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!