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! 

THE STORY OF A GIRL WHO WAS BEATEN BLACK AND BLUE BY HER FATHER - BUT WHY? HOW SHE WAS HELPED?

     It was just an ordinary day. Those were the early years of practice when the patients were few and far between. There was this banker, a promising one at that. Professionally he was doing very well. He had 2 daughters. Normally all 4 would come together for any one's consultation. I thought it was a happy family.
     That day they came for the elder daughter who was about  6 years old studying in the first standard. . She was weeping. Body had bruises. It looked like she had been beaten black and blue. On inquiry, I was in for a surprise. She had been badly beaten up by the father! This was a delicate issue and I had to tread the path very carefully. I asked the mother how she sustained the injuries. She promptly replied that the father her reprimanded her for her poor scholastic performance. I was surprised. I asked her what she meant. She said that the girl was very backward in studies and stupid. This was an irritating factor for the father who was busy with his profession. When he came home after a hard day's work, mother would complain to him about the daughter. Her performance in school was awful. Tuition teacher had almost given up. She never finished home work. She hardly ever did anything right in the school. Teacher and the mother were very worried. Feeling irritated after a hard day's work, the father would lose his cool and beat her up real bad!
     I decided to interact with the girl. She was shy. She was a bit reluctant to interact with me. After a little bit of coaxing, she opened up. I asked her her name and she replied correctly. I asked her to write it. She tried but was all wrong. I asked her about alphabets and she could not answer - unusual for a 1st standard girl. I wrote an alphabet - she read it wrong. I have a bad handwriting. So I now wrote in big size capital letter and she was still wrong. I told her that the alphabet was A and asked her to name something starting with that alphabet. She said Zebra! Obviously wrong. Then I showed her some pictures and asked her to identify them. A house, a tree and the like. She could not. She was bad in repeating what was tols. She could not recite even one nursery rhyme. I realized what the diagnosis was - Learning Disability - Dyslexia. Faculty of recognition of alphabets / pictures / numbers was all wrong. LBLD -Language Based Learning Disability could consist of calculation problems, reading problems, difficulty in auditory processing, repetition, and sometimes motor incoordination.
     I took the parents into confidence. I explained to them what dyslexia was. I also told them that the child was not doing it intentionally. They were surprised. They still felt that the girl was beyond education and therefore stupid whatever the label was. She was a abnormal child and a academic liability. It took me a lot of effort to tell them that there is indeed a solution. She would have to be trained in a special school and would require personal attention and training there. They were a bit reluctant because they saw it as a means of segregation and also felt that the child would be marked as 'different from the est' if she attended a special school. After counselling them and also sending them for special counsellers finally they agreed  with the suggestion o send her to a special school. I am glad to say the girl improved a lot and did well for herself.
     It is very interesting to note that children with these disorders get easily marked in an ordinary school. They manage well in their later life. Obviously the skills required for a career later are much less than those required in the years of schooling! The father went on to become a very successful a banker and held one of the topmost possible position in the banking industry just before his retirement.  This also shows that skills of very fine understanding of human nature and man management are not really necessary to be an outstanding professional . They get easily overshadowed by the extraordinary professional skills!
     

THE GINGER JAKE PARALYSIS - ONE OF THE CLASSICAL MYSTERIES IN THE HISTORY OF NEUROLOGY - HOW IT WAS SOLVED?

     In 1920, 18th amendment prohibited the sale and import of all alcoholic beverages. Attempts were made to produce legal alternatives to usual alcohol. A cottage industry started with this intention. Alcoholic extract of ginger was considered to be a patented medicine This liquid extract of Jamican ginger was called "Jake" and  could be sold legally.
     To curb the abuse of Jake, a standard formula was defined for its manufacture (USP) . The extract had to contain 5 grams of ginger per ml of the solvent. This resulted in a highly unpalatable bitter concoction.People were encouraged to mix this with soft drinks to make it taste better Agriculture department
occasionally boiled the product and studied the extract in detail including the weight of remaining solids.
     In order to make the product cheaper, alternative solvents were tried. Harry Gross, president of Hub products, used TOCP (TriOrthoCresyl Phosphate) thinking it is safe. Shortly after its release, thousands of people in Tennessee, Oklahoma, Kentucky suffered a mysterious disease manifesting as an ascending paralysis. An estimated 50000 people were stricken with paraparesis  or paraplegia.
     Dr. Epraim Goldfain was the first doctor to recognise it. In February 1930, he saw a man with a rapidly progressive foot drop. Within a short time he had 65 patients presenting with this mysterious affliction. Most of them were poor workers habitually consuming Jake. Working on this and other similar clues, the Maurice Smith and Elias Elvoe of NIH after analysing the samples determined that the toxic component to be TOCP These findings were confirmed by animal studies. Music industry picked it up and it went into 12 blues from 1928 to 1934. An United Victims Of Jamica Ginger Paralysis was formed with 35000 members belonging to the poor class.
     Later 105 people including 35 children died of Ethylene Glycol poisoning. Food, Drug and Cosmetics act was passed in 1938 to prevent any sale of medicines without safety testing. Die to weak laws, Gross got away without any Jail time till he again exported 640000 oz bottles to California after the ban He then served a 2 year jail sentence.
     Symptoms of Ginger Jake paralysis developed in a week of the intake starting with the abdominal cramps, later involving the legs and then the paralysis ascended. Sensory symptoms and  bladder involvement was rare. Some developed spasticity later suggesting a motor neuron involvement. Peripheral nerve and spinal cord were also seemingly involved
     The Ginger Jake paralysis taught us a lot about other neurotoxins also. Organo Phosphare Induced delayed Neuropathy was picked up later. Thus TOCP could involve peripheral nerve (long fibres) and the spinal cord. The Ginger Jake tragedy was one of the largest mass poisonings in the history of neurology, many others were  picked up later. These interesting cases included Peripheral neuropathy from Arsenic contaminated beer, Myoclonic encephalopathy mimiking Crutzfeldt - Jakob disease from GI preparations containing Bismuth; Encephalopathy and cerebral edema Triethyltin laced antibiotics to name a few.
     Needless to say the Ginger Jake was withdrawn and the disease disappeared!

THE PRICE THAT SERVETUS PAID FOR DISCOVERING THE SCIENTIFIC FACT AND TELLING THE TRUTH!

    " He who really understands what is involved in the breathing of man , has already sensed the breath of God" proclaimed the 16th century Spanish theologian and physician Miguel Servetus. Through the study of anatomy, Servetus sought rational explanation for the Bibilical passages placing the man's soul in the blood. He wondered how the breath of God reach the blood? 

     In 1553, he published his last work, the treatise Christianity Restored containing a passage describing the path of blood from the heart to the lungs. Servetus had discovered the pulmonary circulation. In doing so, he challenged the wisdom of Galen whose doctrines had survived the Middle Ages to become dogma. Galen believed that the blood mixed with the air in left ventricle( which he believed reached the left ventricle from right ventricle  through tiny pores in the midwall) to become "vital spirit" with the breath of God. We now know that this is not true - blood from the right side of the heart that is from the right ventricle goes to the left side through the pulmonary artery.

       Servetus challenged Galen's then conventional  view and said that the breath of God was produced by "another contrivance". He noted that the blood travelled from the right side of the heart to the left side by the way of a "lengthened passage through the lungs in the course of which it is elaborated and becomes of a crimson color. He was literally describing the pulmonary circulation. "After mixing the blood became a  fit  dwelling place for the vital spirit " and finally entered the left side of the heart. 

     This fact was not observed. When William Harvey described the blood circulation 75 years later, he did not know of Servatus's work. The work of this Spaniard went unrecognized till about 1700 when an English  surgeon discovered the passage. The theological doctrines declared heresy and Servatus had become a casualty of a religious battle. 

     It should be noted that Servatus lived during the period of Reformation, a period of religious ferment that led to the division of the Roman Catholic Church and the advent of the Protestantism. 

     Rebellious and outspoken, he published his first challenge to the church dogma at the age of 20. The work , however, opposed the fundamental doctrine of Trinity. This caused a furor resulting in Servetus fleeing from his house in Switzerland. He moved to Paris and studied Medicine under the pseudonym Michel Villanovanus. After  his graduation, he became the physician to the Archbishop of Vienne. His interest in theology continued to dominate his life. 

     Theologist John Calvin  at Geneva. was a prominent protestant reformer then. Hoping to get Calvin's  approval, Servatus sent him a copy of his Christianity Restored. Contrary to his expectation Calvin was so outraged that he vowed to get Servatus executed if he ever set his foot at Geneva. Undaunted, Servatus got 1000 copies of his book printed in France under a false identity. However he was discovered, seized and handed over to the christian authorities. He knew that his fate was sealed. He somehow escaped during his trial.

     He appeared in Geneva a few months later. Apparently, he was tempting the fate. Calvin had him arrested and put him on a trial for heresy. In the trial, he was found guilty of "infecting" his readers with "unhappy and wretched poison". 

     As the punishment, Servetus was burnt on stake on an October afternoon in 1553. A copy of his offending book was strapped to his waist. 

     I am sure you will agree Servatus was a true hero - he not only discovered the inconvenient truth but had the courage to go all the way to propagate it even if it meant death to him! Science progressed by the painstaking research and  heroic sacrifices made by him and the likes of him!

     

THE UNFORGETTABLE MANIPAL GLOSSARY!

     No one ever forgets their life at Manipal. Most memorable is the Manipal Lingo. The special terms we used there. I will share some of those that  I recollect.
    " IST" - Indian Standard Time - to denote the delay in the arrival for an appointment or a class. Sometimes shortened to IT - Indian Time.
    " No probs"- When a desperate friend asked "can you lend me ten rupees?" an equally desperate friend would answer "no probs - only wait till the month end!"
     Grandfather's road" - Usually mused by a motor bike rider to the pedestrian coming on the way "You think this is your grandfather's road, hah?"
      "Gone case" - Irredeemable / Irretrievable - "You are a gone case man, no attendance, how are you going to appear for the exams?"
     "Fierce" - Terrific / Fantastic - usually used for a good looking girl- "Boy, that girl, sure fierce man; looks like Marylyn Monroe"!
     "Double headed snake" - Untrustworthy / Sneaky - "He is a double headed snake, amn, he stirs up trouble by carrying tales between both the parties"!    
     "Down the valley" - Along the sloping road to Parkala- usually used to denote booze joints - "Hey, exams are postponed; we shall go down the valley and celebrate!"
     "Joint" - That is a tricky one with multiple meanings - In Anatomy - A movable junction between 2 bones; In common parlance " An eating place- that joint is no good, man!"; In the last usage "A rolled up paper or a cigarette containing Marijuana -have a joint I just rolled up one!"
     "Grass" - Multiple meanings - Grass of the KMC greens / vegetables. "He is a grass eater, man!"
     "Cherry" - A fruit - rarely used in that sense ; A good looking girl -"can I borrow your Brut, got a date with a cherry tonight!"
     "Fag" A slang commonly used for a cigarette
     "Pain in the ass" - Sombody being a nuisance - a painful situation about which nothing much can be done! "He is a pain in the ass, man!" Almost an equivalent is " Pain in the neck" which is less disturbing!
     "Heights" - The ultimate level of something  "Heights of stupidity - a real moron- half the students were described so! Hieghts of Insanity - word used to describe the other half of the Manipal students!
     "Bug" - A small unpleasant insect - a term used to denote persistent disturbance or irritation.
     "Take off" - To run away - "We got 3 holidays in a row, let's take off to Bangalore, man!"
     "Tube light" - A person taking a long term to understand simple things. "You are a real tube light, man!"
     "Solid"--  Very good / Fantastic / Terrific" "Hey, that girl is solid, man!"
     "Grub" - Rarely used to denote its true meaning (insect larva) - food / chow "Lets have some grub in the mess, man!"
     "Crash out" - Go too bed usually to sleep undisturbed - " Forget the movie tonight, man, I am going to crash out!"
     "Thengah" Used to denote a dumb person "You are a real tengah, man! You dont even know the way to the Manipal  Power Press!"
     "Lah" A staunch Malaysian word - Cant be defined ; but used with some other word, emphasises what is being said. "I can't come to thew movie, lah; I want to sleep, lah, verry sorrry lah!"
     "Dah" - Another typical Malaysian word- probably indicated darling(?) - No, dah, I can't come; Please lend me your notes, dah!"
     "UFO" - A powerful word meaning "get lost fast" - "UFO dah, I don't want you in this room!"
     "Wah wah " A word usually used to indicate extreme sarcasm / mockery
     "Check the scene" - to verify - "check the scene and tell me whether he is there!"
     "Kachang, lah" Another Malaysian terem used to denote making a task sound easier than it really is - A senior telling a junior (encouragingly) - Just study the tracts, lah, its kachang lah, you cna surely do it!"
     "Vie" - A slang for "to go". "Let's vie for a movie, man!"
     "Got contact" - Know the right people in the right places - "Do not worry about the attendance lah, got contacts lah!"
     "Crap" Rubbish / Nonsense - "boy, you must be nuts to read crap like that!"
     I hope you traveled back in Time Machine and lived a slice of life in Manipal once again in the same old days!

     Congratulations!
   
   
   
   
   
 

CAN COMMON LOW COST DRUGS BE USED TO TREAT CANCER? WHY THEN THERE IS NO HYPE ABOUT THESE?

     Cancer is an expensive disease. Investigations and management cost a lot of money. Insurance does not help much unless one knows the exact method of extracting that from the insurance companies. Availability  of inexpensive drugs is the dream of many patients. It would be even better if drugs which are inexpensive  and are already being used for other common  diseases can somehow be useful for the treatment of cancer. I am talking today of  exactly this scenario. I am sure these facts will leave you dumbstruck and seething with anger against the commercial nature of the pharma industry.
     METFORMIN  is the first drug I am addressing. Everyone knows Metformin. Doctors use it for Diabetes, Cosmetologists for obesity, Gynecologists for PCOS. It is a cheap drug with high safety profile and low cost. It is synthesized from French lilac and is found to limit the recurrence of particularly prostate cancer and early  breast cancer. In fact, the National cancer Institute of US and  Canadian Health services have joined hands for a large clinical study. Interestingly the way it works is by reducing the supply of excess glucose to the cancer cells (on which they thrive) and also affecting the mitochondria within the cells. It has even demonstrated promise in killing chemotherapy resistant cancer stem cells.
     The next wonder drug is CIMETIDINE . This H2 receptor blocker in fact is an OTC drug. This is shown to halt tumor growth when used in conjunction with the standard chemotherapy. It seems to work well in cell culture in human and animal studies. Benefit is seen in Colorectal cancer. It also showed a statistically significant improvement in overall survival.
     The next magic drug is NITROGLYERINE . Originally created to make explosives, it has been in use for more than 130 years mainly for the angina pectoris   Used in conjunction with the standard chemotherapy, it has shown to it has been shown to improve the response of many cancers including that of the lung and prostate.
     The next promising group of drugs is BETA BLOCKERS. Regularly used in the treatment of hypertension and arrhythmias, it has been shown to control the growth of a wide range of cancers, including those involving the breast, bowel, ovary, lung and melanoma. Lab studies have shown promise in the inhibition of progression of the breast cancer and metastasis. Animal studies showed promise in the response to chemotherapy. Humans studies showed promise in the decrease of progression of ovarian and pancreatic cancers. These benefits were seen with Propranolol, Atenolol, Metoprolol.
     The last drug I am going to name will leave you really surprised - It is a commonly used humble deworming agent,  -an antiparasitic drug  MEBENDAZOLE !  When used in in conjunction with the standard chemotherapy, it is found to reduce the tumor growth. It is found to help in the treatment of Brain and Adrenocortical cancers. It has also shown promise in metastatic adrenocortical and metastatic colon cancers. However, no human studies have been completed  upto now.
     The question therefore arises, if these drugs are indeed good, then why there is no focused research going on ? Why serious attempts are not being done to exploit this knowledge to the benefit f the mankind? One does not have to be an Einstein to guess the answer. There is no monetary returns for  the research / clinical trials / clinical usage of these drugs. Unless carefully planned studies are conducted, these drugs will be  soon  shoved to the corner and made invisible to the doctors and patients!

A TALE OF TWO PROFESSORS - BOTH WERE BRILLIANT; WHO WAS SMARTER?

     In the sixties and seventies, there were 2 professors - both brilliant, both were highly qualified academically. Both were gold medalists from London school of Tropical Medicine and Calcutta School of Tropical Medicine. Both were excellent teachers.
      One was a clinician with a highly successful private practice. The legend had it that he saw a patient anywhere - in the market, in a hotel, on the corridor and was very popular. The other professor was witty, with a sense of sarcastic humor. Both were good clinicians with good diagnostic skills. The popular professor  had studied at Rangoon.
      The popular professor  took classes after making sure sufficient students have assembled. If he felt the numbers were not sufficient, he would make the patient sit or stand on an elevated platform so that more people got to see and would get attracted and attend.  He would discuss loudly. The findings existent and non existent would be discussed and his unit PG s would endorse the same. The whole drama was very impressive as well as very educative. The sarcastic teacher on the other hand would take precise, concise , accurate classes. His sarcastic sense of humor would drive the not so intelligent students away. But the classes were highly appreciated. The same case would be presented twice - the sarcastic professor would diagnose Amoebiasis (his favorite diagnosis)and the popular doctor would diagnose Cardiac failure (his favorite diagnosis) and students got to learn 2 diseases!
     Then the popularity with the medical representatives. The popular doctor was their darling. He would oblige them with ready prescriptions. The sarcastic doctor would ask complicated questions at the end of which no prescriptions would follow unless he was thoroughly satisfied about the need and the quality of the drug. The distance  to which he threw the bottle or the tablets was inversely proportionate to the quality of the drug! The legend has it that a satisfied patient of his, an owner of a pharma company formulated Diethyl Carbamazine Citrate syrup to his specification for the traetment of Tropical eosinophilia.
     Then there was the Grand Rounds. Grand rounds was the ultimate event - a sort of show of strength - The chief accompanied by assistants, PG students, Interns, UG students, and students from other units would walk the long corridors together discussing various patients and other clinical problems. One group would have to cross the other person's wards where the group would intentionally slow down and have a show of a discussion. Sometimes they (unintentionally )met on the corridors with their respective groups resulting in verbal fireworks!In one such episode, the popular professor asked the sarcastic professor " I am sorry to hear that your son failed II MBBS exam. What happened? Was he not smart enough?"  The sarcastic professor was enraged. He coolly said "Thanks for the concern, professor.  It is not that he was not smart enough. If that was the case professor, I would have sent him to Rangoon for his studies!"
     The aftermath - The son of the popular professor went on t become a cardiologist and settled abroad.All  the 3 sons of the sarcastic professor became doctors and settled abroad. He died of cardiac failure and arrhythmias believing  all along he was suffering from Amoebiaisis!

WHEN FALCIPARUM MALARIA CAME BACK TO MANGALORE - AN AMAZING STORY!

     Sangeetha came to visit me yesterday with her mother. Ready smile, cheerful personality reminded me of her father, my god friend, Dr. Vaidyanathan, my contemperory, who was a  specialist doctor at the city corporation of Mangalore. Unfortunately he is no more. Sangeetha is his daughter who is a HR Professional and is doing well for herself. During the course of our interaction, I told her a story  She was thrilled. I will now tell you that story.
     One of my professors used to take 3 three hour classes at the bedside on Malaria. We had to stand. for the entire duration. The professor was a gold medalist from the London School of Tropical Medicine and also from the Calcutta School of Tropical Medicine. No one had the courage to ask him why 9 hour class is needed when the disease is never seen in the country! One day, a student asked him that question. "When your city gets Malaria, there will be no one with the first hand knowledge of Malaria. Even this much information will prove to be inadequate!"
     This proved to be prophetic when the event happened in mid 80 s. I saw a 24 year old boy having classical 'malarial rigor'. I had never seen one earlier. I was thrilled. I sent him to the lab for the blood test - P smear for Malaria. I got a phone call from the lab saying that it was positive for Falciparum parasites. I was in the clinic. I left everything as it is and ran to the lab. I saw the gametocytes which were banana shaped. I wanted to scream and tell the whole world I had seen a positive smear for Falciparum. I wanted to learn all that is there and teach my students. I even took a peripheral smear to show them!
     Next day, I got up earlier than usual. I went to the hospital. Took a class for the students. They were also thrilled to see the peripheral smear. After the class I proudly went to the Dt. Malaria Officer. After all, I was the first doctor to see the parasite. Imagine my surprise when I was rudely shouted at and shown the door. "The whole thing is a figment of your imagination, he roared, this is a simple vivax infection!"Do not spread rumors!" I felt very bad. Next I went to the DHO. A worse fate awaited me here. "So you are the rumor monger. Do you know how much work is there if Falciparum is detected. Forget you ever saw it!" he said. I went home crestfallen.
     Two weeks later, I got a frantic phone call from my lab. "We are finding a Falciparum positive in a VIP! What shall we do?"  I insisted on the correct repoting. That evening the DC called a special meeting and declared officially that there was indeed Falciparum malaria in Mangalore.I was curious to know who was the VIP. To my utter surprise, it was Dr.my friend  Vaidyanathan's wife- Sangeeta's mother. I barged into his office and said "How is it that your wife is more important than a common man?"He patiently listened and consoled me with his trademark smile "Dear Raghavendra, it is the DC who thinks my wife is important because he is my friend. I understand you. All are important. In fact, you should  be happy - they have finally accepted the presence of Falciparum malaria in Mangalore" I was happy too!
     When I ended the story Sangeeta flashed the trademark smile and said "Incredible story,  uncle". Incredible indeed. For a moment I thought it was a miror image of my friend  Dr. Vaidyanathan!

MEMORIES FROM CLINICAL TRAINING - WHEN MURMUR WAS MUSIC TO THE EARS!

     Being a clinical student was considered the turning point of the career of a medical student. This enabled him to obtain 2 status symbols - a stethoscope and an apron. The first day as a clinical student was a great feeling. Finding out the posting, locating the ward and finding out who are the teachers wee the main tasks. Fortunate few posted in Medicine would be having a chance to join the clinics and get a ring side view of the happenings (literally!). The Professor taking the class at the bedside would be flanked by the students of the final postings. Around them would be the students from the middle postings. Located peripherally would be the 'freshers' forming the outer circle. They usually got to see the backs of the seniors and listen to their discreet comments made under the breath (about the professor). They would be eagerly waiting for a chance to listen to the heart murmur. Without this their life would be incomplete. Those who got the first chance to listen to the murmur would have to stand a treat to others. Still it was worth it!
     On a particular day, we came to know that the next day's case would be one with a murmur. The news was leaked by the nurse who in the first place told the senior students about it. We came to the ward ahead of time and tried to hang around the patient only to be shooed by the senior students. They were surprised to see us and we feigned ignorance. As expected the professor came and the class was taken. When the time came to discuss the auscultatory findings the professor agreed that there was indeed a murmur. He wanted all students to listen in by turns. We were thrilled. We heard the 'Machinery murmur" a variety of continuous murmur. Then we were told the synonyms - train in the tunnel murmur, rolling thunder murmur, cartwheel murmur, humming top murmur, churning murmur, mill wheel  murmur.We became the eyesore to the other students. The next day one of our batch mates called a girl from another batch to demonstrate the murmur to her mainly to impress her. As the process was in progress, the professor walked in and silently watched the scene. He politely interrupted "My dear boy, you have all markings of a potential good teacher. But remember, the ear piece should be in your ear when you auscultate for the murmur. The boy was so ashamed that he did not turn up fr the class for the next 2 days!
     Hearing the first murmur, hearing the briut over the carotid / aorta/ renal artery for the first time are unforgettable events. We got repremanded for looking for them in the wrong place.  I rejoiced the moment I picked up a bruit on the skull. I would never forget the moment I heard a bruit over the eye with exophthalmos.
     Sadly the doppler and echo have become "killjoys" of Clinical medicine depriving the students of the rightful thrills involved in the learning process.  I agree these modalities  have made the testing more objective but it was the subjectivity and vulnerability that made us more efficient! These are the things that made a teacher important. No doubt the teaching goes on. The pleasure derived in the process of teaching (by the teacher ) and the process of learning (by the student ) are as important as the learning process itself. I am afraid this and the stethoscope - the earlier  status symbol of the clinical student are on their way out!

DOCTOR AS A DETECTIVE - THE ART OF GETTING AT THE ROOT CAUSE BY SIMPLE OBSERVATION - IS IT A DYING ART?

     A young girl  consulted me yesterday. She had come for a general check up. Routine history revealed menstrual irregularity. Her build, dietary habits suggested a possibility of Polycystic Ovarian Disease. On close questioning she said she was on treatment for acne and' migraine.'  I asked for an abdominal ultrasound (which indeed revealed Polycystic Ovarian disesase) serum Prolactin level which promptly came as high. The diagnosis was obvious - Pituitary tumor most likely prolactinoama. One must make use of the opportunity and see whether one diagnosis is possible. Patient gives a story. Doctor must listen to it patiently.
     I remember the good old days where the skill of observation was taught as one of the first things. One of our professors ordered a student to exactly mimic him. The professor dipped a finger in a jar of urine and then into his mouth. The obedient student did just though he felt repulsive. The Professor had a hearty laugh. " I dipped my middle finger in urine and put my index finger in my mouth! You should have observed!" he said. Students had their first demonstration of 'skill of observation'.
     A keen sense of smell was a prerequisite for a good physician. Ability to smell ketone bodies is an asset. It has helped me many times to start treatment before the urine report arrives. One of my professors in surgery could smell malaena from quite a distance. "You learn the trick once and you will never forget it" he would say. So true!
     I remember seeing a patient at home for abdominal pain and vomiting many years ago. A just married girl just back from honeymoon was lying quite ill in a room near the window. She was writhing in pain. I observed urine kept nearby indicating her inability to use the toilet. The sunlight was directly falling on it and the urine had a port wine color. The diagnosis was made on the spot "Acute Intermttent Porphyria". I was a beginner at that time and I discussed with my chief. He gave me the 2nd clue for the diagnosis. "When a good surgeon thinks that the abdominal pain is due to a medical cause after ruling out surgical conditions, and when the physician thinks it is a surgical cause after ruling out medical conditions, think of Porphyria".
     I once visited a young relative of mine, an orthodox girl who had just got married. She was having high fever and loose motions. I was thinking of the possibility if Typhoid. Just then she developed a rigor so typical of Malaria. On looking beneath the bed, I observed stools typical of Amoebic dysentery. I was indeed surprised at the obvious diagnosis of Intestinal Amoebiasis because she had not eaten any external food. How did she get it then? I promptly referred Manson's Textbook of Tropical Medicine. There it was- Acute Falciparum malaria can sometimes unmask Amoebic cysts (the quiet forms) and result in mass excystment resulting in a fresh attack of intestinal Amoebiasis without fresh infection.
     We had a Professor who was an excellent teacher. He was good in bedside teaching. He would attract a lot of students by his dramatic classes. He would demonstrate clinical findings accurately  and at the end of the class ask for the chest x ray. The students would run to the radiology department and get it. It would exactly match with his clinical findings! One day a PG student volunteered to guess the findings on the x ray. Much to the surprise of the students he was right. The professor  was flabbergasted. "How on earth did you guess?" he asked the student. in desperation. The student gave a wide grin and said "Sir, I saw you go to the radiology department just before the class. I went in and saw the x ray too after you came out!"

THE STORY OF ROENTGEN'S DISCOVERY OF X RAYS - A MEDICAL MIRACLE THAT UNSETTLED PHYSICS AND HELPED MEDICINE!

     Today's story is about the discovery of one of the most fascinating things in Medicine - the X Rays.
     In the winter of the year of his 50th  birthday, an year after his appointment to the leadership of the University of Wurzberg, Rector Wilhelm Conrad Roentgen noticed a barium platinocyanide screen flourescing in his laboratory as he generated cathode  rays in a Crookes tube some distance away. 3 days before Christmas, he brought his wife to the lab and took an image of her hand. It revealed bones of her hand and a ring. On the 28th December, he delivered the news of his discovery to the Wurzberg Physico-Medical society. On 4th January the news was relayed to the Berlin Medical Society from where the world press picked it up. On the 13th January he was awarded the Prussian order of the crown. On the 16th January the New York Times announced the discovery as a "new form of photography capable of transforming medicine by revealing hidden foreign bodies"!
     The public and the physicians were equally enthralled by the discovery. It shook the entire foundation of Physics and the Physicists had to change their views on what was till the believed to the gospel truth. The research on the 'cathode rays' continued. Meticulous research by a German scientist, Philip Leonard inspired Roentgen to see that the rays described by him traveled much farther than the cathode rays.
     The Humor Magazine, Punch, gave a poem. I have reproduced a stanza here:
                               O, Roentgen, then the news is true,
                               And not a trick of idle rumor,
                               That bids us each beware of you,
                               And your grim and graveyard humor.
     Though Roentgen himself produced only 3 papers in the field, others jumped in. The X rays were used to locate the bullets; find out breaks in the bones. Dr. Henry W Cattell an anatomist in Penisylvania used it to demonstrate Kidney Stones and 'cirrhotic livers'. In 1896, X rays were used to study human heart and brain(?). Vietnamese mummies and a new born rabbit were x rayed in 1896. In the same year, a German doctor used X rays to diagnose sarcoma of the tibia in a young boy.  In 1897, hair loss and skin burns were identified as side effects.  Roentgen now got interested in the physics of the X rays and was seriously interested in holding a position in theoretical physics a newly emerging German field.
      Other industries also started using X rays - the Shoe industry made it a custom to study the bones of the feet to select the best suited shoes. The fashion industry wanted to satisfy the curiosity of the people by finding out the material used in the stilettos and what the model wore under her dress! The steel industry used it to test the strength of steel. Needless to say the maximum utility was found in the medical indications. Antonie Beclere of France in 1906 used x rays to study the stomach. Soon the x rays were used to treat cancer.
     Now an interesting anecdote - 100 years after the discovery of X rays, a x ray machine was found at the Maastricht University Medical Center in the Netherlands by Gerrit Kemerink. Using that machine he took an image of the hand. The process took him 90 minutes as againt 20 milliseconds for the new machines! The radiation dose needed was also 1500 times more explaining the frequent effects of hair loss and skin burns that used to happen!

SERENDIPITY- ITS ROLE IN THE DISCOVERY OF PENICILLIN

     Serendipity means a "fortuitous happenstance" or a "pleasant surprise"Horace Walpole 1754). It was made in reference to a Persian fairy tale about 3 Princes of Serendip (Ceylon) "who were always making always making discoveries by accidents and sagacity of things they were not in quest of".Serendipity had a role to play in many scientific innovations. Discovery of Penicillin and Microwave oven (Percy Spencer 1945) are 2 examples.
     The days story is about the discovery of Penicillin aided by serendipity ans a chain of people with tenacity and good observation. However, the major credit went to the person who started it all, Sir Alexander Fleming who discovered Penicillin in 1928. When this 'careless' lab technician returned from a 2 week vacation a mold had developed on an accidentally contaminated staphylococcus culture plate. He also noticed that this mold had prevented the development of staphylococci. It had effects only against gram positive strains. He is reported to have said "One sometimes finds what one is not looking for. When I woke up just after dawn on September  28 1928, I certainly did not plan to revolutionize all medicine by discovering the world's first antibiotic, or the bacteria killer. But I guess that was exactly what I did." Fleming stopped studying  penicillin in 1931. Howard Flory and Ernst Chain continued the research at Oxford. The landmark work began in 1938 when Florey and Ernst Chain produced a series of crude fluid penicillin extracts. 50 mice which were seriously ill with staphylococcal septicaemia were promptly rescued in 1940.In 1942, Ann Miller became the first civilian patient to be successfully treated with penicillin
     At that time the problem was of continuous availability of the drug. Albert Alexander police constable who was ill with staphylococcal sepsis responded well to penicillin but died after 5 days of initial improvement due to non availability of the drug. In 1941, Florey went to  Peoria in the US with Heatley ( a biochemist) to study means of mass production of penicillin. They realized that Penicillium notatum would never yield desired quantities of Penicillin. Mary Hunt, a lab assistant  picked up a cantaloupe at the market covered with a "pretty, golden mold".Serendipitiously the mold turned out to be Penicillium chrysogenum which would yield 200 times penicillin as compared to P. notatum. With mutation causing technologies and radiation, the yield of penicillin was increased 1000 fold.
     The acid test for Penicillin came in the form of Second World War. If the drug was indeed good, the mortality due to sepsis should come down substantially. That is what exactly happened. The mortality due to sepsis as compared to the first world war (18%) came down substantially to 1 % during the second world war. Penicillin was made. It had come to stay.
     The story has a not so good ending. In 1945, Fleming, Florey and Chain were awarded the Nobel prize. Heatley was left out. In 1990, Oxford made up for this oversight by awarding Heatley the first honorary doctorate in its 800 years history.
     Is there a word with the opposite meaning as serendipity? Yes, there is. It is called Zemblanity (William Boyd). It means "making unhappy, unlucky, and expected discoveries occuring by design". This term meaning an "unpleasant surprise" is derived from Nova Zembla, a cold, barren land with many features opposite to Serendip (Sri Lanka).
     The search for the first antibacterial drug was greatly aided by Serendipity. It was not done for financial gains. Current research for newer antibiotics which is done keeping in mind the possible financial returns is rightly greeted by Zemblanity!

DO NOT FRET OVER REJECTION - STANFORD UNIVERSITY WAS BORN DUE TO A REJECTION!

     Everyone has undergone an experience of a rejection sometime ore the other. Maybe more often than once. Usually one tends to get upset and give up. Today I want to tell a story of how a great university was born out of an unreasonable rejection.
     Mrs and Mr Stanford - the lady in her faded gingham dress and the man in a homespun threadbare suit went timidly to Boston without an appointment to meet the President of the Harvard university. After all, their son  who was studying at the Harvard University had suddenly died and being grateful (as he was very happy as a student) they wanted to contribute something to the university as a memorial. The secretary gave them a surprised look and felt that the president had no time for such "country hicks". He never bothered to convey to the president their desire to meet him. He would not be interested anyway. Then he faced a strange problem. They would not go away! He had to find a way of getting rid of them.
     The secretary reluctantly approached the president and appraised him of the situation. "They will leave only after seeing you" he said. The president very reluctantly agreed to meet them only for a few minutes. "My son attended Harvard for a year and he was very happy. He got killed accidentally. We have come to see you and offer to build a memorial for him Harvard.". The president was surprised. What kind of a memorial these "country hicks" could afford anyway? He simply told them that was impossible. "We could not erect a statue for each person who died while studying at Harvard. Then this place would look like a cemetery." "Oh no, not a statue. We were thinking of giving a building". The president got visibly annoyed. "Do you know how much a building costs? All our buildings cost more than seven and a half million dollars!". The lady was silenced. She thanked the president and the couple left.
     As they walked out, the lady asked her husband "Is that all it costs to start a university? Why not start one on our own?"  Now it was the president's turn to be bewildered. The couple travelled to Palo Alto, California, and established an university bearing their name - the Stanford University - a fitting memorial to their son the Harvard university no longer cared about.
     The lesson to be learnt from this story is never to judge some one by the appearence. To be able to judge some one's character and abilities one has to spend quality time and listen to them. Only after a tactful communication, one try to can judge the other person
    Next time someone rejects you do not feel offended. Maybe that will be a foundation for a greater achievement!

EXPERIENCES INSIDE THE LIFT - DOES IT REFLECT OUR CIVIC SENCE OR WE ARE ALWAYS IN A HURRY?

     In the olden days, one  always climbed the staircase. The expectations were simple - to reach the destination. Climbing the stairs was a pleasurable activity. We could chat with the others and exchange views. I remember my  chief telling me how he had suffered an attack at of angina pectoris at the age of 35 and then became fit enough to climb staircase. He would never allow us to use the lift (later days)even while climbing the 6 th floor. Sometimes we would have a cup of coffee after climbing down the stairs.Thus,  Intellectual and social interaction formed a valuable part of the stair climbing exercise.
     Then came the era of lifts  (elevators) and later escalators. Climbing became effortless and fast. People forgot the use of staircase. I still prefer staircase. In emergencies, I use the lift. When I climb down the staircase, I find really ill,  disabled, patients with COPD and breathless individuals slowly climbing up the staircase.  When I ask them why they are not using the lift, the answer is the same - they just could not get into the lift - they were kept out by the fitter people! So much for the social understanding  and compassion from the society!
     When there is a designated "doctor's lift", it is common to see the public beat the doctors to it. I once had to explain a group of people that I was the person they had come to see from a far off place and that not allowing me to get in will defeat the very purpose.
     Sometimes youngsters with backpacks get in. With the i- phone in the ears, a hand held device with which they are perpetually messaging, it is indeed anybody's guess as to the fate of the person standing right behind this youngster. He will have to cave in and adjust.
      It is amazing to see fit looking people wait long and use lift to climb 1 flight of stairs up or down. Worst case scenario is when a person wanting to go from the 1 floor to the ground floor gets in as  the lift climbs from the 1 floor upwards.
      It is not as if nothing interesting happens inside a lift. Many calls are made, messages are sent, decisions are taken and perhaps bonds are forged!There was a rumor that a young doctor proposed to his sweetheart kneeling down with a red rose in the lift at midnight as the lift went up from the ground floor to the 10 floor(ICU). I am not sure wha the result was.
      One of the mast important decisions in connection with the starting of our alma mater is supposed to have taken place in the lift. Dr. TMA Pai, the visionary who built the KMC was finding it difficult to get an university affiliation for the college. He went to meet Dr. Laxamansami Mudaliyar (who was the vice chancellor of the Madras university ) who just would not give him an appointment. Not the one to be defeated easily, Dr. Pai patiently waited for many days. He found out that Dr. Mudaliyar would be alone when he went home down the staircase after the days work. He decided that it would be the best time and one day got in with Dr. Mudaliyar. Before the lift reached the ground floor, Dr. Mudaliyar was so impressed with Dr. Pai that he went up again to his office and  invited Dr. Pai to join  him. The rest, as they say, is history!
     I am also reminded of a horrible episode when one of my patients who was staying in a new building (still being completed),  . went into the lift hole (which he imagined to be a lift) and fell into the basement sustaining a fracture. He shouted for his servant to help him who in a state of confusion as how to help his boss, voluntarily jumped into the lift hole causing a second fracture for the bass and one for himself! The boss was lucky to be alive!