Cough Cure

I could hear her violent bouts of cough through the door leading to the waiting room. She came in with her son who has been my patient for some years now. This was the first time she was seeing me. A well preserved and groomed lady of around 65 years, when asked what the problem is, began,’ can’t you hear my problem, this cough; I am having this since the last three months. I have tried many medicines but of no use’ she stopped to let go another bout of cough.
The list of medications consisted of three types of antibiotics, several anti allergic drugs including oral steroids and currently she has been taking copious quantities of syrup of codeine and suffered as a consequence, severe constipation.

I asked,’ where are the prescriptions’?

‘What prescriptions? I don’t need any prescriptions? I am a doctor’. She stopped at that.
Her son added,’ doc, I should have told you, my mother retired as professor of Pharmacology from Orissa few years ago and she has come here for a visit and has come to see you only because I forced her to.’

This explained a lot of things. She has been a senior teacher of Pharmacology and knew in depth all about medicines, but had no practical knowledge about diseases! Having retired she must have felt odd to seek help from her colleagues, most of whom must have been her students. She had made a self diagnosis [many] and has been medicating herself.

I was a worried man. I am dealing with senior medical personality who has come to seek help from a GP at the instance of her son. We GPs are considered as know nothings by many specialists and like many of us GPs thinking them to be doctors with blinkers on and knowing more and more of less and less. In reality both these assumptions are incorrect. I did not know what to make of this lady, a senior professor and teacher who has been neglecting a cough for over three months. But saying so will only make matters worse, this I know by experience.
For a while I kept quiet. By then she had told me few more complaints which were not very relevant like not sleeping well, dry mouth etc.

I asked her,’ have you got any tests done’? She said no but has been planning to get some done. This was like adding insult to injury. Three months of cough and no tests done!

I proceeded to examine her. But for repeated bouts of dry cough, she was alright with fairly clear lungs. I told her so and said I will have to get some tests done which included a chest X-ray, blood and sputum tests. She asked me,’ what you are suspecting? You think I have TB? Sounded more as an accusation than a statement. ‘In this country, madam, that is the first illness that I would want to exclude, though I don’t think it is TB, but one can never be sure ‘. ‘Then what do you think it is? This is another problem we doctors face. When I am not sure how can I tell her what is the problem? I told her that is the reason why I was getting these tests done. She would not leave me. You must have some idea before you asked for these tests’ she said. I had to reply. I said,’ madam it can be any illness starting from TB to asthma to cancer. No, No, No, I cannot be having cancer; I have never smoked in my life, asthma! I don’t have any breathing difficulty, it must be something else’. How can I argue with this professor that all the three diseases are still possible and why. It is simply a waste of time and prolonging the argument which was taking us nowhere.

I felt it is best o keep quiet. She said at last, ‘OK, we will do the tests and get back to you’.

Couple of days later, she and her son returned to see me with reports of the tests done.
One look at her told me that something was seriously wrong. Her face was ashen and her lips and hands were trembling. Here was a lady who was frightened out of her wits. I made them sit down. Even before I asked her any question, she said,’ doctor you are right, I have miliary tuberculosis’. Miliary tuberculosis is very serious form of tuberculosis where in the tubercular germ has widely disseminated and the patient is very seriously ill. I asked her how does she know. She showed me the radiologist’s report which accompanied the chest X-ray. It read,’ fine diffuse nodular opacities in both lung fields. Consistent with military tuberculosis. Please correlate clinically’

The X-ray reader sees and reports on what he sees. He has no clinical experience as he does not see the patient. His job is to report what he sees and that is what he has done. Strictly speaking he should have stopped at diffuse nodular opacities seen and not hinted at military TB. That is the clinician’s job. But the radiologists do commit this mistake of suggesting which they should not do. Our professor has put this finding and her cough and surmised that she has serious form of TB.

I went through the other reports. She had very high percentage of a type of white cell called eosinophil. Eosinophil developed over thousands of years to particularly attack worms [not germs] which infest our body. Especially so, those worms which tend to travel around in our tissues. Coming from Orissa the diagnosis was very easy to make. She had Filariasis.

In Filaria, after the infected mosquito bites, the released larvae of the filarial worm migrates and gets stuck in the lung tissue where the eosinophils too go in large numbers and attack them. The reaction results in small pinhead sized nodules which are seen in the X-ray. The same happens in a different way in TB where another specialist cell called Lymphocyte does the same. X- ray picture of both is near identical. The flood of eosinophils is also seen in the blood much more than what is normally seen. In fact this condition is known as tropical eosinophilia.

I explained to her in detail and also prescribed the 15 day course of a drug called Diethyl Carbamazine that will bring about a near miraculous cure.

She brightened visibly. Next ten minutes were spent not in thanking me but in giving me a lecture on Diethyl Carbamazine.

After all, was she not a professor of Pharmacology?

Ushering in yet another year

A year is about to end and another about to begin and time has come to share my thoughts and feelings and say thank you.
These are:
To those of you who are my patients, a big thank you for keeping me active in the profession and for the confidence, love and affection you continue to shower,
To those of my friends, especially my golfing and badminton buddies, for having kept me happy and healthy,
To my small scattered family for continued support and love,
To the colorful plant and bird life which continues to give me so much of visual pleasure,
To readers of my Blog for the encouragement which has helped me to keep writing,
And lastly, to that mighty force which has kept me mentally fit and physically active, given me the ability to enjoy and appreciate the little things in the evening of my life.

Hope you don’t mind a bit of advice from an old doctor.

Eat less, consume less, exercise more, laugh whenever you can, help out, forget the past, enjoy the present and don’t worry about future.

These are the same ones expressed last year.I could not do any better this year.Therefore I have posted the same!

Travesty of Justice

• I did not know whether to laugh or weep on hearing the news of Dr Binayak Sen being found Guilty of sedition by a judge in Chattisgarh. In this country the state machinery can be used to bend justice to suit its ways and Dr Sen being found guilty is one such. It is not difficult to create documents, get witnesses to testify against anyone the state doenot like and there are any number of officials willing to cater to the whims of the state.
  
  That he was a nuisance to the state machinery was true. His ways of helping the poor and down trodden was not to the liking of the state. He took the health and nutrition care where it was most needed, to the poorest of the poor and to their doorstep. He found by experience that these people had no voice and willy nilly became their voice in the form a human rights activist. To equate this activity as that of a naxalite is shameful to say the least and this is exactly the state government has done. It should have followed his example and reached out to people and won them over instead of giving in to the influential interests of the landed gentry.
  
  Of course the higher judiciary will not be that stupid as the lower courts and will see that he justice will be done, but then if a person of Dr Sen’s eminence can be found guilty, imagine the plight of an ordinary citizen in this country who has been wronged by the state.

Hollow

I was idly rummaging through my collection of books and came across this one. Bound in a buff cover, pages yellowing, the book had a small legend written by my hand. 25/2/77 H.A.L. airport and the scrawled signature of yours truly. It brought back memories of those years. The airport was small and served few domestic flights. Those going abroad had to go to Bombay [oops sorry Mumbai] and take an international flight from there. The road to the airport was a narrow lane with hardly space for two vehicles to pass each other. Vehicles were few and the ride to the airport was hassle free. I rode my motorcycle and would reach the airport in ten minutes. What surprised me was that I had bought that book and that too from the airport bookstall paying obviously much more than in the town’s book stores. Normally my buying was from the second hand book store located off MG road called Rao’s. Mr Rao specialized in second hand books and enjoyed his trade. He had few stools placed outside his tiny store over flowing with books for not too well off customers like me to sit and browse.

The book’s name is Hollow and late Dame Agatha Christie the author. I read the book once again. Set in the post war England where one still suffered [or enjoyed] class distinctions, in the rural countryside, it made good reading. Agatha usually kills her victims with poison but here the murder weapon was a revolver. The story meanders to an unexpected conclusion in typically Agatha way. What was interesting is that after 30 years I could still read it and enjoy doing so. I cannot say the same with some authors whom I greatly admired in the yester years. One such is A.J. Cronin. I read one of his novels and found it too artificial. Whereas, his book of stories relating to Drs Finlay and Cameron remains an all-time favorite. There was a crime writer called Earl Stanly Gardener whose books I avidly read and now I wonder how I could do so. Works of others like P.G. Wodehouse, P.D.James, John Mortimer [Rumpole stories] can be read over and over again without the loss of pleasure.

40 years ago, in the beginning years of my practice, I had oceans of time and one way of spending time in the clinic was reading and those days there were lot of way side book shops in the Cantonment area and near Majestic circle. Commuting was easy unlike now and I would be a regular visitor to these shops. It was quite entertaining in a way especially visiting Rao’s. Old man Rao passed away some twenty odd years ago and now his son [Murthy?] manages the book shop located some distance away with equal enthusiasm. Then there was Premier Book shop run by Mr. Shanbhag who ended up becoming my friend and about whom I have written earlier in these columns. In the last five years there is another bookshop called blossoms that has come up in Church street which too specializes in old books but the owners are not knowledgeable like Rao and Shanbhag who knew exactly what I would be looking for and would put ten books in front of me to choose from.

I miss them

Holding the breath

That was an unusual complaint. She said every time she went for a walk she was forced to hold her breath. ‘You mean you were breathless? I asked. She said,’ no doc, I had to stop breathing for a few seconds and then I can proceed with normal breathing’. She said she had no chest discomfort or radiating pain. This 65 year old woman has been my patient for several years and not given to exaggeration though the unfeeling husband seemed to think that she was imagining a complaint! I knew that an exercise ECG and an angiogram [done for similar complaint?] two years ago were normal.

I did not like it despite her BP being normal and a regular pulse. I sent her to my cardiologist friend and forced him to do an exercise ECG. He called me from the hospital and said she had severe supraventricular tachycardia [very fast uncontrolled heart rate] and atrial fibrillation [another kind of serious rhythm disturbance] within two minutes of excercise! The stopping of her breath was due to inadequate perfusion from a heart which was in serious trouble. She was rescued with medication and another possible disaster avoided!

Tendulkar and Bradman

The present generations of cricket lovers all over, including the Australians seem to think Tendulkar is better of the two. One should really not compare the two in the first place. But if you force me to do it I would place Bradman above Tendulkar. In the era Bradman played, except Leg guards there was no protective gear. One exposed the body and head to the fast bowlers. He had a phenomenal average of more than 90. He may have played fewer tests but that is not taking away from the basic facts of brilliant batsmanship. They had to design the famous bodyline attack to keep him quiet. Nothing of that sort ever happened to the well protected Tendulkar. Given the conditions of modern cricket it is possible that he is one of the greatest batsmen the world has seen in recent times. But then who am I to opine when the majority of voters are young hero-worshippers?

Update

Many of you must have wondered at the prolonged period of not writing on my blog and what may have happened to the old man? Recently one of my patients took objection to my calling myself an old man. When one is old what is wrong with the term? After all the body has to get old but what is important is the feeling. If one feels good in whatever one does and keeps active then one is not ‘old’. In that sense I am not old. Incidentally I have updated my age which should have been done six months back.

Returning to the question of why I did not write for six months, is not due to my passing away or due to ill health, lack of material or sheer laziness, but because of one important factor which constantly and even now disturbs me when I take up to write. This is the thought of the state of my country. This not new and I was able to put these aside and get on with life and my writing. But lately the level to which the governance and corruption has sunk to, is so mind boggling that I am compelled to write only about this and most of you are quite bored with my constant rantings.

But then I have a reason. I was a toddler when the country became independent. We were abject poor but were reasonably administered by the British before that. Our poverty was due mostly to the siphoning of the resources and funds to our host country and to the ravages of world war which made every one poor including the British. They thought it fit quit rather than manage us and there was also the nuisance called Gandhi. So we became independent and I grew up in this independent India. We had visions of a well managed state where in every one lived in harmony and comfort. Gradually reality took over and we realized that aspiration is one thing and achievement is another. The former was high and the latter very low. The real colours of the ruling class [politicians and beurocrats] became apparent as the years went by. Corruption and poor governance which were not rampant in the initial years gradually became common and even worse it came to be accepted by the society and corrupt wealth came to be accepted and even respected! This happened at the cost of development is easy to understand and what we are seeing today is this cancer that is destroying the country and the magnitude of this illness is what the media is highlighting. Then what is this that you hear that India is an emerging economic power and is going to be a world leader? This is because we are a large and populous nation and a small percentage of this population is wealthy it is like the whole of Europe being wealthy. That is what one sees .The doings of this 5% of the population [which includes most of the corrupt]. The state of remaining is going from bad to worse leading to a frightening discordance. It is a joke that this country becoming a world leader. What is then the solution?
Radical surgery is the cure. Not so long ago, corruption was rampant in the state of Singapore. It needed one man [Lee Kon Yew] to set things right. Quick justice and accountability is what he did and you see the results. We need another Lee to save us.

Till then you have not many choices, rant and rave and be called a misfit, get into a self created cocoon [of golf, music and infrequent writing like I have done]and let the world be or become a revolutionary [which may take the country to even worse situation]