we today refer to as acute Serotonin Syndrome. Chronic form was associated with Gangrenes of various parts of the body - Intense burning pain in limbs leading to (in severe cases )dry gangrene, black and mummified limbs which sometimes dropped off. Some women suffered spontaneous miscarriage.
     Finally the phenomenon was traced to contaminated rye - the disease was Ergotism  When this view was accepted, the new incoming Governor ordered the unconditional release of 150 incarcerated suspects.
       Ergot thrived in cold winters followed by damp spring. Acute phenomena observed was really acute ergotism called by some neurologists as St. Vitus' dance ( reserved by some only for Rheumatic Huntington Chorea). Chronic gangrenous ergotism  was referred to as St. Antony's fire St Antony was a pious ascetic who lived in Egypt near Red sea. He fasted for long periods and used to have hallucinations. An order founded in Fance in 1100, took his name. They developed some treatment for the ergotism which seemed to work though the real improvement was probably due to consumption of a diet free of the contaminated grain. Sometimes the amputated limbs were left at the shrine as symbols of appreciation for cured patients.
     Slowly the people noticed the vasoconstrictive and hallucinogenic properties of Ergot. Its use in labour was started in  1600 s though the acceptance came in 1900 s. The active substance useful in labor was isolated by Dudley and Moir in 1935 to be usewd IM or IV in PPH.
     Though useful, the derivatives of Ergot Ergotamine and Dihydroergotamine have side effets - nausea, vomiting, abdominal pain, diarrhea, tingling and numbness, peripheral and coronary artery vasoconstriction. So Ergot derivatives should not be used in peripheral arterial disease, coronary artery disease, severe hypertension, stroke, pregnancy.
     These drugs are metabolized in the liver by the enzyme cytochrome P 450 system .. Any substance leading to a delay in its metabolism could precipitate r enhance the side effects. Macrolide antibiotics like Erythromycin, antifungals like ketoconazole, protease inhibitors used for HIV infections, antidepressants like fluoxitine can all result in this.
     The experience with Ergot should have taught us to be more careful. Unfortunately it has not. We still find humans continuing to be victims of neurotoxins coming in from their own environment usually polluted by humans for the purpose of greed. - tainted products, drugs of abuse, contaminated bread, contaminated water and the like. Despite our knowledge, many of the suffers and the causes must be going unnoticed and the perpetrators unpunished. 

CASE OF THE "ANGRY TENANT" - WHY DID HE SHOUT AT THE LAND LORD EVERY MORNING?

     This is a true story which happened at the beginning of my career.It was the golden era of medicine as the clinical medicine dominated and some investigations were available. The doctor who had good clinical skills was assured of work. However, one had to be meticulous and exhaustive.
     Before getting a job in the medical college, I was working at a private hospital which had a good patient load. The owner of the hospital was also a land lord owning substantial land which was used for cultivation. His tenant was brought to the hospital and I was asked to examine him.
     The complaint of the patient (tenant) was very peculiar. He would abuse and shout at the land lord every day. He was the main tenant, the leader of all workers. He was the key worker with whom the land lord had to negotiate for getting the work done. Usually such workers behave in a high headed manner. But the land lord would negotiate with them and settle the issue usually in his own favor. This tenant till recently was very respectful though his land lord had to bribe him sometimes to get his loyalty and keep him happy. Of late, he had become very arrogant. This obvious change in the behavior was noted by the land lord and the tenant was brought to me.
     I saw him in the evening. He was courteous, smiling and willing to talk and willing to be examined. I found him almost normal. Only thing he told me was that he felt very very hungry in the mornings and lost his temper if the breakfast was delayed. When I went for work in the morning, a lot of people surrounded his room. I was told that he created a scene and was shouting and saying bad things about the land lord. This went on for some time. By then the breakfast arrived and he was visibly relaxed after that.
     At first I thought that I was imagining things. But I was sure of my observation. I had to wait for one more day to validate the findings. The same scenario repeated the next day. I had arrived earlier to witness this myself. Indeed it was truly happening. The person who was sober in the noon, evening and night would flare up early in the morning - the transformation was genuine and reminded me of Dr. Jekyll and Mr. Hyde. Now that I had a lead to go be - abnormal behavior in the morning - I had to follow it and crack the case.
     I had never seen such a case before. Then I tried to correlate the chain of events physiologically. The only difference in the morning as compared to other times of the day was hidden in that word - the event that made him almost normal - breakfast! On eating the first meal of the day, one was indeed breaking the FAST! This meant one thing - there was a connection between the fasting and the clinical features. The change behavior was precipitated by HYPOGLYCEMIA! Now I had to prove my hypothesis. Next morning I went to the hospital even earlier, and made sure I was there when the changed behavior happened. I drew the blood myself. That was sent to the lab for knowing the glucose levels. Lo and behold! The value was very low - something like 40 or so proving that hypoglycemia was indeed the provocating event.
     My next objective was to prove the cause of low sugar which was happening spontaneously without any medicines known to produce it. I had read that retro peritoneal sarcomas can do it but had never seen a case to that effect.
     I did some reading and found that some other tumors like hepatomas and uterine leiomyomas also did that. Those were easier to pick up clinically. The clinical examination was absolutely normal and therefore retro peritoneal sarcoma became the most likely diagnosis. Retro peritoneum is a hard place to examine bare handed. I was trapped in a cul de sac.
     I did the next thing that was common at that time - ask the seniors for their opinion. They were very helpful. They agreed wholeheartedly with my line of thinking but warned me that I was speculating something that was very rare. Finally, I discussed the issue with the land lord who was also the owner of the hospital. I expected him to reprimand me for having thought of a rare possibility. To my surprise, he heard me out patiently, asked a few questions and said " I appreciate the reasoning and the logic. You have worked hard t crack the case. I am convinced you are right. I will operate tomorrow!". Needless to say, I spent a sleepless night.
     The patient was promptly operated the next day. There was a tumor in the retro peritoneum. The biopsy report came as Sarcoma. The patient instantly recovered from the behavioral changes. I will never forget the case. More importantly,  I will never forget the doctor's gesture of trusting a young doctor!

THE STORY OF MICHAEL DEBAKEY - MENDER OF BROKEN HEARTS

     Surgeons trying to mend broken hearts is a recent phenomenon. Michael DeBakey was one of the pioneering surgeons in this field which till then was much reared and respected by the surgeons. The reason for the hesitation of the surgeons was the fact that the same scalpel which could save lives would bring the patients close to death With a fine understanding of the subject and a series of bold steps, the Texas surgeon opened up the hitherto forbidden territory leaving a string of surgical operations to mark the way.
     When DeBakey entered the medical school, arterial aneurysms( deadly bulges on the arteries) and the occluded arteries were thought to be the signs of impending death. Undaunted, DeBakey improvised surgical techniques by replacing the diseased portion of the artery with a strong , healthy graft.
     Soon he realized that for a lasting success, he had to depend not on cadaver arteries but a more durable and a better substitute. He and his team tried many synthetic materials. Fianally in 1953, a machine was designed to manufacture what DeBakey exactly wanted. A seamless, knit, Dacron tube was born. The body was found to adapt remarkably well to the artificial arteries. New tissue would encase the synthetic tube, building in effect, new arteries.
     These Dacron grafts broadened the horizon of the vascular surgeries. DeBakey could replace Aortic Arches, give his patients new Abdominal Aortas, build Bypasses around hopelessly blocked arteries. He could bypass even the delicate coronary arteries. Whenever he could clear the coronary arteries, he used slips of the graft material to widen the arteries. He used these skills to ease the patients' suffering from narrowing of coronary  arteries and carotid arteries (to help the stroke patients)..
     Naturally he became one of the world's foremost vascular surgeons. He now focused on the needs of the heart itself. He knew that the heart needed rest to recover from radical surgery. He found a solution in 1966. He implanted a device into the chest of a woman whose weak heart was adjusting to 2 newly implanted valves. After 10 days, the heart became strong enough to take over and the pump was removed. This success convinced DeBakey to build the ultimate gadget of his dreams - the artificial heart. was a possibility. He decided to wait for some more time so that some more research could be done. Thus he was a pioneer in the field of Coronary artery bypass surgery, Carotid endarterectomy and Left Ventricular assist device.
     He worked in close association with Denton Cooley. Due to a misunderstanding, they fell apart. DeBakey wanted to postpone the first implantation of the artificial heart scheduled for 4 April 1969 due to a speaking assignment in Texas. Unfortunately Denton Cooley went ahead without his authorization and performed the surgery. However, they reconciled in 2007 and DeBakey invited Cooley for his Gold Medal ceremony and induced him into the Michael E DeBakey international surgical society. -In 1987 then President Ronald Regan awarded him the Presidential Medal Of Science.
     In 2005 at the age of 97, he developed aortic dissection. Though he initially refused, the surgical team prevailed upon him and operated. After a series of complications and a 8 month hospitalization, he fully recovered and was grateful to his team! He died on July 21 2008 of unspecified causes.
     In his lifetime he set an example for perfection. He regularly put in 24 hour days and worked tirelessly. He deeply mourned whenever a patient died. He used to say "You never get over that. Never!".
     One patient put it thus "The 2 days I was previleged to put my heart in your hands, I learned what Blake meant - For mercy has a human heart and pity a human face!".

WOULD YOU ATTEMPT SOMETHING NEW WHEN EVERYONE RIDICULES YOU? - WERNER FROSSMANN'S VOYAGE TO THE HEART!

     How many of us chose to think and act differently when almost everyone we know ridicules the concept? It requires a lot of courage to think and act 'differently' in a scientific arena. Today I would like to narrate the story of Dr. Werner Frossmann who did exactly that. What happened to him makes an interesting and highly motivating reading!
     Even as a student of Physiology  Frossmann  was a keen observer. He had seen an image of a man holding a rubber tube inserted into the jugular vein of a horse in an old French Physiology book in early 1920 s. This primitive picture left an indelible impression on the mind of this youngster for several years.
     After his education, he became in intern at a small hospital outside Berlin. He suggested to his supervisors  that such an experiment would be very rewarding if conducted and would give a lot of information about the heart. He went on to argue that this can be safely performed on man.
     His supervisors summarily disagreed. They forbade his testing the procedure on a patient. Frossmann was determined. He offered an option. He said he would test it on himself! This offer was instantly refused. Nobody believed that he was right and that the experiment was safe.
     Frossmann was made of a different stuff. He was certain that he was right and decided to try it out on himself with a secret experiment. He however thought that a vein in the arm would offer a safer route that a vein in the neck. With the help of another doctor, he anesthetized the crook of  the arm, cut open a vein and inserted a slender  rubber tube into it and asked his friend to push it forwards. The doctor who was helping lost his nerve midway and quit the experiment saying it was too dangerous.
     In the summer of 1929, Frossmann tried it again this time with the help of a nurse. Hesitantly she helped him and guided him to the fluoroscope and held up a mirror so that he could see a shadowy image of his heart He watched the mirror and slowly advanced the tube to his heart. When he advanced the tube to 25 and a half inch, it entered the heart.He went into the X Ray room demanding a X Ray be taken. The technitian instead ran out and alerted his colleagues. A well meaning doctor tried to pull out the catheter. Frossmann had to kick him a couple times on his shin to get him back to his senses. He tried the experiment 8 times in next 2 years and even injected a dye into his own heart on one occasion. He had done the first cardiac catheterization without realizing it!
     Frossmann moved out to a small West German town of Bad Kreuznach and started to work there quietly. All of a sudden his work got recognized - he was awarded Nobel Prize for Medicine in 1956. along with American Cardiologists Andre Cournand and DW Richards. The sudden success left him stunned. He felt, remembering with pride, "like a village pastor who is suddenly informed that he has been made a cardinal!".
     I wonder how many of us would proceed to prove a scientific fact on the face of a strong rejection? This is one example where one understands the importance of scientific reasoning and intuition over the current trend of "evidence based Medicine!"

PAUL DUDLEY WHITE - THE CRUSADING CARDIOLOGIST WHO GOT RECOGNITION FOR HEART DISEASE!

     In 1911, Paul Dudley White entered Medicine. That was the year the heart disease was participating in the grim race with 2 better known causes of death - Tuberculosis and Pneumonia.  In fact, he was one of the first specialists in Cardiology which till then was considered an insignificant field by his teachers.
     Plunging into the study of heart diseased, he pioneered the use of Electrocardiograph - then a recently invented tool which recorded the activity of the heart by charting its electrical impulses. In 1914, he set up an ECG machine in the basement of the Massachusetts General Hospital. By 1931, he had collected 21,160 ECG s and case histories. By combining and analyzing this data, he wrote a 10000 page book on Heart Disease. It went on t become the standard textbook of cardiology for many decades.
     He also studied the hearts of animals. He used the electrocardiograph to study the heart beat of animals. He found out that a larger heart beats fewer times than a smaller heart. The heart of a humming bird beat over 1000 times a minute where as that of a whale beat fewer than 15 times a minute!
     He also realized that in the humans, the difference in the heart size could trigger significant variations of the heart  beat which sometimes could be dangerous. He realized that the athletes could have enlarged, slowly beating hearts which could be essentially normal. He warned the other doctors about defining the 'normal' heart with too narrow a definition.
     He became very well known among the doctors. In 1955, Eisenhower, the President of the USA suffered a heart attack while at office and White was summoned to treat him. He would report the daily progress to the people of the worried nation. He lectured to the country about the disease, its causes its treatment in a simple understandable language. This made him very famous with the public also.
     White was a strong advocate of exercise. He was of the opinion that the labor saving devices and sedentary jobs made the Americans more prone to heart attack. He went on to declare " death due to heart attack before 80 is not God's will, it is man's will.
     At the age of 75, he bicycled 30 miles per day. He used to say "people hold up their hands in horror that I do it!". But I hold up mine in horror that they don't!".
     Finally he retired at the age of 86. Soon after, he suffered a stroke. While he was convalescing in the hospital where he had practiced for 58 years, a patient arrived and requested an examination by doctor White. The doctor obliged and examine the patient wearing a bathrobe.
     Paul Dudley white lived his work and also loved it! He also thrived by it! He had a terse aphorism - "Hard work never killed any man!". He was a living example of that!

THAT'S MY DAD! - SOMETIMES I WONDERED WHETHER HE WAS TOO OFFICIAL!

     I got a seat for MBBS in the First ever National level competitive exam held by the KMC in 1971. I was thrilled. I ran home and told my mother about it. When my dad came for lunch it excitedly told him too! He asked me how much it would cost. I said the donation would be 5000 and annual fees would be 1075 each year for 5 years. He congratulated me and informed me that I had to fund the donation  myself and he would gladly pay the fees. I was shocked. I was a mere PUC pass and had no assets of my own. My only hope was my friend whose father was a Manager in the Canara Bank. I ran to him and explained the situation to him. He was very nice. But he did not have the required seniority for lending an education loan of 5000.He made a special trip to HO at Bangalore and did the needful. Just after that I qualified for a Government Merit Seat and got a seat at Mysore. I applied for a mutual exchange and fortunately it came through after some unexpected developments. The next stop was at the office of our founder - he used to meet everyone personally. He discussed the situation with me. I appraised him that there would be no donation if I took a merit seat and he also would have an extra seat at his disposal. He appreciated me ( I was very touched by his gesture) and blessed me. I got my money back and settled the loan with the bank.
     I  was selected for the National Merit Scholarship after my SSLC based on my SSLC performance. I would get the scholarship till I completed my education. There was only one snag - Parent had to sign that the income was below a certain level. I happily went to my dad. His income was exact cut off value. He refused to sign saying that it was not BELOW the cutoff value. No amount of pleading worked. Then I used what I thought was the trump card - "If you do not sign, the offer would pass to the next boy and his father would sign and would get all the benefit even if the income is higher"! I said. "That, my boy, " he said, "is the difference between his father and your father!".
     When I joined MBBS, my friends told me I was 'safe' as he was a staff member. To my horror, he resigned the day I joined. He did not want any favors. He told me only 2 things. "1. Do not ask me to put in a word to anyone. I do not mind your failing. I will gladly look after you as long as you work hard. But no influencing. Achieve things if possible on your own. 2. I have a reasonably good name in the society. Do not do anything to tarnish it."
     Just after passing the Rotary Club which he was a member of asked me to join. I told him about it. He immediately said - "I have a god name in the Rotary movement. Join only if you can follow all rules and stick to the timings. Otherwise wait till the time you can do these things and then join". I am still not a Rotarian!
     Once I had to see a patient in a hospital. I  said I will come at 2 o click. I had to drop my dad somewhere. He accompanied me and asked me to see the patient first. I reached the hospital at 2 15. I saw the patient and came back. He asked me "How many people were waiting with the patient?" I said "4". He immediately said "Then you have wasted 1 hour 30 minutes". I did not understand. He said 6 people including himself and me waited for 15 extra minutes which meant a total of 1 and a half hours was wasted. "Never do that again. Everyone's time is as precious as yours" he said emphatically. "If they are not there on time, you walk away". 

DOES THE GOOD THAT YOU DO COME BACK? MY EXPERIENCE IN HYDERABAD!

     The occasion was a conference at Raichur. My colleague, myself and 2 lady doctors (both post graduate students) were travelling together. First lap of the journey was to Hyderabad by flight. It was a pleasant journey and was uneventful. We were supposed to reach Raichur by road - an Innova was arranged for the purpose. We had to wait for some time at the airport for the arrival of the vehicle. It was a new Innova.
After about an hour's delay, the vehicle reached us and we got into it.
     The driver hit the road and was travelling at a speed of about 120 Km / hour when an unforeseen incident happened. It was a 8 lane expressway 4 lanes on the either side of a broad divider in the middle with plants planted in it. . A huge truck was slowly travelling on the extreme right lane slowly. In  fact, he should have taken the extreme left lane - but that is how the truck and the bus drivers drive with no rules followed and no civic sense. My colleague who was sitting in the front, turned back and started talking to me (I was sitting on the backseat). As I was speaking to him, I could see the road at the periphery of my visual field. I thought I saw a small dot which moved. To my horror, I suddenly realized that it was a human being. I saw it at a distance of about 2 KMs and it took us barely a few seconds to reach that area at that speed. He must have felt that we are fay away and must have tried to cross the road. He came right in  front of our vehicle, hit the windshield and was thrown off bleeding from the mouth,nose and ears and was deeply unconscious. We stopped our car. Reflexly, I  knelt down to examine him for signs of life and to try to save hi till he reached a hospital. After checking him for 3 minutes I found only a feeble pulse and no respiration at all. I frantically called the patrol police and they scoffed at my suggestion. I also realized that I was on the same road exposed to the same risk as the person who just died.
     With nothing better to do, we stood at the roadside hoping for some vehicle to take us. To our bad luck, KSRTC buses were full and Andhra buses were running full. A burly gentleman stopped his car and held me by my arm and invited all of us to travel with him. He looked like a antisocial person but then, was the only hope for us. I persuaded my friends to get in. He promised to drop us at the next station. To our continuing bad luck, no vehicles were to be found in that place. He voluntarily took us to 2 more stations where the same fate awaited us. The he took us to a toll gate where all vehicles had to stop compulsorily. He saw to it that we got in. We had to stand. We offered the 2 available seats to the ladies.
     Then I asked him the million dollar question - why did he chose to help us? His  answer was simple - you tried to help my man - all along risking your own life! He went on to add that we would have been promptly robbed of all our cash and valuables in the next 30 minutes by a gang of highway robbers. When I asked him how he knew all this, his reply was short and shocking. Her was a reformed member of the gang! The person who died was a current member - a petty pickpocket!
     Most of my professional career I worked at the Wenlock Hospital - drawing a salary 25% of what I would have had I worked in the corporate side. I enjoyed my teaching job and treating the poor patients.  I think these poor patients bless us from the bottom of their hearts and the blessings do work. There were many instances in my life where I got this feeling repeatedly. I do not have any other explanation for the timely help that we got that day. Do you agree?

WHY WERE THE CATS GOING ROUND AND ROUND AND COMMITTING SUICIDE AT THE MINAMATA BAY?

     In 1956. cats in the Minamata bay walked around in circles, had convulsions , stumbled  around,  and seemed to commit suicide by jumping into the Minamata bay of Japan. This finding gave an early break in a series of patients with peculiar clinical features. What both the cats and the people had in common was that both ate the local fish. In 1956, a 5 year old girl developed what looked like encephalitis. 8 days later, her sister also developed similar illness. Altogether 54 patients were found to be suffering from Minmata disease. There were many similarities among these patients. Each one had eaten either fish or shell fish. Nearly all lived along the Minamata bay and were occupied in the fishing industry. Epidemiologists suspected the local fish as the cause but could not say why. To prove their theory, they brought cats from 100 miles away and fed them with the local fish. Same disease followed almost conclusively proving that eating the local fish was the cause.
      To understand "why" we have to go back in time . In 1906, a small factory was established in Minamata by the Chisso corporation - a carbide plant for the production of Acetylene. Fertilizer production was also added in 1920. In 1951, the plant began manufacturing acetaldehyde for the used in plastics which involved mercury oxide as the catalyst. Inorganic mercury used was methylated in an acetylene reaction tank forming methyl mercury which was highly toxic. This had to be recycled. As the recycling was expensive, the company started to dump the waste directly into the bay. Locals and the fishermen complained. The silence of the fishermen's onion  was bought by paying the fisherman's union to keep quiet. More than 100 tonnes of mercury was deposited in the bay contaminating the water and the marine life within. Only in 1940, mercury as the toxin was seriously considered after a similar poisoning from a seed company in Britain.
     The epidemiological research proved that the disease is not infectious or contagious. They said that dumping of the mercury waste was the cause and asked for a ban on fishing. Due to inaction, none of the recommendations were followed and many more  persons also became ill. In 1968, another similar outbreak was seen in another town of Japan - Niigata due to water contamination at Agano River. . The public became proactive and saw to it that the Chisso company halted the manufacture of acetaldehyde.
     Minamata disease had 2 major victims - the patients who consumed contaminated fish usually in large quantities and their offspring. Clinical features included ataxia, incoordination, Paresthesias, constriction of visual fields, tremors, dysarthria. Autopsy revealed neuronal damage involving the cerebral cortex and the cerebellum. A variety of Congenital Minamata disease was seen with cerebral palsy like features at birth due to intrauterine exposure to toxic mercury. Mental retardation, limb defects, cerebellar ataxia, dysarthria, chorea microcephaly, hypersalivation were seen. The features developed 6 months after the birth reflecting the sensitivity of the developing nervous system. to the industrial toxins.
     This episode taught us an expensive lesson - there are no shortcuts to waste disposal. Buying silence does not stop the effects of industrial pollution. This reflects the collective greed of the manufacturers, trade unionists and the society. More than 2 billion  were paid as compensation which negated all the concealed illegal savings!