Friday, December 25, 2009

Gautham Gambhir

One day cricket has come to stay and threatens to take over test cricket. This form of cricket is a compromise between the five day [test] variety and the twenty twenty one which gets over in three hours. The twenty twenty is the most vulgar and the test most sedate. The one day variety is a compromise between the two and oldies like me who grew up with test cricket and who intensely dislike the slam bang twenty twenty, have come to accept the one dayer as it still has elements which are pleasant and enjoyable.

There are very few players who can step in to all the three forms with ease without compromising the basic nature of their game. One such player is Gautham Gambhir. It is a pleasure to watch this small built left hander play the classical mould of cricket. He is all style and grace and runs come from shots which we are trained to enjoy. He doesn’t hit many sixes because that is not his way. But the fours he hits are a connoisseur’s delight.

He is also a person with a large heart. He was responsible along with another promising youngster called Virat Kohli in winning the fourth one dayer recently against SriLanka and rightly declared the man of the match. Gautham did something unusual in modern day sport. He gave the award and the prize money to Virat Kohli.

There are still gentlemen left in modern day sport.

Season’s greetings and Ushering in the New Year

A year is about to end and another about to begin and time has come to share my thoughts and feelings. 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 man.
Eat less, consume less, exercise more, laugh whenever you can, help out, forget the past, enjoy the present and don’t worry about future.

Monday, December 21, 2009

Riding a Bicycle

He would not come in when it was his turn. Other patients came and went but he sat there in the waiting area with head held in his hands [common gesture among worried Indian patients]. I went out and called him in. He came in with great reluctance. I asked him what his problem is. He said,’ Nayak sent me here.’ This was no answer to my question. I repeated my query. He broke into a sweat and started to stammer. The answer came in bits and pieces. ‘I went cycling to Yelhanka [small township then way out of town and now an important suburb] two days ago and since then I have this severe burning when I pass urine’, he said. Few more questions got me the information I needed. He also had the urge to frequently urinate and also was discharging pus from his urinary opening. The diagnosis of Gonorrhea, a type of easily treatable, acute venereal disease was easy.

The story of pedaling a bicycle for long hours was a lie and the patient wanted me to treat him without going into the sordid details of how he got it. Those days, thirty years ago, I was rather pig headed and did not appreciate the fact that patients often lie not because they want to but to save their faces. I insisted on the truth and he persisted on his bicycling story. I refrained from asking him whether the cycle he rode was male or female. I told him unless he told me the truth; I cannot treat him and told him to find another doctor who would treat him. ‘But saar,’ Nayak told me to see you only.’

Here I must tell you about this Nayak. Nayak is one of early patients and was a travelling sales man for a paint making company [he recently retired as one of the top guns in the business]. His travels took him to different parts of the state and later when he rose up in his profession, to different parts of the country and even abroad. During his travels he would stay in hotels and guest houses and was not beyond picking up a skirt if he found one to his liking. He would occasionally end up with the kind of problem this young friend of his was having now. He made no bones of what he did and how he got it, took the medication and got better and stayed so till the next event. This experienced man had correctly spotted his young friends problem for what it is and had advised him to see me.

‘Riding a bicycle will not get you this disease and unless you tell me the truth I will not be able to treat you’. The young man stood his ground for a while and then wiping his sweaty face went out of the clinic. I got on with my work and soon forgot the episode.

Two hours later came Mr Nayak,’ How are you doc, now don’t worry, I have not got my old problem, but my young friend has got it, I know he told you some cock and bull story and you threw him out, you know how ashamed these fellows are to tell the truth, you please treat this katthe [Donkey] a common word used to describe dumb fools’ He said in one breath.’ But he has gone’, I said. ‘Where will he go? He is here with me’ Nayak said and called out loudly for the youth to come in.

A less shamefaced young man of the morning came in. He was now spared of telling me the details of his misadventure. I gave him an injection of penicillin. Those days [even now but at a much higher dosage] it worked like magic. Within a few days he got completely cured. He is still my patient, now a sedate and respectable family man.

A word about gonorrhea. Before the advent of penicillin this was a dreaded disease and would leave the urinary passage scarred. This [stricture urethra] would result in obstruction to the flow and to ease the obstruction the doctors of yester years would periodically pass a metal tube down the passage to open the passage and irrigate the area and bladder with mercuric chloride solution, an antiseptic. I remember, during my college days, doing this procedure on some relics of pre penicillin days. So the saying those days when one saw these unfortunates was,’ five minutes with Venus, lifelong with Mercury’!

Saturday, November 28, 2009

Passing motions

‘Saar [slr], it is again paining’ he said.
I did not remember seeing him.
I asked him,' when was it that he last saw me’.
He said ‘five years ago’.
‘Have you brought any of my records? I asked.
‘No saar, I lost it’ he said.
‘Where is the pain?’ I asked.
‘Same place as last time’.
So here is a person who expects me to remember the place of his pain that occurred 5 years ago. I told him.
‘Sorry’ he said but won’t tell me the place of his pain.
I insist on knowing.
‘There, where I pass motions’ he said, pointing to his neither region.

This place of motion passing needs some explanation. In the heavily vernacularised English, motions mean moving the bowel and the place where this occurs is anus. So this patient is having pain in his anus.

The first hurdle in this intricate art of history taking has been won.

Now comes the next step of the battle.
‘Do you have the pain all the time or only when you pass motions?’ [I speak his language]
‘What saar?’ He asks.
I repeat he question.
‘Both times’ he says.
So he has it all the time.
I ask him, 'does it become worse when you pass motions? ‘Yes Saar, very very much, I cry and shout with pain, wife comes running.’
This wife comes running part is to impress me the severity of pain.

I am now duly impressed that this man does indeed have severe pain and needs urgent attention.

I ask him to undress so that I can have a good look at the place he is having motions.
‘Saar last time you have seen saar’ he pleads.
This man thinks that I am some super doctor who has the memory of seeing ‘his place where he passes motions’ 5 years ago.
I tell him the need to examine him again
‘Last time you give motion making medicine and I became ok. You give this time also’ [this motion making medicine is a mild laxative given in painful anal conditions and he thinks if he gets a prescription for that he can avoid the unpleasantness of examination].

Like many other young men and women he is shy to show the part. This reluctance is cultural and was much more so in the past than it is now. But I still get an occasional young man like the present one.

A see saw battle ensues with I trying to pull his trousers down and he trying to hitch them up.

Ultimately I succeed and to our mutual relief the consultation gets over and he gets his motion going medicine.

He had anal fissure, a fairly common condition and easily treatable.

On golf ball
My friend and avid golfer, Jnandev Kamath, has sent this poem. I think my golfer readers will enjoy reading this.

In My Hand I Hold A Ball,
White And Dimpled, Rather Small.
Oh, How Bland It Does Appear,
This Harmless Looking Little Sphere.

By Its Size I Could Not Guess,
The Awesome Strength It Does Possess.
But Since I Fell Beneath Its Spell,
I've Wandered Through The Fires Of Hell.

My Life Has Not Been Quite The Same,
Since I Chose To Play This Stupid Game.
It Rules My Mind For Hours On End,
A Fortune It Has Made Me Spend.

It Has Made Me Yell, Curse And Cry,
I Hate Myself And Want To Die.
It Promises A Thing Called Par,
If I Can Hit It Straight And Far.

To Master Such A Tiny Ball,
Should Not Be Very Hard At All.
But My Desires The Ball Refuses,
And Does Exactly As It Chooses.

It Hooks And Slices, Dribbles And Dies,
And Even Disappears Before My Eyes.
Often It Will Have A Whim,
To Hit A Tree Or Take A Swim.

With Miles Of Grass On Which To Land,
Finds A Tiny Patch Of Sand.
Then Has Me Offering Up My Soul,
If Only It Would Find The Hole.

It's Made Me Whimper Like A Pup,
And Swear That I Will Give It Up.
And Take To Drink To Ease My Sorrow,
But The Ball Knows ... I'll Be Back Tomorrow.

Sunday, November 22, 2009

Never say die

You read about Ratnakar Shetty and his heart attack in my last post. This time another incident involving him. As can be surmised by the previous story, Ratnakar is an avid golfer. Once, some years ago while out golfing he was hit on the eye by an errant golf ball. Instead of ducking or swaying this brave man looked straight in the direction of the shout and got hit. Despite it being a half volley the injury was severe and he was taken to the hospital for expert eye care.

I went to visit him in the hospital few days after the incident. He was sitting alone with a huge bandage that covered his injured eye. Doctors had told him of the possibility of his loosing sight in that eye and he looked disturbed. Later it proved that he retained some vision.

I asked him,’ how are you coping’?

‘They have said I can play golf ‘he said!

Here was the true spirit of golf on display. To keep the talk going, I asked him,’ when are they operating’?

‘They have told me that I can play next Sunday’ was his reply

Then on the talk centered around not his eye but on how he was going to play the blessed game and how soon after this unwanted interference in the form of his eye injury.

When I was taking his leave, he asked me.’ Doc, tell me is it true that one eyed golfers put the ball better’? Putting was a weak part of his game.

Another demo of true golfing spirit.

He got operated and returned to active golf some months later. His vision in the affected eye was poor and nothing much could be done to improve.

He met me some time later and said that he was having trouble playing because the image from the bad eye was interfering with the one from the good eye and wanted my advice. On the spur of the moment I told him the best option is while at play he covers the bad eye with an eye patch. ‘Perfect solution’ Ratnakar said.

Then on he was seen on the golf course with a black eye patch covering his affected eye! He looked quite funny with the black patch on his left eye and swinging the golf club.

He was never a great golfer. So his loss of sight in one eye did not male much difference to his game, It however provided his friends some more fun.

Mini miracle
They lived in a duplex apartment. From the base to the first floor there was flight of steps that ran up to 12 ft. On one side there is a protective railing and the other side there was a wall. The mother and her two children, a toddler of three years and a girl baby of 14months were in the upstairs bedroom, when the phone rang. The mother rushed down to answer the phone leaving the children in the bedroom and the door ajar. The toddler quietly followed the mother down. The baby crawled and walked to the railing looking for the mother who was directly below, busy on phone.

She slipped through the vertical slats of the railing and fell on the tiled floor below at the feet of the mother!

The shocked mother took the child to her doctor neighbor who advised her to take the baby to the hospital. While on their way they found the baby playing and smiling and looking quite normal. They turned around and came to see me.

The mother stood with the baby grasping the mother tightly at the chest and shoulder, turning occasionally and giving me frightened looks. The father and the toddler took their seats. The father explained the incident and their fear. By this time the little girl had lost her fear and was playing with the pencil I had given her and was trying to eat the blunt end. She had no pain, was moving her legs and arms, breathing normally, had no bruises or cuts, no bleeding from the nose or ears and had not lost consciousness after the fall.

I examined her. There was no hint of any injury. She was perfectly normal and I had to believe the parents that she had fallen from a height of 12 ft on hard floor and sustained no injuries!

If this is not a miracle what is?

This took place two days ago.

Thursday, November 19, 2009

Lucky and Daisy

Though his name was William Herbert D’souza, every one called him Lucky. I believe he had another name called Stonehead when he was young. How he came to be called by these names is interesting. When he was a schoolboy, while out playing, a coconut [a raw coconut weighs more than a kg] fell on his head and Herbert escaped with a mild bruise and continued playing. This incident made people call him Lucky and also Stonehead because his head withstood the fall of a coconut from that height! In the course of time the name Stonehead came to be used less and less and the name Lucky more and more. Herbert used to say that old timers who met with him after many years still called him Stonehead.

After school he did a stint in college and then like many of his community of Catholic Mangalorians, went to the Middle East to seek his fortune. Not only did he get his fortune in the form of a well paying job with an oil company but also got his future wife Daisy there. After thirty years of life, they came back and settled in Bangalore and became my patients.

Both Daisy and Lucky are no more and I have lost touch with the children. The story relating to the couple however is still very green in my memory. Lucky first came to me to get his pain in the abdomen treated. This problem of pain and burning he has had even when he was in the gulf [common term used when one referred to Middle East]. He showed prescriptions for antacids and acid blockers which he said gave him some relief. Those were the years when we had to rely on careful history and our own intusion to make a diagnosis. The only investigation we had was known funnily as a barium meal study. This was no meal and quite unpleasant one at that. We made the hapless patient swallow the barium liquid and took pictures of the liquid passing through the patient’s entrails. It did show if there was frank pathology like a big ulcer or a growth. More often than not, we missed the diagnosis unlike now when it has become easy to diagnose ulcer disease with wide spread use of flexible fibreoptic endoscopes.

Naturally the examination did not reveal any thing in particular and I told him the same as other doctors had done before. I gave him a prescription for the latest acid blocker and sent him home. He had told me that he was a social drinker and I advised him to go slow on alcohol as it was not good for people who had his problem.

It was only after three years and many consultations later I came to know that Lucky was addicted to alcohol. I had to make an urgent house call as his wife Daisy was unwell with a severe bout of giddiness. When I reached their house, I found her in bed unable even to get up because of intense vertigo. Lucky came to help me to make her sit up and he was close enough for me to smell alcohol. At 11 in the morning! How long had he been drinking? Is his chronic gastric pain due to drinking habit? I should ask him when he came to see me next. Third day the couple visited me in the clinic when she had become fit enough to move around. After finishing seeing her I asked him how long he has been drinking. Daisy answered,’ has he not told you? He is drinking for many years and mow he drinks in the mornings also. He hardly eats and gets angry when I tell him not to’.

The pieces fell into the place. The red flushed face, warm hands, muscle wasting and the prince of symptoms, chronic gastric pain. How did I miss the diagnosis for this long? Why did I believe him when he said he drank casually when there were tell tale signs and symptoms of alcohol abuse? I felt very bad that he would go to the extent of lying to keep this a secret. I told him so and asked him why in a pained voice. ‘Doctor, he said, I didn’t want you to join Daisy and father [his priest] in giving me sermon to give up alcohol’.

Here is a patient who doesn’t want to give up come what may. I had to do my duty. I told him the inevitable end and painted the ghastly but true picture of bloody death due to cirrhosis of liver. He heard me in silence and then said,’ I cannot sleep with out my drink’ that was easy enough to solve with a nightly dose of a sleeping draught. I told him if he tries to give up I would give him a prescription. He said he will try. His wife said,’ How many times have I not heard him say this’ he won’t doctor, you wait.’ They left with this pessimistic appraisal by Daisy.

After some months of trial and trabulation, Lucky gave up his drinking altogether! His gastritis disappeared and his liver recovered in about six month’s time.

Things thus stood for a couple of years and it was a pleasure to see Lucky in such good health. Then came the unexpected shock. Lucky came in one day and said,’ doc, please come home with me. Daisy is very sick’ I took my bag and went with him. On the way he was unusually silent which I attributed to his worry. I too did not speak much. We reached home and I went to their bedroom where Daisy lay breathing deeply and in some kind of a semi coma. The whole room reeked of Gin. Who has been drinking? I looked at Lucky, ‘not me, she’, he said’ pointing to the prone form. I examined her and found her in no danger and she would come out of her alcoholic stupor by evening. I told Lucky as much and asked him,’ since when she has been like this?’ He said since his recovery.

As long as he was drinking she was busy looking after him and getting him to stop drinking. After he gave up she had no purpose left and with gin handy she took to serious drinking and never even once came to see me. Was there something more that went on between them that I was not privy to? I don’t know.

I tried my best to get her off the habit. A A, Antabuse, psychiatric help, you name it, and she gave it all a try. She made many promises but did not keep them. The down hill course was rapid. She died of cirrhosis of liver with in five years. Lucky survived her by a few more years and died of a stroke.

Sunday, November 15, 2009

Lucky escape

‘Can any one have a heart attack and recover with in an hour?’ Ratnakar Shetty asked.
I did the mistake of telling him no.
‘I have’ he said.
This was becoming interesting. I asked Ratnakar who has been a friend and an occasional patient of mine for many years, ‘How do you know?’
This Ratnakar Shetty has a number of close relatives who are doctors and he gets free advice and treatment.
He rarely has to consult a doctor out side this immediate circle. When ever he does so it is for either third or fourth opinion and I am one of these.
‘The doctor told me’ he said.
‘Which doctor, you nephew?’ I asked. I knew one of his nephews who practices close to his house in the other end of the city, to whom Ratnakar usually goes. I thought he would have gone to him.
‘No, No, not my nephew, this happened in the middle of the night and I phoned him [his nephew] and that fool told me to go over to the hospital and see a cardiologist. He said it is a waste of valuable time coming over to see me.
‘So what did you do?’
I drove over to the hospital he said.
‘You drove? I asked him, a bit surprised that a patient who was having a heart attack could drive.
‘Yes, who else will drive and take me at the dead of night’ he said. ‘Why did you not call an ambulance?’ I asked. ‘I wanted to save time’ he said.
This of course was true but I still could not stomach his driving to the hospital in pain.
I asked him, ‘did the pain not bother you’?
‘No, there was no pain, by then Brufen had taken affect and I was pain free’. His wife had given him Brufen, a pain killer, as soon as he complained of pain.
‘So you went to the hospital.Then?’
Then what? One young fellow [young doctor] made me lie down took an ECG [electrocardiograph] and took some blood and told me that I have had a heart attack and wanted to admit me.
‘Did you?’
‘No, Don’t I know you doctors [I did not like him including me] I told him no admission gidmission for me, as I was feeling good’.
What did that doctor do? I asked
He was insisting and wanted to call a cardiologist to put a tube into my leg artery [a procedure called angiogram] he said pointing to his groin. ‘I told him I am going home’ Ratnakar said.
He [the young doctor] would not let me. He wrote a letter, ‘discharged against medical advise’ and made me sign and then he let me go.
‘So, you came home’.
‘Yes I drove back home and slept nicely and next morning I went to office’
.Then why did you come here? I asked
‘All because of that nephew [doctor] of mine’ he said.
‘What did your nephew do’, I asked
‘He took me to a cardiologist after three or four days and that man wanted to again admit me and do this test [putting up a tube into his groin artery]’.
‘And you refused,’ I asked him
‘Yes, I did’
‘Because I felt well and I had played golf the previous day,’ he said.
Now even I began to wonder whether the doctors were right. How can a person who has had a heart attack two days earlier, go and play a full round of golf?
I asked him why he did that.
‘Why not? I already had fixed the fourball and did not want to let down the partners, I am sure you too would have done as I did [again he included me against my wishes]. Knowing how crazy golfers are and the important place this game occupies in their lives, I could understand him going to play but not when you have just had a heart attack.
I told him so.
‘That is why I have come to see you. You look at these reports and tell me what the truth is’.
I had a look at his reports. There was no doubt about his having had a hear attack. A fresh ECG done showed an infarct well on its way to healing. I saw no point in restricting his activities ten days into recovery.
I told him that he was one of the lucky few who did well despite the doctors.
He came four weeks later and the stress ECG showed good effort tolerance and he did not really need any further intervention. He did well and it is nearly ten years since that episode and he has had no heart related problems.

Wednesday, November 11, 2009


Perisamy Gounder was not a regular patient of mine. He came to me when his own doctor, a senior general practitioner in the same area of my practice was not available. This doctor, Dr G was in his sixties when I began my practice and was well known and I would spend time with him when ever I found some time. Though I did not get any value from the point of improving my medical knowledge, I gained a lot by the way of improving my patient management skills from him. He too came to like me and after few years he told his patients to seek my help when ever he was out of town. That was how Perisamy came to see me. The first encounter with Perisamy was memorable in more ways than one.

This middle aged well dressed person asked me as soon as he came in, by the way of confirmation that he has come to the right doctor,’ Are you doctor Rao, Dr G’s friend?’ this he did in Tamil. I said,'yes' in the same language. ‘I need to take this injection’ he said, placing the vial on my desk. I looked at the injection vial. It was 400,000 units of penicillin. I was curious to know why he needed this injection and I asked him. This irked him a bit and he said with obvious irritation,'nee chumma kudayya’ [you can interpret this Tamil sentence as simply give it to shut your trap and give the injection]. Seeing me hesitating, he said Dr G gave him this and he has come here because he was asked to by the old doctor. This meant many things. One is that he would not have otherwise come to me and gone elsewhere to a more senior GP who did not ask stupid questions to that by hesitating I am not sincere to the old doctor’s advice.

I thought it better to give the injection as advised by my senior friend and ask him [the doctor] on his return why and what of this. I loaded the syringe and gave him the shot. Perisamy became very friendly and jovial after this and appreciated the old doctor and told about his friendship with him of over twenty years and took my leave with the parting advice that as a young doctor I was lucky to have won the confidence of the senior man. The fee he paid for that small service was more than what I made from seeing five patients!

Dr G duly returned from his holidays and I made one of my periodic visits to him. I asked him about Perisamy, the injection and his reluctance to tell me why he was taking the injection. The good doctor let out a loud guffaw and said,'keep this to yourself, this Perisamy is a wealthy industrialist from Coimbatore and comes to Bangalore fairly frequently. When ever he is here he sees a woman and spends time with her. The reason for taking the injection is prophylaxis [prevention] against Venereal Disease but he is a good man', the old doctor said as an after thought.

So that was Perisamy’s secret. I could now understand his reluctance to share this secret which he had shared with his own doctor of many years. As I grew older and [wiser?] I too became privy to many such secrets and learnt to keep them to myself and also became less judgmental.

Both Dr G and Perisamy are no more.

Sunday, October 25, 2009


When I went to the house from where the call came, I was received by a gentleman who had oriental looking face and a wide grin not at all in keeping with the one in whose family someone was sick enough to have needed a doctor to call home. Later I realized that this man Bir Bahadur had this grin on his face most of the time.

Col Sukmoy Das must have been in his seventies when I first met with him. Unlike other retired army officers he did not lead a genteel impoverished life entirely dependent on the measly pension that the army gave them. At least it was so in those days [twenty odd years ago]. He attributed everything that happened to him to lucky providence. His coming to riches too was one such. The shares that were pledged to him against a loan which was never returned by one of his friends who later died appreciated so much that he ended up a rich man. Did he then live like a rich man? If you go by the usual definition, definitely no. But my own assessment, he was a very rich man at heart. Let me explain. You can draw your own conclusions.

I told this grinning Birbahadur who I am and about the call and the reason why I am there. He became alert and for a moment his grin was replaced by some anxiety. This I have noticed on several occasions. When they see me, instead of relief they become anxious as though at the next moment I will be passing a death sentence. ‘Yes sir, saab he not well, come come, he in bedroom’, and without much of a ceremony, he escorted me to the sickroom and the job done and his grin back, he disappeared.
I found no one in the bedroom which was in considerable disarray. At that moment I heard loud sounds of retching from the closed doors obviously a bath room. A moment later an exhausted looking Col Das appeared. I introduced myself and told him about the call that came from his home. ‘Yes, yes, rather peculiar this happened, normally Hercules rum [ a popular brand those days] is of good quality, but you never can tell these days, even rum they have started adulterating’ he stopped to catch his breath before continuing, ‘normally I drink four large rums at night and I am fit as a fiddle next morning, but this time I have this violent hangover, there must be something wrong with the bloody stuff I drank yesterday night’. I did not have much to do as the diagnosis was fairly accurate. Nevertheless, I had to examine him. I found nothing wrong and he appeared quite fit considering he was past 70. I gave him a prescription for an antacid and returned home. On the way the anxious Bahadur asked me about what was wrong with his boss. When I told him the reason he wouldn’t believe me, he said,’ I drink same rum, but I am Ok, why saab get stomach trouble? I said,’ may be you drink less’. ‘No, doctor saab [Sir in Hindi] he drink four and he give me also four same same’. This master and servant sharing the same drink to gether appeared very strange because at that time I did not know the friend ship between them. I did not have a definite answer but hazarded a guess, I told him he was younger than the Col and his stomach could take the load and the older stomach of the Col couldn’t. Birbahadur did not agree. He said,’ you don’t know Col saab, he drink half bottle, and then thread a needle, maybe he eat wrong at night’. May be you are right, I said and I returned home.

I and Col became friends over the years till his death some 15 years ago. Though retired and rich, he never wasted his time. He would call me for trivial reasons when he could easily have come to my consulting room. It is quite possible he wanted my company and to share his rum [I did drink this obnoxious alcohol occasionally those days]. After getting me a drink which Bahadur brought, he would tell Bahadur in chaste Ghurkali [language of the Ghurkhas],’ fix one for yourself and join us’. The three of us would sit and spend some happy time. Of course I drank far less than these two old soldiers but it did not take away from the connival atmosphere.

He rarely called me during day time but when he did I usually found him tinkering with his car or doing odd jobs around the house or his well kept garden. His friend cum assistant usually stood around watching the boss work, occasionally handing him the tools required. He had an Ambassador car [those days this doddering hulk was the most popular car on Indian roads as other cars were not available] which he personally maintained. Once when I went to his home and asked Birbahadur where is the col, he said,’ under the car’ I went to the back of the house where the car was parked to see the col wriggling out with grease on both hands. He wanted his blood pressure checked! Another reason to get me over.

Those were the years when I was building my practice and col was aware of the many problems I faced and it was his way of helping me. He was such a gentleman that he never made me ill at ease when I was with him. My army service of few years also helped to cement our friendship.

Bir Bahadur and Col Das had served the army in the same regiment and they developed a special relationship and after his retirement Birbahadur was invited to share the living with Col Das. Birbahadur was the man Friday and his wife was the house keeper. Col had lost his wife many years ago and the only son was away living in Germany.

Col died in his sleep one night. When I went to certify the death I found Bahadur very sad with moist eyes. Later I came to know Col had made his life secure. Both Bahadur and wife went back to their native Nepal. There is a multistoried apartment complex where the house once stood and whenever I pass by that place, the memories of these two old soldiers and the happy times I had with them come flooding back.

Friday, October 23, 2009

Disappearing family doctor

Scene one

Patient A goes to his family physician and says,’ doc, I have this head ache again since this morning’ ‘When was the last time you had it?’ Doc asks. ‘Six months ago, and you gave me some pills to take for two weeks and I became Ok and now I have it again’. Doc refers to the records , quickly checks his [patients] blood pressure and temperature and gives him a prescription and tells him to see him if not better in the next two or three days. Patient thanks the doc and leaves. The whole process takes less than 15 minutes.

Scene two

Patient B finds it hard to go to a family physician or doesn’t have one to go to. But there are hospitals he can go to. He goes to one such. He struggles to find parking place and after that ordeal over he reaches the reception area and stands in the queue. When his turn comes the pretty woman asks him in a monotone about his problem. He begins describing his head ache. She cuts him short and tells him, ‘neurology’ [hospital protocol: all head ache cases are first seen by neurologist] and names a fee which is collected and a file with a doctor’s name on it is given to him. Patient follows the directional arrows leading to the neurology department and ultimately, after several false turns finds it. Another reception area and another receptionist, grim faced one this time takes the folder, looks at it and tells him to wait for the doctor to come as he is busy doing the ward rounds. When his turn comes to see the doctor it is two hours and his head ache is now crescendo. The doctor asks him how long he has had it. He says one day. Any earlier episodes? The doctor asks. Yes he replies. A 15 minutes examination later he is asked to do some tests which includes X-ray of his face [sinuses] and a MRI scan of his brain. [Hospital protocol: for all head ache patients these two investigations are to be done]. The patient trudges to the imaging section and waits in the queue. For his pictures to be done it takes another two hours. He is asked to come next day to collect the reports and see the neurologist. It is past 3 pm and the hungry patient with continuing head ache heads home. Seeing his condition, wife gives him a tablet of saridon and then his belated lunch. By evening after a much needed nap he is head ache free!

Next day he goes and meets up with the neurologist with the reports and tells him that his head ache has now gone. The neurologist prescribes a drug any way and asks him to take it for next two weeks.

The drug given to patient A and B was the same.

Patient A spent 150 Rs and patient B spent 8000 and wasted two days of his time!

The latter scene is likely to be the norm if the present tendency of directly seeking help from the hospitals continues as it is likely to be. The reason why this is happening is the gradual disappearance of family doctors.

I recently attended a CME [continuing medical education] for family physicians. Normally my preferred seat is in the front two rows where the speaker is more audible and visible and it is easy to interact if the need were to arise. But occasionally I prefer the last row. This is when for one reason or the other I find the speaker difficult to suffer and a snooze is preferable to the talk. On one such occasion occupying such a vantage seat, I had a view of all those rows of seated doctors in front. There must be about 80 of them. All the heads were either bald or covered with thinning grey. No black at all! Most were on the wrong side of fifty.

If no young doctor wants to be a family doctor what will the patient do but become patient number two?

Why the young have turned away from family medical practice?

Another post, another time.

Thursday, October 22, 2009

Appreciation of beauty

What is beauty? Generally we say she is beautiful to describe a good looking woman or it is beautiful to an object. But is it only the looks that the eyes see that matter? I don’t think so. Or am I looking at objects animate and inanimate differently? It is the feeling of joy that one experiences when looking at an object that can be described as beauty.

I had one such experience when I visited the exhibition of cartoonist Mario Miranda’s works few days back. What is it that made me so happy? Is it the brilliance of execution? Is it the humour? Is it the type of scene or objects he chooses for his paintings and drawings? Or is it the mixture of all these? I don’t know. I only know that I felt happy and I had no other thought in my mind in the three hours I spent appreciating this great artist’s work.

I bought the print of one of his paintings. It is of a failure [Hobo] leaning against a lamp post. There is such intense pathos in that picture that it is difficult to put into words. Again one should feel it as I felt it and I was compelled to buy it. Why did I do it when there were pictures which would have made me laugh which is a positive emotion instead of this picture which will make me feel sad? Appreciation of art need not always fill you with pleasure; sometimes the agony too is sort of enjoyable. I am tying myself into knots trying to explain what I felt. I hope you guys get the meaning any way.

I also bought a beautifully written book on Goa [Inside Goa] by Manohar Mulgoankar, richly illustrated my Mario Miranda. Those of you who are planning a holiday in Goa will benefit reading this book.

Sunday, October 11, 2009

Muniyappa wins the Indian Open

From time to time I have written about this young golfer from my club who overcame the major disadvantages of poor socioeconomic and educational background, to excel in this difficult to master game of golf. Please read my blog post of 20, sept, 2007 to know about his background.

I just now finished watching him winning the Indian open in a play off and a purse of 195000 dollars is his. The manner of his win was nothing short of extraordinary. His tee shot [drive] found the edge of a bunker on a downhill lie. He choose to hit over an intervening tree when the easy option would have been to chip the ball on to the fair way there by loosing distance but making sure he is on the fairway for the next shot. He managed to hit a brilliant lob from the thick grassy lie and the ball flew over the tree to lie perfectly on the fairway giving him an easy approach shot which he hit with in ten feet from the pin to hole out with a birdie and win!

This is his first major win and he has made all of us who have supported him very proud.

Congratulations, Mr. Chinnasamy Muniappa. You have done it and in style.

Thursday, October 8, 2009


He sat some distance away from us. We were four. I was a fledging medical student and the two with me were elders from my home town and one of them was the father of the youngman who sat away from us. They had come to see me to get help to access a psychiatrist in one of the premier neuropsychiatric institutes of the country [true even after 50 years, the Institute I mean]. As a medical student I could get them to see the specialist without much hassle. But before that we had to have our lunch and we had gone to a nearby eating place. The patient in question chose to sit apart or the seniors made him sit apart I don’t know.

The problem was that the youngman was not like others of his age. He hardly talked, was not much interested in dress, took bath several times a day, extremely poor in scholastic performance [he was 20 but had not passed his metric [high school], very fond of animals but cruel to his brothers and sisters, disobeyed orders etc. They were advised to see a psychiatrist and this commodity of doctors were hardly there in those days and only ones present were in this institute. If they had taken all the trouble to come from such a far off place, there must be really something wrong with the man I surmised. Then who am I to decide, my job was to take them and make then see the nut cracker [psychiatrist].

We ordered meals for four. Those days, food was very cheap and came in unlimited quantities. For half a rupee [three cents] one could eat a stomachful. The tray had rice, lentils, pickles, three vegetables, a bowl of curd and four rotis [kind of flat whet bread]. You can order a refill of any of the items any number of times! We were all finishing our respective meals when the waiter came to our table and pointing to the youngman sitting at a distance asked us,’ is he the part of your party?’. We said yes. He said, ’please tell him we have run out of roti dough’.’ You are supposed to serve unlimited number, how can you run out of food’ I asked the waiter. ‘Yes, what you say is correct under normal working conditions, but he, again pointing an accusing finger at the distant figure, has already eaten 25 rotis and is demanding more’

25 rotis! Enough to fill stomachs of five normal persons and here is this thin built man who has eaten 25 rotis and is demanding some more!’ 'You tell him that that is all you can serve him and no more’ I told him. ‘I did that and he is showing the board [which declared unlimited food] and has also taken out his pocket knife and is making threatening gestures. He is part of you guys and you please handle him’ said the waiter.

We were now faced with a new problem. I asked the father about his violent nature and the prodigious appetite of his son. He said,’ sometimes he becomes violent for silly reason and after a while he calms down but I have not seen him eating this much before. I will go and tell him that the food is over and he has to stop eating’. The father went to his son and tried to explain. After some loud altercation the son seemed to simmer down and there was peace once again in that hotel. The father returned to our table and said,'this is another problem, you never can tell what this fellow will do next, I only hope the doctor will help him’

Bakasura is the name of a demon mentioned in the Indian epic Mahabharata, who terrorized villagers around and demanded and got a cartful of food daily. His appetite was so great that he not only ate the food but also the bullocks and the cart man! How the distressed villagers were saved by Bhim is part of the story of Mahabharath. Looking at this thin tall man I just couldn’t believe his stomach could accommodate so much of food. A true modern day Bakasura I thought.

Consultation was duly done that afternoon and he was prescribed some medication and the party went back to the village. Many years later I came to know that this youngman, though academically a failure, became a successful agriculturist, married and raised a family with no apparent problems!

This brings me to the problem I have often faced in my practice. Who is really psychiatrically ill? How many of the patients who are presently being treated as ill are victims of the oppressive or unacceptable environment and their reaction is interpreted as psychiatric illness? Are we doctors dumping patients who are normal and because we cannot find anything wrong, as mentally ill and treating them?

Today’s psychiatrically ill, may be tomorrow’s normal person?

Tuesday, October 6, 2009

Conversations with a guide

I don’t know why he chose me for comfort and advice. It all began like this.
‘Sir, I hope you don’t mind me asking you’ he said. I said. ‘certainly will not’
‘Sir, I don’t know why Mr. R doesn’t like me?’ I asked him how does he know. ‘Yes I know, I heard him say, I take cut from the shops I take you people to’. I asked him, ‘Santo,’ have you ever worked as a cook’?. This question took him by surprise. He must have been wondering what cook has to do with the problem he has come to discuss with me. He said no, he has no experience as a cook. ‘Supposing you worked in a kitchen as a cook, will you not taste the food? Now he brightened up a bit. He said,’ yes sir I will, otherwise how I know food is good? I said, ‘the same thing is true with tour guides. They must taste the items they make the tourists buy’. Now he was visibly happy. ‘Sir you really think so? I said yes. But still he lingered on. ‘But sir, he thinks I take money. I told him it doesn’t matter which ever form one tastes. ‘Sir I cannot do it, I am Buddhist’. I said Buddhist or no you are a guide and you must first taste the food before you make us eat’. ‘Thank you sir for your advice’ and he left.

Another day he came to the room,’ sir I have one more problem. I asked him what it is now. ‘Sir that old man [all of us are old but he singled out one] Mr. P asks difficult questions. I said we tourists don’t know which questions are difficult and which are not. But sir, ‘it is not once but many times,’ today he asked me why Buddhists don’t follow family planning? I told him,’ sir there is no state policy’. He says state doesn’t say when one has to have sex, it is individual’s decision, you are a Buddhist you should know. ‘Sir how can I answer this question?’ I said,’ you be quiet and don’t answer such questions. ‘Sir I did, but he won’t leave me. ‘Santo, he tell me, why are you quiet? You not answered my question? ‘What did you tell him?’ I asked him. ‘Sir I told him I don’t know about Hindus but we Buddhists enjoy sex’. I came to like Santo. I asked him what he [Mr P] said to that. ‘Sir he became quiet but I see he not happy with the answer’. I told him I was very happy with the answer. Santo appeared pleased with my response, but ‘sir,’ I cannot upset people’. I told him not to worry.’ Mr. P will be secretly happy, any way old men of our age just talk about sex where as you guys actually do it’. A very pleased Santo left me.
‘Sir another problem’ Mrs. K thinks that the store where we went this morning sells fake jewelry. I told him all costume jewelry is fake. ‘Why sir, you too think so? I said the jewelry sold is not made of silver or gold, they are all plated. ‘Aaah,’that kind of fake,’ that everyone knows’. ‘But Mrs. K doesn’t’ I told him.’ she must have heard that in Srilanka jewelry is cheap and she must have been disappointed to find it is cheap because it is plated. ‘I will be careful hereafter and tell all Indian women tourist that the jewelry is plated, they will not blame me for taking them to a fake store’ Santo said before leaving.

Another day another problem, Sir that man who always has a serious face; he found it difficult to remember the name. I told him he is Mr. S. ‘Yes, Mr. S,’ he says why is it raining here always? You should provide umbrellas to all’. ‘Sir, he continued, do I make rain? I said no. ‘That too not in season?’ For this also I said no. ‘Then why sir, this gentleman wants umbrella at all times?’ I told him, ‘see Santos, why some people wear a coat at all times? Even when it is hot? He said he doesn’t know. ‘That is because it is a habit. Mr. S carries an umbrella all the time when he is in Bangalore and that is why he wants you to provide an umbrella and because he cares for others he has included all of us’. But sir,’ giving umbrella to all 21 is difficult, but still I will tell the company for future [he made a note in his diary]. From umbrella he jumped to another topic. He said sir,’ I am also a sportsman’. I became interested and wondered why he was telling me this. I asked him what sports he plays. He said,’ I play Billiard’. I said,’ very good ‘[felt the game suits his paunch] ‘Sir, you play billiard?’ I said no. ‘Sir Billiard is also like golf, you put ball in the hole, but area of play is small, not like golf’. He waited for my reaction. I said.’ Yes Santo,’ but Golf is easy.’ No sir,’ golf very difficult,’ in golf you have to walk all over, get wet, hit a small ball with a long stick, get leg pain, then sir you have to drink beer after you finish’. I agreed with most of what he said but not the last part. I told him drinking beer is not compulsory. We drank beer because Srilankan beer is very good; He beamed with this appreciation of Srilankan beer. ‘But sir there is one gentleman, Mr. P who drinks only Srilankan Arrack, not good for his age, you are a doctor, you tell him not to drink like that’. I told him, ‘Santo that Mr P can drink a bottle of arrack and still play a round of golf’.’ OK, then sir don’t tell him, let him drink Srilankan arrack, only two days left [for the tour to finish] you know’.

Another day. ‘Mr S, he don’t like me. ‘Why not, I saw him with you talking and laughing this afternoon’ I said. ‘Talking yes but no laughing no sir’. ‘Why does he not like you?’ I asked. ‘Not liking, not in that sense sir, he does not like me sitting with you yesterday at dinner table. I think he belongs to superior caste. In India, I think you have this caste superior and inferior, I have heard’. Santos, I said, ‘You are a Buddhist, you belong to the most superior caste and you have right to sit at the centre of any table’. ‘Sir then why he told me so?’ Santos asked. ‘See Santos, that Mr. S, he is big businessman, he wants to talk business and if you sit with him he cannot talk business, but only about tour, that is why he told you not to sit at the table’. This placated him. ‘Oho so, but I will be careful [another note in his diary].

‘Sir, Janak thinks you all are very good people’ .This unasked for compliment from the bus driver took me by surprise. I asked him how he has classified us thus. He says,’ all of you wish him before getting into the bus ’. If being good is just wishing then the whole world would have been of good people. I kept quiet. ‘But there is one person, Mr. S who has not wished him so far’ Santos complained. I asked him, ‘why are you telling me this’. He said,’ I must tell for your future reference’. What it meant I don’t know.

On the day of leaving Santo came to see me one last time, He said,’ sir this tour was very good, you all are such good educated people, your wives also’ he added as an afterthought. I asked him, ‘but you had so many complaints’. He said,’ sir that is for my education, last tour group had only Germans, I suffered so much I cannot tell you, your group very good’

On that salutary note our Srilankan golf cum sightseeing tour ended.
[Some facts and lots of fiction]

Thursday, September 24, 2009

Chappal doctor

They should have named him mercury but he was called Chotu, fondly by all of us. His real name is Kailash. He is now a prim and proper 12 year old, but when the incident occurred he was around three or four years old. I have tremendous admiration for his mother Arti who being a mid level [now senior] business executive for managing this boy and his less troublesome elder brother, a very sick mother and still successful in her job which also needed constant travel. From the day Chotu saw me after his pediatrician gave up [not really, more so, because it was more convenient to see me] he decided that I am one person with whom he can do whatever he wants and get away with. He also found my clinic a treasure house of material with which he can play. I have a tray which has many odds and ends on it and these he found fascinating. Before his mother could stop him he would pick up a pen or a pencil or even my Knee hammer and throw it on the ground for his mother to pick up. This done he would go to the window and try and close it with a bang. Then he would hop on to the examination couch and curl up so that I cannot examine him unless I straighten him which took all our effort. Would he keep quiet when he was doing all this? He would be shrieking with unadulterated joy. I have never seen a child who got so much of pleasure with so little. These antics of his took more time than actual examination. His favourite position for getting examined was to sit on my lap. No other position was acceptable. If I tried to put him on the table he would jump down or cry loudly. Soon I realized that to get his cooperation I had to make to do with examining him as best as I can in this position of his sitting on my lap with feet dangling. This position he was most cooperative and would open his mouth if asked him to do. But imagine my plight. How would I examine his throat or for that matter his abdomen with him astride on my lap?

Chotu began getting sudden episodes of abdominal pain. He would hold his abdomen and double up with pain. He would also give out loud howls. You have not have had the benefit of listening to Chotu’s howl. It brought the roof down along with the neighbors of the two houses on either side of Chotu’s house. When the concerned neighbors arrived they would find a laughing and smiling Chotu whose pain would have gone by then. Occasionally the same would happen when the panic stricken mother would bring to him to me. I began to suspect whether he like my other child friend like Meghna [see Meghna’s ear pain] is feigning pain to get his mother to bring him to see me and he can have his fun. He would get better whatever I gave him; even a glass of hot water did the trick.

But I was not satisfied. No child would do this repeatedly to attract attention even it meant fun with the grandfatherly doctor. I got an ultrasound scan done. The boy had narrowing at the junction of the funnel like structure which collects the urine [pelvis] that is produced by the kidney and the conduit which brings the urine [ureter] down to the collecting bag [bladder]. When sufficient urine got collected in the pelvis [funnel], it would try to push it down and the portion of the tube where the obstruction was, would not respond due to a defect [present since birth but came to light at this age in Chotu’ s case]. This would result in a colicky pain which could be pretty severe. This was the reason for Chotu's pains.

Dr R is my choice for handling surgical problems of my pediatric patients. Chotu was duly sent to Dr R. Some more tests later it was decided only surgery will provide lasting cure. Chotu came to see me with his mother. First thing Chotu said to me was,‘I don’t like your friend doctor who wants to cut my stomach’. I was very surprised. I thought the boy might be very scared of the surgery. I told him not to worry as it will be painless and he will be pain free after wards. 'I am not afraid' he said with his chest thrust forwards. He said, ‘you come there and do operation’. This kind of confidence is a bit unnerving. I explained to him why Dr R should do it and why I cannot do it. Chotu said, ‘he has coat, shoe, tie and the nurse holds me tight’. Now I knew the reason why my little friend doesn’t like Dr R whose nurse must have held him tight when he was being examined and Dr R must have appeared to be forbidding in his dress.

His mother added,'he has been telling me, ‘take me to chappal doctor', this is what he has been calling you ever since we started visiting the hospital where he is seeing all the doctors dressed in suits’! The boy is comfortable with this grandfatherly doctor with grey hair with his feet in chappals, who allows him to ride on his laps, sit on his table, play with all the odds and ends in the consulting room and thus thinks he is more qualified to operate on him!

Consultants and doctors who work in the hospitals wear either jackets or white coats. This is because of tradition and habit. One consultant friend who came to the golf course on a sweaty hot Sunday afternoon after his hospital rounds was in his full regalia of suit and matching tie. When I asked him how come even on a hot Sunday afternoon he wore a jacket,’ he said,'I feel naked if I did not wear my jacket’!

In contrast I have no such inhibitions. My normal working dress is a half sleeved shirt and trousers with Hawaii chappals [slippers] for the feet. On the rare occasions when I am forced to wear a suit [once or twice a year] I feel like being in a straight jacket!

Nevertheless it was comforting to know, at least my children patients appreciate my dress code!

The boy duly got surgical repair done and became pain free.

Sunday, September 20, 2009

Convert to allopathy

Worry writ large on her face, she sat stiffly facing me. I asked her, ‘How come you are here?’

This will appear a strange question to ask a patient, you may think. But you don’t know Saroj as I do. Her first court of appeal is her favorite family homeopath who is also her close friend. By the way of answer she gave me a hard stony look. Her husband, Sanjay prompted her,’ go ahead tell him’. Thus encouraged, she said,’ I have it again’. What you have it again? I asked her. She said doctor,’donot make fun of me, you know what I am referring to, I have it again’. Those of you who have read my last posting know Saroj’s travails with tuberculosis of her neck glands and how she was managed by her homeopath.’ If you have it again why come here when your homeopath friend is still around and kicking’ I couldn’t help taking a dig at her half jokingly and half seriously. She was quiet. That meant only one thing. She had already consulted with her friend and then has come here. I told her, ‘first of all I don’t know what you have got, let me have a look’ and then I said rather pointedly, ‘with your cooperation this time, we will tackle the problem, provided you keep your friend away when you are under my care’.

Her being quiet meant acquiescence. I proceeded to examine her.

Her right neck was empty in the sense there was no tissue under her skin, thanks to her old infection, the lymph nodes have been wiped out there and only an ugly scar was seen and felt. But the picture was different on the left neck. There were several matted [adhered to one another] nodes, a hall mark of gland TB. She also had low grade fever and felt unwell. She agreed to whatever I said. A piece of tissue was taken out of the lymph node and it confirmed TB. She also agreed to take the treatment for the next six months and come for follow up as advised. Not even a whimper about drug induced side effects etc. This kind of resigned acceptance is not in keeping with the character of this spirited young woman. ‘What? You have no questions, I asked her’. ‘What questions?’ she said, ‘what I am going to go through with your treatment cannot be worse than what I went through last time when I had this illness’. That said it all.

Had she taken, in the first instance, the six months anti tubercular chemotherapy she would not have had this relapse as the organisms would have been effectively removed from her body. I was prudent enough not drive home the point.

Later I came to know from Sanjay that they both had done an extensive net search and found the consultation with the homeopath did not answer their questions as well as mine did! She successfully finished the treatment about a month ago and I can now say I have a convert to allopathy.

Sometime later I will tell you all how Saroj saved her homeopath friend’s life, which is another story.

Wednesday, September 16, 2009

Belief and faith

I have known Saroj since her school days. The young man she fell in love with and married to is also a patient of mine. This does not mean she always came to me. It needed two separate disease incidents to make her believe that the system of medicine that I practiced compared with her and more importantly her mother’s diehard belief in the curative powers of homeopathy.

It was some six years ago that she came with a swelling on the right side of her neck. Gradually increasing in size she ignored it for a few weeks wishing it to go away. The swelling did no such a thing. Instead it grew some more and she was brought by her husband Sanjay to see me. It was obvious that it is a lymph node mass and by the way it felt most likely cause was tuberculosis, Tuberculosis popularly known as TB spares no one in our country and I sometimes feel it is an Indian’s birth right to suffer this disease. A fine needle aspiration showed the typical histology of lymph node tuberculosis. When she came this time for review it was with her mother who was grief stricken that her precious daughter has TB and her attitude said that the doctor [me] is taking it lightly. This to certain extent was true because I was happy that the swelling turned out to be tuberculosis and not lymph node cancer. We doctors practicing in India eat and drink TB and at any given time a doctor has couple of TB patients taking medication and TB, especially gland TB is eminently treatable. I told the mother that it is easy to treat this provided she [the daughter] took the prescribed treatment for the duration of six months. The mother ignored this excellent prognosis. She said,’ none in our family has had this terrible disease, how did my girl get it?’ ‘What crime she has committed to be punished like this?’ I couldn’t relate to this grandiose idea of suffering and said that it is our birthright to get it as it so widely prevalent and family and ancestry has nothing to do with this. This, instead of satisfying her seems to upset her more. She said I don’t understand her problem. I agreed. I asked her daughter who is the patient whether she is willing to take treatment and almost certainly get cured.

She [the daughter] asked me one simple question. Will you promise me that he drugs will have no side effects? I said,’ I cannot promise’. She then said, ‘my homeopath has promised me that she will cure this disease without causing any side effects’. Now I knew that the mother and daughter combination has made up their mind to take Homeopathic treatment and were enacting a drama to get rid of my nuisance. I felt bad not because a homeopath has scored over me which has happened often enough, but because the suffering this young woman is going to go through if she were to take homeopathic medications. I told her the swellings will increase in size and will become soft in the centre and in a matter of few months will burst and ooze pus which will form tracks and will ultimately heal leaving ugly scars. They said nothing and took my leave.

Few months passed. I met Sanjay one evening and asked him how Saroja was doing? He said, ‘doctor, the swelling has burst and the pus is oozing out and the homeopath says that is what exactly the medication does and all the pus will drain out and she will heal’. My wife is virtually home bound with a bandage tied around her neck. I don’t know when the misery will end’. The misery ended some months later and as expected the natural healing took place with a hideous scar. Fortunately the scar was in the dimple next to the inner end of the collar bone and Saroj was able to hide it well with a strategically placed necklace. The matters thus stood for a few years and the homeopath continued to manage them. Saroj’s husband however kept in touch with me and came to me whenever he had a problem.

Their daughter Kusum is a pretty fifteen year old who occasionally came to see me with her father. The homeopath was managing her too, till she came down with a mysterious illness. She began having fever which would come and go and the girl would complain of fatigue and was listless. This went on for a few days and the family homeopath’s ministrations were tried but the problem continued. Now the family thought it best to get an opinion from yours truly. Fortunately that inveterate believer in the merits of Homeopathy as a cure all form of medical discipline, the mother of Saroj, did not accompany Kusum when she came to visit me. The girl was really off colour, had fever and had palpable glands in her neck and armpits. She also had enlarged tonsils which were unusually red. Her spleen was palpable. These signs and symptoms in this age group could be harbingers of serious disease. I kept the possibility of serious illness to myself and asked them to get some tests done. The results came back as positive to Glandular fever or what we call in medical term Infectious mononucleosis, a disease of viral etiology which after a variable course of time limits itself. The girl and parents were accordingly advised as to the need for no active interference and were asked to see me a week later. When she came for review a week later she was back to normal. I later came to know that the grand mother took her to the homeopath after the diagnosis was made and administered the recommended medications and the spontaneous cure was attributed to Homeopathic medication

I often face these situations. I have one simple philosophy, if a treatment does no harm I will not interfere. If I know that it is going to cause problems I try to interfere but often fail as it happened in the mother’s case of gland TB. But then, I did not really fail as the post script to this posting will show next week.

Sunday, September 13, 2009

Dropping a brick

Some time ago I wrote about the numerous castes and sub castes that divide us Indians. One such caste is the Brahmins. Among this large group there are hundreds if not thousands of subgroups and one of them is the predominantly Tulu [a dialect] speaking Brahmins who reside in the coastal region of Karnataka. Like in any other caste for the social functions of these communities only those who belong to this sub caste are invited and therefore when I found a Tambram [short form for Tamil Brahmin] Thyagarajan in one such function, I was naturally surprised. I know Thyagarajan pretty well and wondered whether his wife is a Tulu Brahmin and he by marriage qualified for the invitation. But I had met with his wife and she did not look or behave like a Tulu Brahmin woman. Still I was glad to see him after two years and went to him to exchange pleasantries. Seeing me he gave a smile of recognition and asked me how am I doing. I said fine and asked him, ‘Thyagu, how is that you are here at this function?’ He appeared surprised,’ he said, my name is not Thyagu, it is Srikrishna and Col Acharya is my father in law'. The function was a housewarming ceremony of Col’s new home and naturally the son in law has the right to be invited. A bit crestfallen at the mistaken Identity, I apologized which was well received.

Some months later I met him again in another function which was secular and there were persons belonging to all communities as the local bank had called a customer meeting. This time when I confronted him I began,’ you know Thyagu, what happened last time’, and proceeded to narrate the story of mistaken identity. He heard the story in stoic silence and said,’ doctor, I am sorry to disappoint you, but I am not Thyagu, My name is Srikrishna and we met last time at my father in law’s house warming ceremony’. I was taken aback. Such uncanny resemblance and speech! Again apologies were in order but were accepted with some asperity.

There was another function where the participants were mostly Tulu speaking Brahmins and this time too I found Thyagarajan, sorry, Srikrishna. I made sure that he is indeed Srikrishna and then went to meet with him and to prove correct the third time. On seeing me coming towards him, he hurriedly got up and walked to another corner obviously afraid that I would once more call him Thyagu!

I did not have the heart to chase him to prove to him that this time I have indeed made the recognition right.

Thursday, September 10, 2009

Identity crisis

‘Why are you not on inhalers’? [Inhaled steroids are the main stay in the treatment of chronic asthma] I asked. He did not respond but the sheepish look on his face told me that he has not been taking it. I asked him,’ where are my case notes’? He did not have them with him.

Here some explanation is required to understand this conversation between the patient and I. With rare exceptions all my regular patients carry my case records and some of these go back to over 40 years. They are a reflection of not only the quality of my practice but also the patient and his disease characteristics. I find it extremely upsetting when a patient comes without my notes because the treatment often depends on what I did when he visited last time. This patient had not only come without my records but also was not following my instructions. ‘When did you last see me’ I asked. Five years ago he said. This was a blatant lie. I knew Jayaram to be not a very good patient and often did not keep appointments and came whenever he was in trouble with his asthma and not when I had asked him to come. This led to my having problems of management and caused lot of worry. I had even told him last time he came, which was certainly not 5 years, that if he does not keep the appointment and regular follow up, he better find another doctor and I really meant it.

Here he is again up to his old antics and adding insult to injury was also lying.
I could barely control my anger. I told him to get lost and not to see again. He started saying something in placation. But I had enough of this man who had bothered me over the years and it is a good opportunity to get rid of him forever. He stood for while wiping his sweaty face and seeing me unrelenting, went out.

I got busy seeing other patients and after an hour or so, in walks Jayaram who must have been waiting outside. By then I too had cooled down. He said, ‘Sir, I really saw you five years ago and you did not put me on any inhalers and I did not see you for asthma, this is the first time I am seeing you for this trouble’. I had a closer look at him and asked,' are you not Jayaram?' He said, ‘Saab, my name is Abrar Ahmed, I am Abbas Ali’s nephew. You know my uncle very well’.

I could have sworn that the person in front is Jayaram but the fact was that this poor man who took the flack was indeed a different person with remarkably similar looks. My apologies were gracefully accepted and of course the treatment details are of no interest to you.

The errant Jayaram is still my patient and continues to persecute me!

Next week I will narrate another episode where in I had dropped a brick not once but twice.

Monday, September 7, 2009

Ring side view

They called me by many names. For some who were my friends it was a white boy. For some others who were not so friendly it was white cockroach and for some others it was cat’s eye. With my thin build, fair complexion, green eyes and red lips, I stood out like a sore thumb in the sea of brown and black. Occasionally a snide reference was made to my ancestry. The small town I grew up had schooling up to high school and it was not very pleasant to be constantly reminded of one’s body and colour. Occasional physical encounters ended in my getting the worse of them. Though unpleasant, most of the times they meant no real harm.

It also rained cats and dogs for almost six months in a year and I frequently fell ill during rainy season. Attacks of asthma and bronchitis were constant companions. I must have suffered all the childhood illnesses like whooping cough, diphtheria and any number of episodes of diarrhea and dysentery. These illnesses we hardly see these days thanks to the successful immunization in childhood. Looking back I sometimes wonder how I survived this illness ridden childhood

This was the negative aspect of my life but the positive side was also there. There was plenty of open places to pay and virtually no pollution. You could play to your hearts content and not worry about regular school attendance. The school was run by the government and the teachers were not very particular about attendance. And my illnesses came in very handy to bunk school. Few teachers were even indulgent because of my frail build and disease prone nature. There were other attractions like the local cinema and cheap eateries. There was also a major weekly attraction which we all looked forward to. That was the weekly fair.

The fair was held on a large piece of flat land [this was difficult to come by in that hilly terrain] located on the outskirts of the town. To the fair came villagers from nearby villages to buy and sell produce and products. It also attracted travelling salesmen of all kinds who set up their stalls where ever they found a place. It was a kind of haphazard mela and our weekly delight. We children preferred some stalls to others. There was one guy with a bioscope which showed magnified photos of distant lands and famous people and also some weird and exciting scenes that interested us. There were wrestling matches where well built men wrestled in specially made sand pits. This was special to me, being physically thin I liked watching these wrestlers. One of them was called Mutton Usman and the other was Dhobi Bojanna. One was Mussaleman and other was Hindu. What was surprising was the Mussalman wrestler trained with Hindus and the Hindu with the Mussalmans.The rabid differences between the two communities which have come to the fore recently were not that visible those days.

There was another who sold medications and I must tell you about him because I was his victim.This person was dressed in a coat and trousers which in itself were a novelty. He also had an impressive belly. He usually held court under a tree and I was a regular attendee till the narrated incident occurred which made me avoid him. He hung several large banners with pictures of well built men and women. There was also picture of a skeleton next to the picture of human anatomy showing what lies under the skin. Muscles in pink, blood vessels in blue and red, bones shown as white and a skull with mouth open. This gave the face a curiously melovelant grin. The sales man would wait for some thirty or forty people to collect and then would get his assistant to distribute handbills to the adults. These handbills proclaimed the sales man as a doctor with many degrees and accomplishments and miraculous cures. He had a cure for arthritis, snake bite, phlegm, impotency, head ache and to build one’s body. He would then proceed with his sales talk which would last for about ten to fifteen minutes. He held his audience spell bound with a mixture of demagogy and humour. This done, he would go around with various pills and his customers would choose whatever they thought was good for them. This done he would get his assistant to collect all the hand bills from the audience for reuse next time.

Once he was demonstrating the effects of his medicine for body building, repeatedly showing the picture of the well built body and the skeleton and how he would make the skeleton look like what is shown in the other picture. I had occupied the ringside seat and was so engrossed with this superman’s talk that I did not realize being caught by the arms and dragged to the middle of the ring by his assistant. Now he had a living skeleton to show his power. He asked another who was well built to come forward and comparing us he said he would guarantee the result if I took his pills that I would become like the other person. This sales talk brought many forward to buy his pills as many in that crowd were under nourished and thin. His work done he let me go and that was the end of his show for the day and he started winding up. He sent his assistant for his much needed cup of tea. I stood there waiting. He turned and saw me standing alone with the entire crowd having gone and what business I had to be waiting. He asked me. I told him I need to have some of his body building pills for free as he had used me as an object for public demo. He became very angry and gave me a shove with a shout to get lost. I walked away with some disappointment and lots of anger and after having reached some 50 yards or so took a piece of stone and hurled at him and was rewarded with a strike and a cry of pain from the doctor. He of course could not match me in running and his assistant was away. I stood there for a while as though to challenge him to catch me if he can and seeing no challenge forthcoming went my way. Then on I carefully avoided visiting this travelling doctor.

Some years ago there was a product launch and I attended that meeting. A well known doctor was hired by the Pharma company for the talk with many colorful slides the doctor made his case. He was impressive and his talk was punctuated with lots of wit and some wisdom. He never once used the pharmacological name of the drug but repeatedly used the trade name being promoted by the Pharma company to drive home the message that we fools in the audience will be better off using this magic pill on our hapless patients. The additional bonus was the cocktails and dinner that followed.

I wonder if there is any difference between the itinerant salesman cum doctor of my childhood and the hired qualified professional who promoted the product of the Pharma company.

Sunday, August 30, 2009

Ignorance is bliss

Sometimes patients don’t know the danger they are in and even if it is explained to them. They either are not bothered or not intelligent enough to understand. Four days ago I had this man Satish who works for a friend of mine. Satish developed some discomfort in the chest which he attributed to gas and managed a day or two with antacid tablets. As the pain kept coming back, his boss forced him to see me. There was nothing remarkable in his history except that there was early death of his father when Satish was a child of five years. Satish is now 40.

A blood pressure check was horrifying. This otherwise hale and hearty looking fellow had a blood pressure of 240 over 140, highest recorded in my practice in recent years. His pain chest was due to his heart bursting virtually at its seams against this high resistance! Immediate administration of quick acting medication brought his blood pressure down to 160 over 90 and the tests showed strained heart muscle. His blood lipids too were sky high.

His chest discomfort had disappeared. I interviewed Satish and his wife and spent time explaining the seriousness of the illness and why he should change his lifestyle, take regular exercise, eat low calorie food and take medication. The vacant and rather bored expression on their faces never changed throughout the half an hour they spent with me.

The parting question that was put to me by his wife said it all. ‘Sir, he is very fond of ghee, can I put two spoons of it in his rasam rice?’

If I felt like beating my head against the wall will you blame me?

Friday, August 28, 2009


When I first met Cyril Naronha he was past seventy. That was some twenty-five years ago. He just peeped into my clinic one day and having found no patient waiting, sat for a while chatting. I later realized that it was his nature to be pleasant to everyone around him that included the daily sweeper of his house and the neighbor’s gardener. He spoke Kannada with a delightful Mangalorean accent. He spoke the language out of choice, though he could speak impeccable English when the occasion arose. In contrast his wife, Miriam Naronha always spoke to me in English. Not that she couldn’t speak Kannada. But English came naturally to her and she was comfortable conversing in it. At home they spoke Konkani, a language which I spoke as a child but since have forgotten to speak but can understand very well. This came in handy when there was any conversation between husband and wife in Konkani that they thought was private and excluded the doctor. This occasionally led to hilarious situations.

Mr.Naronha always paid my fee with a new note. He sometimes took the trouble of going to the bank and exchanged the soiled one with a new one before visiting me. His wife had no such compunctions. When they visited me together, she being the cashier of the house would pay. Once she paid my fee and the notes were visibly dirty. An irritated Naronha told her, ‘I did not know of your love for the old and the decrepit, extended to the old notes; do you think our doctor is there to dump your filthy torn notes?’ She would have none of this unjustified criticism, she said, ‘my husband, what can you expect out of a wife who has had to make do with second hand things most of her life, including the husband! [He was her second husband]!

There were other features that made me like Cyril. He was always impeccably dressed. He had braces to hold his trousers up, first time ever that I saw them. He told me that when young with a bulging belly he needed them to keep the trousers up and now that he had lost he midline bulge he needed the braces to keep them slipping down and making him liable to the charge of indecent exposure! He also had a tie on, that had seen better days. In winter he would have a coat on and in summer he would do without. All this meant, given the slowness of age, he took more time dressing and undressing than the time spent in examination, quite exasperating when you have a houseful of patients waiting. But he more than made up for this by his humor I don’t remember an occasion when he went without making me laugh. Though he did not need to visit me frequently he made it a point to come once a month usually during the first week when he still had his pension money to spend as he once said. My guess is that he came any way to spend some time chatting up with my patients and my attendant and then with me and thus to have a good time. It is only after his death that I realized how much his visits meant to me.

He also told me some home truths about us doctors. Once he compared to Church priests. Both spoke in a language that the clients did not understand. The priest said his prayers in Latin and though doctors spoke in English it is as bad as speaking in Latin. The priest took confessions and the patients too did that with their doctors. He had a very valid explanation for obesity. It was his belief that when you diet you put on weight and when you don’t you remain normal! He gave his own experience of weight gain and loss. When in service he was careful with what he ate and drank but still gained weight. But now in his old age he ate everything edible and drank good wine but had lost the weight and felt never better. He joked that in this country when you hold official position of power it not only swells ones head but also one’s belly! He did not much like my habit of not giving medication when none is needed. He once told me that one must always give something even if not required. He said the bitter the medicine the better the patient felt. He was all for the mixtures [name for liquid medicines doctors made up those days] dispensed as part of the treatment. He compared this with the practice of temple priests giving something away to the devotee in return for the prayers offered. That is one way of getting the till filled he said. When I told him the psychological and placebo value of these mostly useless ministrations and the need to educate the patients, he said patients will always remain ignorant, and felt it is good for their health not to know too much!

He suffered from stable angina and lived with it for several years. The basic investigation those days was the two-step treadmill, and it was strongly positive. They had just begun doing angiography in few centers and no one did it for a seventy plus person. They were destined to be treated conservatively with the mainstay drugs, the nitrates. Cyril did very well with three four tablets of these a day. I visited him on one of those occasions when he had just recovered from an attack of chest pain. He was not sure where the pain actually was. Was it located in the upper abdomen, lower chest or both? This kind of confusion was not unusual and we had no way of knowing whether the patient has had an ischemic episode, a full-blown infarct or just an episode of hyperacidity. We relied mostly on the resting ECG, the patient’s history and our past knowledge of the patient. I found the ECG no different from his previous ones; his blood pressure and pulse were stable. I reassured him and joked that he will live to a hundred and came home.

That night Cyril died in his sleep. They realized it when he did not wake up in the morning. I was now sure that the previous day’s pain was the beginning of a heart attack yet to show in the ECG. I felt terribly guilty not having sent him to the hospital. Instead I had assured him 100 years of life! I went to his place feeling terrible. There was a somber atmosphere with the body laid in the main hall. The parish priest had just left and I went to his wife and couldn’t help apologizing. She said, ‘doc, it is good you did not send him to the hospital, he died peacefully with no suffering, thank you very much for all that you did for him’

Few years later, Miriam too died. Their son, from Cyril’s first wife, comes periodically to Bangalore to visit his mother in law who lives here and drops in to see me. Except for the central bulge he is a replica of his father.

Thursday, August 27, 2009

Spell check

Many years ago, in the early days of PCs, I got this one from an unknown source.

Eye halve a spelling chequer,
It came with my pea sea.
It plainly marks for my reviue
Miss steaks eye khan knot sea

And an apt rejoinder from Jeff Aronson, who wrote [still writes?] filler for BMJ, follows.
Eye have run this filler threw it,
I am shore your pleased to no.
Its letter perfect all the weigh
My chequer tolled me sew

On growing old

The foot less prompt to meet the morning dew,
The heart less bounding at emotion new,
And hope, once crushed, less quick to spring again.

Mathew Arnold

Clinic capers

Loud annoncement heard over the public address system in the patients waiting area of a hospital's gastroenterolfy clinic. 'Mr Ramakrishnan, please come for your enema'

A patient told my doctor friend that he [patient] has been having wireless fever for which he has taken kerocine [Crocin].

Sunday, August 23, 2009

Incence and Asthma

25 years ago I used to make many house calls. I do hardly any now. Those days the emergency care in out of office hours was provided by us general practitioners and a large percentage of these calls were from those suffering with acute asthma. Asthma then as it is now is a serious disease and our visits meant a great deal to the patients and often was life saving. They were also the days when there were no inhaled bronchodilators and corticosteroids which have virtually eliminated emergencies of the kind we saw then. This city as it is now even then had a high incidence of asthma. There were also fewer institutions and doctors to provide emergency care. It was thus common place those days to drive 20 kms and back after making a house call. It was not difficult to drive as the traffic was thin and road users were less aggressive. I cannot imagine doing the same with the chaotic traffic of today.

This was also an essential part of our lives and these house calls helped us to get to know our patients better. It begets a special relationship when you share a cup of tea with the patient’s husband/ wife/ father after the visit before you started back on your lonely drive back home. You could also subtly assess the economics of the household by the way they lived. Though what the patient paid or could pay fell far short of our expectations, the indirect professional rewards made these house calls worth making.

When the call in question came, it was past 11 pm and I was just drifting off to sleep. It was the frantic voice of my friend and patient Arif that I heard, he said, ‘doc, my wife is having an attack of asthma, if you don’t do something quick she will die’. I asked him to give her a tablet of Alupent [a popular remedy those days]. He said he had already given that and it has had no effect and he stressed the need for me to hurry.

It is no exaggeration that acute asthma can kill if not relieved urgently and it was experience of many of us to have witnessed such deaths. I pulled a pair of trousers over my pajamas, told wife where I was going and not to expect me for another two hours [the house was 15 kms away], took the ever-ready kitbag containing all the essential equipment and went to the car. Took the car out and came on to the main connecting road.

Here I must describe how this extension was 25 years ago. The main road which is now a bustling wide road and the commercial hub with traffic round the clock was a barely motorable road which became narrower at both ends where it met the high way. There were no streetlights worth the name. The houses on either side were few and far between. Now if you add to this scenario a constant drizzle very few would venture out. It was November and Bangalore was colder then than it is now. This was the scene when I went out to make this house call. A km down the road I felt the characteristic wobble of my car indicating a burst tire. I had a car that went by the name of Gazel, a version of the popular standard herald car of those days. For a doctor, especially a GP, his car is his best friend. But I cannot say this to my Gazel. The amount of trouble I had with this car, no enemy [even imaginary one] could cause. That is another story which I will narrate some other time.

I had to take the car to the side of the road for an inspection. The rear tire was indeed flat and I had no option but spend some precious time changing the tire. They were pre cell phone days and I had no way of getting in touch with Arif to give the news of my delay. The best way is to change the tire as quickly as possible and be on my way. This was not as easy as it sounds. For one it was pitch dark, there was a cold drizzle and I had only a flickering torchlight to go by. There was no choice. I went back, opened the boot, took out the tire wrench and the jack and turned. That was the first time I noticed the presence of the Dog Doberman. The dark shape merged perfectly with the background. Unlike the other breeds Doberman attacks first and barks later. This dog fortunately just stood there staring at my torchlight and my hands that held the tire wrench and the heavy jack. I let go the jack which fell to the ground with a thud. The sound brought out the fighting instinct in that dog; he let out a huge bark and jumped. At the same time I also jumped and took a swipe with my wrench. Fortunately both of us missed the target and he landed on the car and gave a painful yelping bark and I hid behind the other part of the car away from him. He started sniffing the fallen jack, satisfied that it is no enemy and finding none else he let out another howl. This brought out a chorus of barks from all the dogs in the neighborhood, both strays and the domesticated. I also could see several strays running into join the battle. Thankfully for me the strays were friendly to me but were hell bent on attacking the Doberman. I could now safely retreat to a distance and watch the battle in the dim light.

The commotion brought the lights on in many houses and one of them realized that it was their dog’s cries of anguish. Mongrels [stray dogs] are good fighters and the Doberman was outnumbered. Out came the gentleman of the house calling out, ‘tiny, tiny, where are you, come in my pet’. The dog retreated into the compound and both the master and the dog went in, completely ignoring me and my predicament. This did not bother me, as I knew how my upper class countrymen behave in such times. Seeing only a hapless human, the canine pack quietly retreated leaving me to do my tire-replacing job. With the slippery conditions, placing the jack at the right place was no easy task, and must have taken much more time than usual. With grimy hands and anxiety in my heart I drove the distance to Arif’ s house.

I found him restlessly pacing up and down the verandah of his house. ‘What took you so long? you left the house an hour ago, I called your home and bhabhi [sister meaning my wife] told me you had left, she must be worried, I will call and tell that you are OK’, Without waiting for me to say anything he went to call my home. I knew she wouldn’t be upset but the thought of her waking up once again was not pleasant. I went into the house.

There was a pungent smell coming out of the patient’s room that had spread to the whole house. My tired nose started twitching and the irritating fumes made me cough, by then Arif arrived having assured his bhabhi that her husband is safe and at his assigned job. I asked him,’ what is this obnoxious smell?’ He said that is his mothers doing, after waiting for you so long she went and put something into the fire and this smelly vapor is supposed to help my wife’. Here I must tell you a bit about Arif ‘s mother. Being a mother of 8 children and innumerable grand and great grand children, she is the matriarch of the whole clan and her word is the law in that home. We have a love hate relationship, having crossed swords many a time with the same intention of healing the sick, she her way and I my way. Now, this way of effusing pungent fumes in an asthmatic’s room is tailor made to worsen the asthma. Those days I had even shorter fuse than now and my encounter with the Doberman had made my mood foul. I couldn’t help making some acerbic remark about the old lady little realizing that she was standing just next to the door we were entering. She said to me without mincing words, ‘ are you going to stand there making unwanted remarks or are you going to see the patient and give her some relief, you have taken your time to reach here, Allah ka marzi [thanks to merciful Allah], she is still alive’. Though angry enough to give a fitting retort, I held my tongue, as the patient was indeed very sick. There was much labored breathing with wide spread fine ronchi [sounds made when there is obstruction to the free flow of air] in her lungs with a tinge of blue in her tongue indicating insufficient oxygenation. The fast heart rate was due to a combination of breathing difficulty compounded by the thumping dose of alupent.

I loaded the syringe with Aminophylline and began the slow IV. After this was over, gave her dose of Betamethasone again IV. Now was the time to wait and see what relief one would get or what side effect I was going to produce with the aminophylline, a dangerous drug at the best of times. No immediate adverse reaction to the drug occurred in the first ten minutes and I heaved a sigh of relief. Now I could take stock of the surroundings. I noticed the closed windows and the stuffy and smelly air in that room. I went and opened the windows and let in some fresh air. By now the son and the mother had removed the Chula [earthen stove containing burning charcoal] with the dhoop [name of the incense] to some far corner of the house and the smell became considerably less. The matriarch was nowhere to be seen. I waited another ten minutes. The patient was significantly better and was actually able to smile at me. The atmosphere was much less tense and I could feel relief all-round. Another ten minutes of wait Syeda [Arif‘s wife] quietly went to sleep virtually free from the terrible spasm. The relief was so spectacular that it was difficult to believe that she was the same patient whom I saw 45 minutes ago.

Now I made my preparations to go. It was now the turn of the matriarch. She had already heard of my ordeal on the way, had seen the near miracle of her daughter in law’s recovery. She said in chaste Urdu, ‘doctor saab, I consider it a favor if you stay and have a cup of tea with us’. I was not that crass as to refuse this peace offer. We had a cup of much deserved hot tea and after thanking the old lady, I returned home to wake up my wife, the fourth time that night.

Sunday, August 9, 2009

Doctor as the detective

The call came again from Mr. Devarajan’s apartment. I had gone there the same afternoon and found him fairly alright though his arm was still twitching a bit. He was able to swallow food and was comfortable and even spoke to me with some optimism which had cheered me. Now, comes this call of distress.

Devarajan was a senior executive in one of the top food processing companies with its head quarters in Bangalore. When this incident occurred some fifteen years ago, I was the company’s medical advisor and would visit twice a week in the afternoon. The company had built apartments next to the office for twenty odd senior officers with all in built amenities, befitting a successful company. Devarajan and his family were occupying one of these. My practice being close by, I got not very infrequent calls from these in house families whenever there was an illness that needed to be attended to at home. Lately calls from Devarajan had become frequent and urgent and what was worrying was that I had not been able to find out what was wrong with him.

I saw him sitting hunched up with head held up. There was uncontrollable twitching of the face and lips with drooling of saliva. His jaws were clenched tightly and he could open the mouth with great difficulty. Neck was held rigidly at a tangent. Lower limb, abdomen and trunk muscles were less affected and he was able to walk without any difficulty. Hands and arms were also rigid but not to the same extent as muscles of the face, jaws and neck. He was not able to speak with any degree of coherence. Going by the past experience I gave him an injection of Diazepam and oral clonezepam with baclofen [all are muscle relaxants].He settled within a few minutes and I was sure he would be ok at least till morning.

Devarajan began having these problems a month ago one evening. Though certain that these were caused by unopposed motor impulses from the brain I did not know the cause. Other conditions which cause rigidity and spasm like Parkinson’s disorder and Motor neuron disease have a chronic course and there is usually a history of many years. Another factor was that he was too young to have any of these. A brain scan did not reveal any abnormality. Elaborate blood studies, opinion from two well known neurologists did not produce any result except the prescription which controlled the acute symptoms as described above. There was even a suggestion for a psychiatric consultation! I wondered how a person can voluntarily bring on these painful spasms just to mimic an illness even if he did have some psychiatric disorder.

The management was worried as the man’s work was suffering and he could hardly attend office as he was doped most of the time [thanks to my ministrations] though during the day his problems were manageable. Devarajan’s misery had me worried and puzzled. Worried because of his suffering and no long term solution in sight and puzzled because I was unable to find a cause even with all the expert help that was available.

This was the state of unsatisfactory affairs when Devarajan had to go to Chennai on some errand for a week. He called me soon after his return. I went to see him. He was not home. I went to his office. He was busy with work and welcomed me with a big smile. He was completely fit and there was no evidence of any illness at all and it was so since a week! Devarajan said when he was at Madras he went to see a doctor who practiced Ayurveda [Native medicine] and since he started the medication he has become free from all the symptoms that has been bugging him for the past one month. He just wanted me to see him free of the spasms and share the good news with me. I don’t know who was more relieved, the doctor or the patient.

I have on occasions, though rarely, come across such cures. Though there is no evidence that alternative approaches have cured a particular condition which we, allopathic practitioners have been unable to cure, the cure itself is most welcome. Though how the medication brought on the cure was a puzzle, I was relieved that I no longer had to worry about Devarajan and see his misery.

This happy state of affairs did not last long. A week later he called me again as the problem had recurred and a telephonic consult with the Ayurvedic practitioner ended in doubling the dosage with no relief. This was the time I started looking for causes other than are normally known. Reference to a text book on advances in neurology made mention to acute onset of symptoms such as experienced by Devarajan, in persons exposed to pesticides, who have a genetic predisposition. But how is Devarajan, living in the well appointed flat, be exposed?

The flats are treated once a month for vermin with insecticides. Could this be a cause? But why is he having this problem almost daily? Then it occurred to me. The possible cause could be the clouding that is being done almost daily to the whole campus to ward off the mosquitoes. The poisonous [to the mosquito] cloud contained organochlorines and there was indeed a reference that these can cause the symptoms.

I saw to that he stayed out of the campus. That cured him. He was one of those rare individuals who had a genetic presdisposition to develop acute Parkinson like syndrome when exposed to pesticide spray!

Before writing this story I did a net search and found hundreds of references! Had there been this kind of connectivity, fifteen years ago, Devarajan’s [and mine] misery would have been short lived!