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!