Sunday, December 30, 2012

New Year
Another year has arrived and the old one gone forever. As usual my thoughts stray towards many events and persons. My first thought is towards my own country and people. It has been a year of awakening. They seem to have realized how they are being duped by the political class and have thrown up a credible young leader, Arvin Kejriwal. I wish Arvind and his new Aam Aadmi party all the best this year and hope they come to power in the next elections and save this country.
Next my thoughts go to the women of my country. They too seem to have woken up to the reality of exploitative paternalism. I see a silver lining in the massive protests by them against sexual and economic exploitation. They make 50% of the electorate and if they want to they can change the face of this country. My prayer is that they do it.
Next in my list is the average Indian who needs medical help. Falling sick in this present day scene is worse than death. The government has gradually withdrawn and has allowed private players into the health scene. Result is that no poor man has access to quality health care and health care costs are the major reason for debt burden among the Indian poor. I wish the state wakes up and provides care with dignity to the majority of my countrymen and women.
I am now 71 years old and in the evening of my personal and professional life. I do believe in a super mega force that controls my life and I am grateful to that force for having kept my faculties intact and allows me to think rationally and look after my patients, kept me fit that I can indulge in golf and badminton, my hearing well enough to enjoy talking to people and indulge in my love of classical music and my eye sight to enjoy the nature around me.
To my small family, my grateful thanks for the affection shown despite the fact of my being not relating to them often enough.
To my friends, [doctors, golfers, badminton buddies and others] my thanks for their company.
And, despite minimizing my practice hours, to my patients who continue to have faith in me, I owe them a grateful thank you.
Lastly, to you all, my blog readers, a very happy new year.

Sunday, December 23, 2012


The nationwide outrage over the assault and rape of a young woman in a moving bus made me feel a bit optimistic about the nation’s future. There are other such cases occurring all over the country and the law enforcement and the society at large seem to think that crime against women is not a serious crime and not worthy of strenuous investigation.

There several reasons for this. Most of them sociological. As long as society is patriarchal and women are treated as objects of sexual gratification for men designed by nature, instances of rape will continue whatever may be the deterrent punishment. Add to this attitude, rapid urbanization and influx of single young men to metropolitan areas in search of jobs, you have a tailor made situation of these instances to occur.

Will amendment to the laws help? The demand by the protesters that the crime of rape be punishable by death penalty is a deterrent/ will the assault on women come down? How about the law being misused? What will happen if a man is falsely accused? My personal view is that strict enforcement of law will only help to some extent. Real progress can only be achieved if we learn to treat women as fellow humans and parents bring up both boys and girls in the same manner

Coming to the role of women. What can they do apart from protesting? They should boycott and get their parents, boyfriends, brothers to protest against the electronic media and movies which exploit women and show them as sex objects to sell a commodity or a film. The songs and dance sequence in the so called item numbers are nothing but veiled pornography. They must also learn to dress decently. Liberalization and economic independence doesn’t mean that one goes around wearing next to nothing or wearing clothes designed to show explicitly one’s body contours.

Arvind Kejriwal has let loose the hidden resentment against the whole governmental hierarchy and the protests which one is seeing in this unprecedented scale is partly due to his activism.

I hope women will vote en masse for the Aam Aadmi party in the next elections

Thursday, November 15, 2012

When Calamity strikes

Reading latest issue of New England medical Journal I was impressed with the way Newyorkers handled a very grave emergency when the Typhoon Sandy hit them.

I imagined a few calamity situations that could hit this city of Bangalore and would like my fellow Bangaloreans to get a bit worried.


Massive power failure due to River Sharavathy drying up and no hydroelectric power and Raichur thermal power plant trips.

No water supply due to power pumps failing to pump water up the gradient from river Cauvery to the city

Out break of variant of HINI virus for which there is no cure and fatalities are 80%

Do we have a disaster management plan to tackle these three real possibilities?

Answer: my friends is a frightening NO
Obama Re elected

I have always been Obama's admirer. Not because I share his skin color but because of his basic qualities of head and heart. Social concerns are difficult to implement as they cost money and will be resisted by the affluent upper class [it will mean more taxes]. Spending money on welfare will necessarily mean more taxes and who will pay more taxes? Those who can afford to pay. The upper economic group. Many who belong to this group will have reached there after hard struggle and naturally will grudge the government who will ask them to pay more taxes to look after the less privileged.

Is there no other way to raise money other than taxation? There is. Our basic living style has to change. The way we now live encourages consumption and wastage. If we consume less and thus spend less we will improve savings and an economy based on savings is better than an economy based on borrowing and increased taxation. If there is less consumption what about production and what about job creation? Won't we have increased unemployment?

Difficult questions to answer. But watching wasteful living indulged by many just because they can afford,I am convinced that less consumption is the answer.

I hope USA is better off with Obama and democrats.

Wednesday, November 14, 2012

Hope and Despair

It is nearly a month since I wrote about Arvind Kejriwal.Since then he has come up with some startling revelations about corruption at high places with names of the powerful personalities involved. He also said that in the present system of governance prevailing in the country these will come to nothing despite these being true.
His sole purpose appears to be to sensitize the population to the large scale wrong doing that is going on in this country and then prepare them for a peaceful revolution at election time. Will he be able to put up the right candidates to contest elections, will he have the wherewithal,  will he be able to build an infrastructure of motivated workers, and will the emasculated voters of the country wake up to his call? This is my worry and hope.

Deepawali is a festival of lights. Over the years this festival has become a festival of noise and pollution. The city's air becomes murky and the streets littered with graffiti strewn from the fire crackers. These two days
are also occasions to show off the wealth. Gift giving and taking used to be a delicate and informal affair and now it has become an affair bordering on vulgarity. Unable to personally come, the gift giver has taken to sending the gift with a courier who demands a receipt for the goods received!
I received a four page ornate wedding invitation which must have costed the sender at least two hundred rupees! Imagine the kind of money he would be spending on the actual wedding. Founder of our nation, M.K.Gandhi tried teaching us the virtues of simple living. We are doing any thing but that.
This is despair

Saturday, October 6, 2012

West Indians.

There is something special about these people. They are naturals and uninhibited. Whether it is dance , music, sport, one can see the exuberance and when they win there is spontaneous joy that erupts on their faces and impromptu dances will be performed.

Yesterday, Darren Sammy and his men won the semifinals of the twenty twenty cricket against the much fancied Australians.This win brought back memories of the sixties when the Calypso Islands were the kings of cricket. Then the team was led by the legendary Sir Frank Worrel and had Clyde Walcott, Everton Weeks [the famous 3Ws]. If I remember right it also had Sir Garry Sobers in the team.

The present team too has big talent yet to be proved on field and they proved it yesterday in style. Chris Gayle with his black head scarf with a back drop, enormous height and the inscrutable face which only on rare occasion breaks into a smile and characteristic dance, reminds me of  some medieval King.

Even the West Indian spectators are a pleasure to watch. They are more or less the same as the players. I am glad this rather dull game of cricket has the west Indians playing. They add the much needed spice to the game

Wednesday, October 3, 2012

Arvind Kejriwal's new party

This was launched on 2nd of this month which happens to the birthday of Mahatma Gandhi, the founding father of independent India. The party was launched with very little fanfare and principally aims at contesting elections with honest candidates and aims at clean and efficient governance. India against corruption had many active and silent followers and all of them with two notable exceptions are in this new, yet to be named party. These notable exceptions are the prime mover Anna Hazare and the other is Madam Kiran Bedi.

Anna feels any form of political party is no good and agitation approach is the best and Ms Bedi feels that it is better to support BJP than floating another party. Most feel BJP is also in its own way corrupt and not much can be gained by supporting it.

Building any political party from the grass roots is not easy given the vitiated atmosphere in the country. Sympathy need not necessarily convert into votes. This brings back memories of Swatantra Party floated by Late Rajagopalachary who was fed up with woolly headed, and what he thought with good reasons, self destructive policies of Jawaharlal Nehru. This party did get some support but failed in the electoral politics and died a natural death. When the party was floated, I remember the optimism that some of us felt.

I feel the same optimism with Kejriwal and his group and I wish them all success.

Thursday, September 27, 2012

Few minutes with Venus

Those were pre penicillin days. Penicillin came into universal use only in the late forties and early fifties of last century and revolutionized the treatment of many infections. Venereal diseases [diseases that are transmitted by sexual contact] were amongst these. When I was a medical student in the early sixties we saw a few of these relics who were suffering from the effects of having contacted gonorrhea in the pre penicillin days. The common complication was stricture [narrowing of the urinary passage]. These sufferers would periodically come to the hospital to get the passage dilated. The instruments uses were called bogies [don't ask me why this name] . These were graduated curved steel tubes which were slid down the urethra one after the the other and the narrowed portion was forcibly opened. Then the whole passage and the bladder would be irrigated with liquid mercuric chloride solution [an antiseptic].The victim would howl with pain during the procedure.

Once when I was doing this procedure, hearing the cries of the patient my senior said 'few minutes with Venus [sex worker] and life long with Mercury'

Monday, September 24, 2012


As most agree, it is a state of mind influenced by external inputs.Few days ago I was very happy when Khalin  became the number one amateur golfer of the country. That he also broke the course record by playing the round in 62 strokes only added to the pleasure.His father Hitesh Joshi [a scratch golfer] is a personal friend, topped my cup of joy. Khalin Joshi who is all 18 years will turn pro by the year end, and I hope he will keep making us happy.

Some days I feel happy even when there is no such input. This kind of stupid happiness and elation is akin to feeling sad for no reason. A state of mind devoid of all thoughts is supposed to give one great mental peace and many are the methods of meditation that are taught to achieve this. I have failed to achieve a thoughtless brain or mind.

As you age and see the world around you becoming increasingly unfamiliar, you begin to think that it is the ageing process. This is not really true. It happens because you are no longer in the thick of things and your utility to the community is much less or not at all.This creates a sense of dejection and older persons thus become mentally and physically aloof. The only way one can avoid this state of mind is to keep it occupied.

Occupying the mind is not easy with out exercising the senses. If one is idle then he will be forced to live in the past and his company will be so tiresome that people will avoid him adding to the misery. Using the eyes to appreciate the beauty around you, ears to listen to fine sounds of music, nose to smell the scent of flowers or aroma of a cup of coffee or the whiff out of a bottle of mature single malt whiskey, get the warmth of the morning sun and the cooling breeze of the evening wind on to your bare skin, stretch your muscles and bones. These activities will keep your brain cells so occupied that the mind [ a collection of past and present thoughts] has very little time for mischief and this is the best way to avoid depression of  old age.

Talking of old age, many elderly are over medicated. Older persons need lesser and fewer medications. But I see the reverse. Any number more than four is not easy to follow. I mean if one were to take four medications at different times, one can be sure that an elderly man or woman will not follow the regimen.
Most vitamins, minerals, tonics, nose drops eye drops, ear drops are useless and waste of good money. Medication for high BP should be such that pressure doesn't fall too much.Low BP is as much of a problem as the high BP.

It is time I stop these ramblings of my mind which started with some thing and ended up with some thing else.

Old age?

Saturday, September 22, 2012

Bismillah and his Shehanai

Since I gave up my evening clinic work I find some idle time at my disposal. I use it to play golf, badminton, afternoon naps, reading and more importantly, listening to music. Readers of my blog are familiar with my love towards Hindustani classical music.Though my first love is vocal music, I often listen to this music played on Shehanai. Shehanai is a reed instrument and the note produced is smooth and easy flowing. I have found a lot of mental peace listening Shehanai.

Common knowledge is that the instrument came to India along with the invading Muslim armies around the 10th century. I also was under the same impression till I read a well researched article written by Dr Dileep Karanth, [who incidentally is my wife's nephew][Indian Oboe reexamined, published in the journal of Asian studies] Dileep is by profession a physicist and has other interests as one can make out if one reads this article.

Shehanai in one form or the other existed in old India since prehistory and spread from there to other parts of the world and the music played of course came under a lot of foreign influence notably Sufi Islam.

The greatest exponent of Shehanai was Late Bismillah Khan, Bismillah died recently at  the ripe old age of 90. Honours came to him aplenty including the Bharath Ratna. Despite all this he remained a simple person managing his large family and dependents. His home was the temple town of Banares and in one of the interviews he said he found the presence of God while playing the shahnai on the banks of river Ganga which flows by Banares. He also often performed inside the Kashi Viswananth temple. He in fifty years transformed shehanai from an instrument performed during festivals and marriages to that of an principal instrument of classical Hindustani music performed on stage like any other.

Though he is no longer with us I have vivid memories of him playing the shehanai. It was a visual and auditory treat. I remember his face with the trimmed white beard and the laugh lines around his twinkling eyes. With black coat and a write cap he had  stage presence rarely seen these days. What I liked about his music is that he rarely gave in to musical calisthenics to impress the audience. His was smooth and easy on the ears and played as much for us as for himself.

Traditional music as we have seen is slowly disappearing. Shorter versions with more titillation seem to be the order of the day. But old music like old wine is still available thanks to quality electronic storage devices.

Sunday, August 26, 2012

Arvind Kejriwal

Every now and then, India throws up extra ordinary men and women. One such person who is making news and forcing us to take notice is Arvind Kejriwal. To swim against the norm, to protest against injustice, delay, corruption, poor governance against an all powerful state is no easy task and requires extraordinary courage.
I don't think in recent times any individual has won my admiration as this man has. At present he is crusading to get this country a clean administration.

I wish him success.
Club of fifteen

40 years ago, the conditions of medical practice were very different. The support systems that have developed over the years were nonexistent then. There were no ambulances and to transport a seriously sick patient to a hospital was a night mare and I was witness to many a death occurring for want of timely help. Adding to the many owes, the doctors worked in utter isolation and there was no communication at all, even among doctors working in the same area. They often faced the same problems but were unable or didn't want to get help from others. Was it fear of loosing patient to the other doctor, or a innate complex or lack of confidence or  combination of all of these? I didn't know. There was a local association of doctors and this was dominated by hospital based doctors whose ethos was very different from that of us general practitioners.

I set out to remedy this. I went around and met doctors who were running solo practices like mine and got five of them to agree to meet once a month over a cup of tea. The first meeting was held in my house, some 30 years ago. This was a success. Then others joined and we limited the number to 15 as we found this number manageable in our homes. The group became so popular that we found a waiting list. The new one could join when one of us left the group, This generally occurred by death and rarely by resignation. If the members of this group are considered good and well informed doctors, a lot of credit should go to the club of fifteen and the members have remained close friends over the years. The once a month meeting has gone on nonstop in all these thirty years!

An offshoot of this core group is a larger organisation called Family Physicians Association, Bangalore.
About this group, I will write some time later.

But my first love remains the club of fifteen!
Test Cricket

For a lover of test match cricket, the just concluded test between India and Newzealand was a rare visual treat. Despite the fact that the test didn't last five days, it had enough to give me pleasure. There was correctly played 158 runs by the youngster called Chateswar Pujara. Unlike in the one dayers and twenty twenty cricket, a century in the tests has to be built on technique and temeperment and this youngster had both. Then there was spin bowling at its best. I was able to see an off spinner bowling what appeared like a ball which spun from right to left, a kind of reverse googly and and another ball which skidded through like a top spinner. This remarkable bowler who goes by the name of Ravichandran Aswin may be our next Chandrasekar who got our first test wins abroad some forty years ago. That the oposing side had to suffer this excellent performance didn't matter. I was able to watch some great batting and bowling and also some excellent catching as a bonus.

Under 19 Champions

Normally, in the present day India, good news is rare. But two items of good news is indeed a luxury. India won the test match against Newzealand at Hyderabad and the under 19 world cup in Australia on the same day! I was fortunate to watch both. The boy with a strange name of Unmukt Chand led the under 19 team from the front and beat the favorites Australia to lift the cup. The juniors doing well augers a bright future for Indian cricket.

Much ado

Our 80 odd Olympians returned with six medals and none of the six was gold. But the way these second class winners were feted and awards showered on them left me wondering. One sports writer felt it was a great performance as we had only four medals in the last Olympics! One of the most populous of nations, claiming to be an emerging economic and technological power house could produce only six medals should be a matter of concern and shame, but we celebrated. One of the medal winners, an army man demanded to be promoted to the officer grade!

Every thing is wrong with us. Our priorities, policies, programmes, delivery systems. You name it. We have become experts in not doing it well.

Except in cricket as it happened to day!

Thursday, August 16, 2012

Brahma Kamal
This extraordinary flower blossomed two days ago at night in my back garden. It has several unusual features. The single most unusual one is that it flowers at night and has a life of six hours. You can see by the picture that it buds out of a leaf and belongs[?] cactus family.
Some questions naturally arise. The extraordinary beauty attracts which pollinating agent? and that too at night?

Monday, August 13, 2012

Futile Exercise

He had a big file tucked under arm when he came in. He said, 'all appears OK', 'What all appears OK? I asked. 'The tests, he said, pointing to the thick file that he had now placed on my desk.

Who asked for these tests? I asked as I didn't remember to have ordered any tests neither did I remember to have seen him recently.

'No doc. You didn't but I went and got these done on my own'. 'Why did you do it? I asked. 'Because I felt weak', he said in defense. Has your weakness gone after doing the tests? 'No doc, it is worse and that is why I have come, the tests all show normal values.'he stopped

I have another of these fools who have fallen prey to the advertisement blitz in the lay press and electronic media. He has spent over 7000 rupees [nearly 150 dollars] on tests with out getting any medical advice and wants me to advise him as to what he must do.

This has become a none too uncommon experience for me and my irritation continues to grow with each such incident of doing the tests and seeing the physician later episodes. Marketing their services whether needed or not has become common practice. Yearly tests have become the norm. Nine out of ten such tests are unnecessary but are done.

Coming back to this patient, I told him I will look at his glossy file after giving him a physical check. He readily agreed. Examination revealed overt anemia and no other cognizable illness. I had a look at his reports and found all were normal except borderline low Hemoglobin and red cell numbers. The possible diagnosis was recent blood loss yet to be fully registered in the tests. He gave no history of rectal bleed. Still I did a rectal check and it showed active second degree hemorrhoids [piles]

Did he not know he was bleeding from his piles? Possible. Unless one's bathroom is well lit it is easy to miss blood in the commode.

To exclude possibility of colon cancer a endoscopy was also done.

Finally it was proved that his tiredness was due to recent blood loss due rectal bleed. He regained normal health after stopping the bleed by a minor surgery.

The expensive tests didn't reveal his piles.

Moral of the story. When in trouble see your doctor first and follow his advise. It will save you time and money

Sunday, August 12, 2012

End or beginning?
Team Anna gave up it's fast after failing to get the government to see reason. It may be that it was felt a waste of effort or as others feel, more effective methods are needed to get the torpid political class to wake up. One such move is to start a new political party.

Will this move to initiate a new political party succeed? Those who have had the experience of watching the experiment of the Janata party rule after the defeat of Madam Indira [1975] will realize my fear. I cannot forget the euphoria I felt at her defeat and the bitter disappointment of the failure of the Janata party to give a viable alternative.

To start an agitation is not that difficult but to build a party from the grass roots level is a very difficult and time consuming task. I have great respect for Anna Hazare and his team members, but will they be able to build a party with out the pulls of caste, religion, language and other local issues? I very much doubt it, especially in a short period available before the next general elections are due.

Jayaprakash Narayan led a countrywide movement against Indira Gandhi's despotic rule but he didn't build a viable party. The result was the misfire of Janata hotchpotch.

Then should they not try? Yes they should, even if it takes 5 to 10 years. The sociopolitical climate in the country is ripe for a transformation and an alternative to Congress [major evil] and BJP [minor evil]. If this doesn't happen, we will be left with more of the present and progression towards anarchy and bloody revolution and more mess.

Cruel game

The game of golf is more a mind game. This applies to the pro as well as to the amateur. Adam Scott lost The Open because of the tension and inability to keep negative thoughts away. It happened to me this morning. I was playing to one over till the 7th hole when my fellow golfer put the idea that I was playing well under my handicap. This made me think and a wave of negative thoughts took hold of my brain and I finished the next eleven holes 12 over!

So easy to self destruct when you play golf!

Wednesday, August 1, 2012

Corruption as a way of life

Team Anna is in the second phase of their fight against corruption. Their fast is on at the Jantar Mantar grounds in New Delhi. A scheming government has succeeded in blunting their impact on the conscience of the middle class. Why has the response been poor compared with the response when they began their agitation last year? I can think of many reasons. Some of them are:

The decision makers in this country are the people belonging to the middle class. This middle class is scared of any kind of violent or abrupt change. The government has succeeded in fanning the fears of anarchy and utter lawlessness that would come about if Anna’s team had their way. The middle class though small in numbers has accepted and even come to terms with corruption. This class is afraid of change.

There is also lack of motivation. When we gained our independence there was a major motivation and there were extra ordinary men and women who led from the front and people had everything to gain and nothing much to lose. Now it is another matter. Except members of the team Anna and few others there is a major dearth of morally superior leadership. Most politicians are considered corrupt and not worth following. So where are the leaders to follow?

In this kind of atmosphere is there any wonder that team Anna’s effort at rooting out corruption is destined to fail?

Monday, July 30, 2012

Why we don't do well

The grand, once in four years, extravaganza called Olympics is on. Viewing the first round elimination of Indian sports persons is quite depressing though not unexpected. One only has to compare with our neighbor,China to understand why it is so. Sports as a way of life gets very little priority in our scheme of life. Our children are from the very beginning are kept away from organised physical activity and those who do are made to pay a heavy prize by denying them off academic performance as both don't match. Sporting activity like academic activity takes lots of energy and time. Most of our educational institutions don't stress the importance of sports as a form of overall development. Thus there is no grassroots base for any sport. If any sportsperson comes up from this poor base, it is entirely because of the sacrifice of the family and often by sheer accident.

Nutrition and fitness are linked.If you don't eat the right kind of food and do the right kind of exercise your body doesn't develop properly. Most of our country's population is undernourished. Where there is natural talent there is this big malady of malnutrition. Added to this and parental apathy there is our government. Less said the better as far as the role of the government is concerned in the development of sports.

Madhura Honey
She marched with great aplomb with the colorfully dressed Indian Olympic contingent, dressed in red and blue. By doing so and enjoying herself hugely, she left many an official red faced and left me laughing. She had no business to be there in the first place. How did she mange it and with such ease?

Sunday, July 29, 2012

In the defense of the unqualified

In recent times the media is awash with reports of medical malpractice and images of unqualified persons handling cases are flashes across the small screen. There were images of a person who is qualified to sweep and clean, giving injections and suturing wounds. There were also reports of doctors performing surgical procedures without taking permission and causing fatalities. These reports received wide spread public reaction mostly directed against the profession.

North India, that too states of Bihar, MP, Orissa, UP, Rajastan are very backward going by the social and economic criteria. That is why they are called BMARU[ILL] states. In many areas of these states, medical aid is nonexistent and any aid is better than no aid. I watched the programme aired by Times Now, a popular English TV channel which showed the sweeper doing the procedure. Instead of getting disgusted I was very impressed with his performance. He wore gloves, drew the local anesthetic well into the syringe, injected the wound and sutured it expertly. There were no nerves at all and this must have been routine for him.

It reminded me of an incidence which occurred many years ago. I was a young subaltern in the Indian Army Medical Corps and was posted to a field hospital. As it was just after a conflict we had a number of casualties and three of us had to do lots of minor and major surgeries. We did have one doctor who was trained in anesthesia but he couldn’t be in four places at the same time. The job of administering anesthetic was left to two nursing assistants [in the rank of lance corporal]. They did the job better than I did! They were so well trained!

What is important is not who does the job but how well it is done.

Even well qualified doctors err. The doctors who did the Kidney and pancreas transplant were qualified and the patient needed it. That it was high risk surgery with very high mortality was not appreciated by the relatives. Here lies the crux of the problem. We doctors are poor communicators. We get so engrossed with the problem that we often neglect the human emotions involved and pay a very heavy price. These days, in corporate hospitals, money too plays its role and surgeries are often done when there is no absolute indication. One such is caesarian section about which I have written earlier.

Therefore, before branding something as demonic and unethical, one must, especially the media, and personalities like Aamir Khan should be careful and understand the realities of the profession in the country.

I have tremendous respect for Aamir and many aspects of his show were true.

Thursday, July 26, 2012

BJP and the Bofors scandal

Have you ever thought why the then NDA government did not pursue the Bofors pay offs and let the Italian friend of the Family live in peace? Read Vinod Mehta’s well written memoirs [Lucnow Boy]. The proximity of Hinduja brothers to Atal Behari Vajpayee is highlighted in this book.Vinod Mehta was privy to many of the murky episodes that took place and still taking place in India’s corridors of power. He has spared none and though the BJP [Bharatiya Janata Party] comes second worst compared to the congress, the clean image it tries to present to the people of the country is exposed very well as false by Mr. Mehta with facts and figures in this book. The horrifying wheeling dealing that went on behind the scenes in the G2 scandal spearheaded by Niira Radia is also there in the book. Our TV queen Bharkha Dutt too has been brought down from her high pedestal.

A must read book for all of us Indians

Wednesday, July 25, 2012

Ernie Els wins The open

British open is known as The Open. It is one of the three major golf tournaments held yearly. One is the Masters at Augusta [USA], the second is the US open and the third is the British Open sorry, The Open. Golf played on courses laid by the sea side is called the links golf. Links golf is a unique feature of The Open. Links golf is a different ball game in the sense, wind rain and the man deep sand bunkers come into play, making the game that much more trying.

This year saw a spectacular collapse of the Aussie, Adam Scot on the last of the four days of the tournament. He led throughout till the last five holes. Then came the collapse. He made four straight bogies and lost to Ernie. Nerves, Jitters, Yips, bad luck, poor club selection were all there for us to watch with pity and disbelief. Ernie who had finished his game an hour earlier saw the trophy handed over to him on a platter.

Ernie Els is one of the most popular gentleman golfers on tour. The personal misfortune[he does not consider it as] of having an autistic  son has only made him a more mature and humane person and his acceptance speech and the way he commiserated with Adam Scott exemplified it.

Scott should have won. But then it is some consolation that he lost to Ernie.

Super sycophant   becomes India’s president

Today we have a new president In Pranab Mukerjee.  Mr. Mukerjee has been a political top brass for over forty years and has held most of the top ministerial posts whenever the congress party has been in power which is most number of years since independence. Arguably most intelligent, well informed and friendly, Mr. Mukerjee has seen the congress led government through many a tough time. At one time or the other he has bailed out most of the top brass in our country’s ruling elite both in politics and industry and here lies his popularity and it came as no surprise to me that he won.

Nehru Gandhi [not Mohan das] family has had many articulate, intelligent, hard working and personally honest men who served them and continue to serve them. Pranab Mukerjee heads the list. From the Bofors scandal to the black money hoarders abroad he was and is instrumental in protecting the guilty. That he does all this under the garb of stability cuts no ice with many an honest person who has watched the politics and businesses of this nation over the past forty years. There are others like him, A.K.Antony and Jairam Ramesh who I suspect will serve the royal family with the same zest and reverence as Pranabda did.

Now freed from the shackles of politics and servitude, will Pranabda put his undoubted good qualities to serve the nation instead of serving the Family?

Sunday, June 3, 2012

Crows and men

Some forms of life and humans have a symbiotic relationship which dates back to thousands of years. Dogs and cats have manipulated us to their survival advantage. So are the food crops like serials and grains, not to speak about meat on hoof.

Crows and sparrows too have lived with us humans and have depended on us for their survival. Some time ago I wrote about the disappearance of sparrow from urban centre and the advent of jungle crow at the expense of house crow.

Some Hindu castes have this yearly ceremony of commemorating the dead forefathers once a year. Female ancestors are not considered worthy of commemoration. This ceremony is confined to three generations to make it convenient. The ceremony involves offering of cooked rice balls to crows. Crows are considered to be representatives of the three generations of the dead. Only when the crows eat the offered rice the family can eat is the rule.

Crows are becoming rare in the city centre and the report of a family waiting for over six hours for a crow to arrive made hilarious reading. As this ceremony is quite sacred and a must, these Hindu castes have to think seriously as to ways to assure that crows are around.

One way is to keep the crow as a pet like one does with the parrot and put up with its constant cawing. But would the free spirited crow accept captivity? Would non availability of the crow and inability to complete the propriation ceremony land these Hindu castes in trouble? The disquieted spirits of the three generation of the ancestors would probably haunt the living with unknown dire consequences!

Why have the crows become rare? May be one reason is the garbage collecting system which is in place for the past ten years.  It may also because modern Hindus are giving up the yearly ritual as a worthless ceremony? Or is it because the priestly class of Brahmins who officiated these ceremonies is becoming rare and therefore necessarily there is no rice offering and therefore the crows have vanished?

Interesting thoughts.

Thursday, May 10, 2012

Conversion rate

This heading should not lead you to think that I have suddenly become an economist and have started thinking about conversion rate of rupee against the dollar or have become an evangelist counting number of heathens I have managed to convert. I am writing about what a doctor friend told me about conversion rates related to a corporate hospital.
My friend is one of those rare birds who tries to follow medical ethics. His hospital outpatient work is fairly busy as he is good in his job and in his approach to the patients. He and I have become friends over years and he occasionally confides in me and seeks counsel.
Recently his hospital’s chief called him over for a chat and during the course of the talk gently reminded him of his conversion rates! He had a chart in front of him which gave him the year’s figures of the number of patients he has seen as out patients and the number of admissions he has made. Compared to the previous year the admission rate had come down and this from his point of view is not good and my friend was gently reminded to improve his admission rate.
I have grown old watching the changing medical scenario in urban India. Thirty odd years ago it was doctors who were hospital chiefs which were the beginning years of corporatization of health. Now it is the finance mangers with MBA qualification who become hospital chiefs and their method of management is how much profit a particular input shows at the end of year. The input may be a respected physician or a Sonography machine. The hospital chief is likely to be a much younger person than the doctor who is responsible for patient care. If I were in his position I would congratulate the doctor for having reduced the admissions while seeing more number of outpatients.
Hospitals are not factories which produce consumer products. These are institutions that mange sick patients and if a sick patient can be managed as outpatient at much less cost it is a service to the patient and indirectly to the community. If the same patient were to be admitted and treated when he could have been managed without admitting him, it may be beneficial to the hospital but it is very unethical.
 This is not an uncommon practice and there have been many occasions when I have given contrary advice to that of the hospital consultant who had advised intervention and very rarely such advice has been proved wrong.
What should doctors, who are at the mercy of the hospital owners to do in such a situation? Many are forced to compromise values and stay on, as quitting the job often means a major drop in the income.
What did my friend do?
He quit.

Monday, April 23, 2012


The slam bang veriety of cricket which goes by the name Twenty Twenty Cricket is back. It is sad that in this format where it is designed to badger the hapless bowler, the viewership seems to be good though not as it was last year. Most that pay exorbitant amounts of money to see this murder of cricket are young and I feel sad to see their hysterical behavior in the stands. Then there are the cheer girls with their skimpy dress or undress gyrating whenever a four or six is hit. What a weird spectacle!

A gentleman’s game to be enjoyed in leisure over five days has been reduced to this Jamboree of instant gratification!

 Are we seeing the last days of test cricket? I am afraid so.

Identity Crisis

We, Indians are called so by others. But those living inside the borders of the country called India have no single identity. We have many identities especially those of us who are grouped under a religion which goes by the name of Hindu. Followers of Islam and Christianity when asked their nationality if they are living in India are likely to say they are Christians or Muslims but ask a Hindu, he will confuse you by saying he is a Jat or Yadav or Curmi or a Reddy or a Gouda or a Vanniar etc, depending on where he lives and practices his caste. For this group of so called Hindus, their caste identity is more important than his Hindu let alone his Indian identity. 

We also suffer from afflictions of language. A person is likely to identify with the language he speaks and say he is Tamil, Telgu, Punjabi, Bengali etc. Again here, the Hindu is more likely to identify himself thus than others. This love of language can take extreme forms to be downright ridiculous. Considering we have twenty or so major and some thousand minor languages this attachment further divides us. I have seen people who speak a dialect, group together and from social clubs and exclude others and take great pride in doing so. This allegiance to language and caste is not only prevalent inside the country but is exported abroad too. Where ever there are a sizeable number of Indians living, you and be sure to find Guajarati, Bengali or Punjabi Association of [Indians]

When a human being decides to associate with another human being because he or she belongs to same caste and speaks the same language and not because of qualities of head and or heart, how do you expect progress?

To a great extent the ills we in present day India are facing is because of these strong multiple loyalties which blind us to the recognition of talent in those who don’t belong.

Tuesday, April 3, 2012

Rule of Geriatrics

Most countries retire those at sixty. Rightly so. Physical and mental decay begins about this age and the above sixty cannot perform as the below sixty. Brain degeneration makes them slow to react and they become indecisive. They tire easily their hearing and vision deteriorate. They have to go to the loo more frequently. They are more prone to arthritis, heart and lung ailments, cancer and auto immune disease. Therefore it is best they don’t work in responsible positions and endanger others. They can however contribute by being advisors to the younger decision makers.

This, at least in India, does not seem to apply to our politicians. Here Gerontocracy rules the roost. We have an eighty year old Prime minister, a seventy eight year old finance minster and an equally old foreign minister. Our defense minister is only slightly younger. The results of these tired old [not necessarily wise] men ruling the country is there for all to see. Their inefficiency is leading us from one scam to the other.

When they were moving from one scam to the other, on the way sweeping the other scams under the carpet, our army chief did not want to retire without bringing out the truth about the state of affairs in our defense forces. You can ignore any one else and get away with it but not an honest soldier who refuses to be bribed and adding insult to injury, wants to bring it into the open.

Our geriatrics are now stuck in a deeper mire.

Rise of field Hockey

There was a time we reigned supreme in this game. For over 50 years till the sixties we were unbeatable. Then started the era of decline. Slowly and gradually Cricket took over and Indians switched their loyalty and showered money, love and adoration to this game. But there were a few like me who continued to nurture our love for the game of Hockey. Hockey has some features which Cricket can’t have. It needs skill, speed and stamina. You cannot afford to loll at first slip or mid on and while away your time even if you are past 35 and your only qualification is that you are a good batter and the country loves you. I wrote about how the short form of Cricket, The so called Indian Premier League has sounded the death knell of the real Cricket, the Test Cricket. That this shorter version played in the IPL is hugely popular does not make my statement less true. Over the years we had to bear this pain of popularity at the cost of talent and merit. One look at our politicians and their popularity will make us wonder how these people can be popular. Look at the likes of Yeddyappa, Mulyamsingh and the Dalit Queen Mayawati, and you will understand what I say. This is also true to some extent as far as the twenty twenty form of cricket is concerned.

While I intensely dislike the abridged form of cricket, there is no chance of this happening to Hockey. Hockey, unlike Cricket has no abridged version. It is played over a period of 60 to 90 minutes and the result is guaranteed. India over the past ten years had a dismal record both the quality ofplay and its administration. We did not even qualify for the last Olympics. This time however we did qualify by beating France. I watched that game and it brought back memories of the golden era of Indian Hockey. This was followed by two weeks of scintillating Hockey which went by the name of World league of Hockey.

Taking the cue from the IPL the organizers of the World Hockey league divided the teams based on Urban centers and called the teams with fancy names. There were players from Australia, Canada, Pakistan, and Malaysia in this league along with Indians. It was a spectator’s delight.

That the Indians who played were not the best [as the top 20 who played for the country were not allowed to play in this league for the fear of injury keeping in view the forthcoming Olympics] did not matter. There were so many young Indian players with so much talent who played in this tournament that I felt the future of Hockey is bright.

That the league was a huge admin and financial success means a lot for the players who were treated so shabbily hither to. It is high time this happened to Indian hockey and the money and fame will surely lure our school children away from Cricket to this wonderful game.

Thursday, February 23, 2012

Flock of sheep

MCI has recommended an increase in the number of seats in the medical colleges and this will help to meet the need for doctors in the country. The human resources ministry also seems to think that by allowing or forcing the IITs to double their intake they will meet the demands of the industry and also will help the socially and economically weaker sections to get access to these premier institutions.

Is increasing the numbers without caring to increase the infrastructure [buildings, equipment, and personnel] bring about the desired result? Answer is no and one can see this happening in post independent India. There is definitely an increase in the number of professionals of all types but their quality has suffered over the years as evidenced by the calamities we hear every day in the media [collapsed bridges, train accidents, fires, buildings giving way, patients dying because of wrong treatment]

Some twenty five odd years ago Late lamented Prof B.G.L.Swamy wrote more out of sorrow than anger, ‘I was forced to take double the number of students for the course, this and the number of repeaters made the work of conducting examinations in a decent manner nearly impossible. When I brought this to the notice of the principal of the college and the director of education, the common answer was ‘Swamy, you have to manage somehow’ this somehow resulted in students taking examination, spilling over to the pavement. The principal who came to inspect, seeing students sitting on the pavement, tried taking his ire on me. I said,’ sir, what you see inside the room is any and the one you see on the pavement is how’

This over flowing ill trained students become tomorrow’s professionals and what we are seeing all around is the handiwork of these. A flock of sheep incapable of original thought and deed, capable only of incompetent repetition and blunder.

Who can save this country full to the brim with incompetence?

Monday, February 13, 2012

Cult of violence

The incident of a 15 year old student stabbing his school teacher to death should come as an eye opener to most of us. While not condoning the student who was driven to this, one should consider why he did this. The teacher who was concerned with the poor performance of the boy reported it to his parents who in turn took the boy to task and the enraged boy took out his frustration on his teacher. For many students, the present day schooling and the methods of learning are worse than spending time in jail. A society which puts scholastic performance as the acme of achievement places enormous pressure on parents and indirectly on school teachers who in turn pass on this burden of performance on school going children.

In post independence India there have been two primary casualties. One is health and the other is education. The government has gradually withdrawn its responsibility of providing these two to its citizens and has allowed the private players to enter the field. I wrote some time back on corporatization of health and the aftermath. The same is happening in the field of education. All sorts of player whose motive is to make money are entering this arena across the board from primary education up to post graduate level. This has not come cheap. These institutions are prohibitively expensive education shops. A situation has arisen in this country where in an average parent is finding it difficult to foot the education bill of his or her children. I know of many who are either stopping at one child or not having children at all for this reason!

Those who do send their children to these privately run schools are under considerable financial strain and to get a report that their ward is poorly performing and thus a poor return on investment must be indeed galling. They will vent their anger on the child and he in turn will resort to violence either on himself or on others, in this instance on the hapless teacher. Suicides are not uncommon during exam time and at the time the results are made known.
To add fuel to fire is the general atmosphere of violence in which we are living. Our media, TV serials and movies, Computer games that children play, glorify violence. A child who grows in this kind of atmosphere can easily justify violence [a la Taliban].

In this land M.K. Gandhi. We are slowly and inexorably slipping into a land of himsa [violence].

Thursday, February 2, 2012


I first read P.G. Wodehouse when I was in school. Both my knowledge of the language and the society in which the characters created by Wodehouse lived were rudimentary. I only read them to please my English teacher and never understood a word of what he wrote. I read him again when I was in college and the results were a bit better. I must have read and re read them many times since then and now his books are my refuge. Whenever my moods turn sour which is often, I take recourse to his books and return refreshed.

Many have told me he is a farce. Of course he is. But he makes me happy. He created a new world of farce based on characters drawn from pre Second World War British society and the characters have stood the test of time and have never become stale. The stories written 75 years ago can still make you laugh. One doesn’t have to necessarily go back to that era to enjoy his works. There is no need to imagine the scenario as it is vividly described when the characterization is done.

Wodehouse was an avid golfer. Another reason for my liking him. He once famously said,’ I wasted the first fifty years of my life because I began playing golf only after’. All golfers will whole heartedly agree with this sentiment. Our lives will be barren and purposeless [exaggeration?] if this game is taken away from our lives. He created a character, an elderly retired gentleman who no longer could play golf but who nevertheless waylaid the unwary in the clubhouse and told them stories recalled from his memory. The stories told by this oldest member [Sage] is available as golf omnibus and these too can be repeatedly read without loss of flavor.

The outstanding characters are of course that of Bertie Wooster and his valet Jeeves. The related uncles and aunts, friends and acquaintances, churches and clergymen, country houses and city clubs fill his books. Some characters are outstanding such as the pig lover Lord Elmsworth and the genteel poor PSmith.

At present I am reading another of Wooster stories and how he is being helped to get out of or prevented from entering holy matrimony yet again. It is fun reading.

Those of you, I am sure, who get occasionally depressed, given the dismal environment [at least true in India] will surely benefit if you take up reading him.

Happy reading

Monday, January 23, 2012


This for us medical men and women means meeting periodically to learn, update and exchange ideas. In short, it means learning so as to ultimately benefit our patients.

To conduct a conference we need several requirements. These are: a suitable place, an organization to oversee the conduct, participants, delegates and speakers. One needs money to take care of the hunger and thirst of the speakers and delegates for the period of time these worthies hang around in the memorable cause of learning.
Over the years it has become a custom to hold these conferences in hotels. Depending on the reputation of the organizers the hotels are selected. If it is lowly paced general physicians it may be in three star hotels and if it is a super specialty conference it may be in a seven star location.

The concerned body of doctors will start working months in advance advertising in the specialist media as to this meeting and we begin getting mails giving the details of the topic and the registration charges. The higher the hierarchy the higher is the registration fee.

Now it will be interesting to know who will be the delegates [listeners] and who the speakers? Delegates are supposed to pay the entry fee which will cover their lunches and dinners and other expenditures incurred by the organizers in hosting this conference. The speakers are specialists in their fields who will have either paid for their coming or they will have been sponsored by the research grants to present their views. In reality none of this is true. The delegates are there because someone would have picked their bill of travel and stay. And speakers would have been taken care of by the companies or firms interested in high lighting their research to boost their sales of a particular product or devise.

In a major conference which drew 1500 delegates on the subject of advances in diabetes there was no registration counter! This means there were none who paid and came as delegates! Diseases like diabetes, hypertension, and heart disease afflict the rich more than the poor. Drug companies are interested in selling their products related to treatment of these diseases. They know that here is a huge market for drugs used in the treatment of diabetes and India is emerging as the diabetic capital of the world and here lies the truth of this mega conference where in an estimated 2 crores of rupees were spent. How appropriate it would have been had this money been spent on funding research on a vaccine to cure malaria [essentially a poor man’s illness]

Let us assume there are still doctors who don’t want to be sponsored and would like to pay and attend and learn. This foolish class is rapidly dwindling and if things are going as they are they may soon disappear! These doctors are generally honest professionals and therefore unlikely to be rich and cannot afford the travel and stay expenses of going to another city or country and therefore are forced to stay back. What about their learning? I asked a friend of mine who attended this hyped up sponsored conference on diabetes as to what he learnt new? He said,’ very little of practical importance.’

There is still hope for this class of doctors. Internet has come to their rescue. Most advanced research of practical importance gets published in journals and subscription costs of one or two standard journals is sufficient to keep one updated. These journals have very interesting and novel teaching methods which I find far superior to the didactic delegate’ speaker method of learning/unlearning.

What is the future of these conferences? As I see they continue to thrive but the quality is likely to come down. There is going to be major changes in learning methods and these will be more and more web based and my worry is that here too drug companies will play a role [as they will have to spend less!] and this will leave a set of unhappy doctors who are denied of their free travel , food and drink!

Wednesday, January 18, 2012

Communal feasting

My balcony overlooks the backyard of another home. Here grows a Sapota tree. Sapota or Chikoo [Manikara Sapota] is a fruit bearing tree which originated from Brazil and has spread all over the tropics and in India Chikoo is a major horticultural produce. The tree fruits twice a year and a well looked after tree bears fruit in thousands.

The owners of this tree are old and cannot reach the upper levels of the tree with ease and thus lots of fruits remain unplucked and I am ever grateful to them for their unintended generosity. Twice a year the tree fruits and it becomes veritable bird watcher’s paradise. I have on a previous occasion written about a family of squirrels who has laid claims to the fruits and how jealously they guard against predators, mainly the birds. It was a pleasure to watch the mostly futile attempts of these small animals trying to chase the birds away.

This year they seem to have found that it is waste of time to chase the birds away especially when there is plenty of food for all! Another new feature I noticed this year is that all the birds have begun feeding at the same time unlike previous years when they took turns. The green barbets came first and the others followed. This year I am able to watch all of them feeding at the same time. I had not noticed Mynas in the earlier years. This year there are at least ten of them. Most fastidious and elegant of all the feeders [according to me that is] is the Koel. This big bird perches next to the fruit and elegantly pecks without disturbing the fruit or letting it fall. The worst of the lot is the Parakeet. Not only is he very noisy [I tolerate his screech only because he is a bird, good looking one at that!] but also he is very wasteful. Parakeet’s beak is curved and designed to open pods and eat the seeds and not really to eat ripe fruits .In attempting eat, he ends up in dislodging the fruit which falls to the ground only to be eaten by the crow. More I see the crows, more I am impressed with their intelligence. Earlier I used to see them eating the fruit still attached to the branch. Now they wait below for the half eaten fruit to fall to the ground. They unlike the other birds are unafraid of us humans and can risk doing this, their easy way to get at the fruit.

Parakeet [Rose ringed] till recently was a visitor. Now he has become a resident. I was wondering at the unusually prolonged presence of this bird around my home when I discovered his nest! The preferred nesting site is a tree with a dead branch or one with some holes in the trunk. There is a dead coconut tree some 100 yards away and this dead tree stands some fifty feet tall. This is an ideal location for the parakeet’s nest. I have begun watching these birds sallying to and fro and by the way they are behaving there sure to be hungry chicks in there.

Chikoo is a not a fruit where one sings paeans of praise unlike Mango where people go crazy in their praise. But it is a great fruit not only in the abundance of yield but in taste and structure. There is very little wastage in this fruit. The skin is thin and the seeds are few and the rest is delicious flesh. No wonder I and my avian friends like it so much.

Sunday, January 8, 2012

Going back to dark ages?

It was in the twenties of last century that antibiotics were discovered. First came the sulfa compounds and then came that remarkable antibiotic penicillin and then many more. In less than 90 years the microbes have learnt to live and occasionally thrive in the presence of these antibiotics. The last shock of the discovery of ESBL [Extended spectrum betalactamase resistant] was some years ago and now comes the report not of multi drug resistant but all drug resistant Tubercle Bacillus which causes tuberculosis. This is like icing on the cake or to be more precise adding insult to injury.

This means that in the near future if you get tuberculosis there may be no drug to cure you and in likelihood you will die. How you will die depends on the organ that is infected. TB germ can infect all organs from head to foot.

Human arrogance that he is the sole lord and master of this earth is responsible for this state of affairs. Microorganisms have been in existence for many millions of years before multicellular organisms AND other forms of life including humans evolved. They are self contained remarkably efficient life units who have learnt to survive in extreme adversity. We, primarily doctors believed that we can win the battle of infection by using these antibiotics. We used these liberally and indiscriminately and are still using them. Most infections are self limiting and antibiotics are redundant. But it has been common practice to use these in all infections trivial or otherwise. To give two examples. One is Staphylococcus. This is the germ which causes the common furuncles and abscesses. These, left alone will burst and heal or can be drained by a simple cut. But we routinely use antibiotics and now this organism has developed multidrug resistance. Another one is a germ called E-Coli. This one has a special liking for our urinary tract [especially women’s].This one too has become multidrug resistant. These two have become major headaches for us doctors and now are no longer simple germs that got killed by one or two doses of antibiotics. They have become killers.

If one considers one out of one hundred Indians have TB, then imagine the havoc this all drug resistant TB germ is likely to cause?

We are heading towards the dark ages of pre antibiotic days and we may have to look up and see how the physicians of those days managed their patients!

Friday, January 6, 2012

Awareness of self

When I wrote the story of Mrs A, I said I would write about two of them. This one is the other which I meant to.

She has been my patient for many years and must be in her mid sixties now. With a strong family history of cancer and heart disease she is extra careful with her health and gets her tests done on a regular basis and keeps her twice a year visits to me without fail. Living with another sister who keeps indifferent health adds to her worries. Let me call her Ms M.

When Ms N came to see me when she was not due to see me, some three months ago, it was for another reason. She had severe back and hip pains of few weeks duration. Ms N is a frail vegetarian and when I found that her back and hips were generally tender with no specific localizing signs, I thought she has osteoporosis with add on Vit D deficiency, this despite her taking calcium tablets and a drug named alondrenate which is given for osteoporosis.

Vit D is manufactured by our skin only when there is sunlight exposure. Modern living and fear of sunburn makes people become Vit D deficient which can give rise to many signs and symptoms and aches and pains are some of these. Vit D deficiency was virtually unknown in the earlier years of my practice. Now I see this quite frequently for reasons mentioned above and also easy availability of tests to detect deficiency.

Mrs N was asked to do these tests and come back. The bone calcium density was not bad but her vitamin levels were low. I thought there you are! You have the diagnosis and the treatment is easy. Just give her Vit D supplements and get her to sit in the sun and her pains will disappear in a month or two. Thus reassured, Mrs N went her way.

She came back six weeks later, in acute distress. She was in such severe pain that she had to be assisted into my clinic by her brother. Instead of getting better she had gotten worse. I really cannot blame her for having gone to a specialist doctor in rheumatology [illnesses related to what is loosely called connective tissue]. This doctor had done a large number of tests to detect antibodies against her own cells. These were negative.

Here I must explain the basics of this fascinating aspect of life. We are each of us, unique, in the sense our cells [the ultimate functioning units of our body] are our own and there is an elaborate mechanism which allows our cells to recognize each other as belonging to one person and this mechanism has the ability to recognize something which enters our body as foreign. After this recognition there is an elaborate system of defense [major research area] to counter these invaders. This recognition of self from non self is fundamental to life. Occasionally, for various reasons, some understood and some still to be understood, this intricate system of recognition fails and the resulting clutch of disorders, go by the name of auto immune diseases.

Like we all have a life span [bible limits it to three score and ten, meaning seventy. I should be dead by this time going by this!]. Our body consists of various organs which perform various functions. Each of these organs is made up of millions of specialist cells. And all these cells too have their own life span and it is not threescore ten. Cells lining our mouth have a shorten life span than that of cells of our brain. When a cell dies the innards are released and these find their way into our lymph and blood stream. This dead material when once it comes out of the cell should be quickly disposed off. Or else these become potent antigens [foreign] and the our immune system begins to fight these by forming antibodies and the resulting fight takes place all over but when it occurs in our connective tissue it becomes painful and the illness too is widespread. Connective tissue is the one which binds the various structures and gives shape and structure to us. The resulting plethora of illnesses is called auto immune disease. I have given a rather simple explanation and I may be pardoned by my specialist friends for any error.

Ms N had one of these illnesses. Which one was the issue? The rheumatologist too must have been in this quandary and therefore had given her a non specific drug and wanted to review her after she tries it for few weeks. Why then she got back to me when my earlier treatment gave her no relief?

Sometimes we doctors stick our necks out and sometimes it is to benefit our patients and occasionally we get hung by! This is what I did. While reading about another problem I chanced upon this condition called Polymyalgia Rheumatica and the symptoms and signs fitted to what Ms N had like a glove. It occurs rather suddenly to only those above sixty, three times more common in women, large muscles of the spine hip and shoulders are preferentially involved, and markers of inflammation CRP and ESR will be very high. All of these were true in Ms N’S case.

I made bold to call her. I knew her name and the locality she lives and finding her number in the phone book was not tough. She must have been taken by surprise at my request to see her as soon as possible and she agreed and thus the present consult.

I explained to her the possible diagnosis and treatment. It took some convincing for her to agree to the treatment as it meant taking small dose of steroid [compared to what is given for other allied conditions]. Another motive was the dramatic freedom from pain she is likely to get if the diagnosis is right [sticking my neck out]
She agreed and three weeks ago took the initial shot of long acting steroid followed by oral tablets. Even I was surprised by the result.

When she came ten days ago, she came on her own could move all parts of her body, could bend, sit up, walk all without pain. Both her CRP and ESR which were sky high had returned to normal!

Practice of medicine is indeed rewarding. Don’t you agree?

Sunday, January 1, 2012

Cure or Kill?

My fading years of practice still provides me with patients whose problems test my skills, patience and occasionally my knowledge. Experience gained over 40 years of practice and occasionally sheer serendipity comes to my rescue. The month of December saw me solving two such problems with the help of a combination of the factors told above and I consider them as the best New Year gifts received even before the old year ended.

It is required that I take permission to tell their stories, especially when they are alive and kicking as in these two instances and I have done so and I must thank them for permitting to do so. Let me begin with the first one, Mrs A.
Mrs A is mother in law of a close friend of mine. She is a well built lady in her mid eighties and spends time living for some months with each of her children and for a long time she was my patient until her elder son retired from the army and came to live in this city 5 years ago. Since then she is being cared for in the army hospital and in a private hospital whenever an emergency arose. With another son living abroad money is not an issue that came into the picture as far as care is concerned.

As it often happens with us GPs, patients leave us to what they think or what their children think, for better pastures, which often is true but not in this case as later events proved. Fifteen or so years ago, when she came under my care, she was an obese, hypertensive, seasonal asthmatic and had fairly well compensated heart failure due to leaking heart valves. She was also severely arthritic with painful hips. Averse to any form of regular exercise and fond of food it was no surprise she kept gaining weight and her hip pains only became worse. We took a risk and got one of her hips replaced and the cardiology opinion was that she was a high risk patient and ideally have her heart valves replaced and the surgeon felt it was not worth doing it considering she is being fairly well managed medically as far as her heart failure was concerned.

Four years ago, when she was not under my care she got her other hip replacement done! She had a stormy post operative period but made good recovery and now she has both hips replaced and was pain free. One would have thought she would exercise and get her weight down but as I said earlier she did not and her weight remained as before and when I occasionally saw her socially [as she is my friend’s mother in law] I felt her weight had only increased. Since last one year her health seemed to worsen and she has been in and out of hospitals for one reason or the other.

Six weeks ago, she was taken to a nearby hospital [with corporate ethos] and was admitted as she was complaining of weakness and was short of breath. Given her heart condition the diagnosis was obvious. She was in heart failure due to leaking valves. The cardiology team of that hospital is good and most of them are known to me but as I was not involved in her care I did not personally check with them as to the details of the treatment. What her son in law and my friend told me was that the cardiologist felt her heart failure was under good control and he advised her increased activity and she was discharged home.

This time the home she came to was the daughters. She continued to be unwell and kept telling her relatives that her end is near, so bad was her feeling! One evening, the son in law [my friend] came to my home and asked me to come and have a look at her before they took her back to the hospital.

I went with him to see her. She was lying flat on bed, a slab of pale flesh with deathly pallor. She looked very ill. She had constant feeling of nausea and was off food for the last week and was barely able to keep fluids. She also felt it impossible to even to get up and sit and the daughter was having a hard time nursing her. Quick examination showed her blood pressure under control, but her heart’s beating was irregular. Her feet were swollen and her lungs showed few abnormal sounds suggesting beginnings of fluid accumulation. She complained of discomfort in the pit of her stomach.

I wanted to see her records. The record keeping had stopped in the year 2006 when she was under my care. Rest were all hospital discharge summaries and prescriptions. I saw the latest prescription. This had 9 drugs. One to stabilize the heart, another to remove the fluid from her lungs, yet another to keep her blood pressure under control, a different one to prevent clotting, another to prevent the possible side effects on the stomach because of all these drugs and the usual masala of vitamins.

Digitalis is a time honored drug and has a fascinating history. The plant Foxglove from the leaves of which the steroid glycoside Digoxin was extracted, belongs to the family Sacrophulariaceae, was time honored native medicine in Europe for many centuries. It came to widespread use due to an accidental discovery by the 18th century English physician William Withering. A patient of his was very unwell with Dropsy [old name for fluid accumulation all over the body]. After visiting her, Wuthering came back home leaving her to die, so hopeless was her state. Few days later the patient, now recovered, visited him. The surprised Withering found out that she had consumed a concoction made out of the common garden plant, Foxglove! It to his credit that he published his meticulous observations and extract of foxglove, digitalis, came to be used universally in heart failure patients and has with stood the test of time and is in use even to this day.

This wonder drug however, has one major problem. The margin of safety between the therapeutic dose and the toxic one is thin and if one is not careful the drug can become from a life saver to a life taker!. This is especially true when used in the very young and the very old. The toxicity is on the stomach and worse, on the heart. In the stomach it causes severe gastritis manifested as loss of appetite and severe nausea and on the heart with irregular to very fast beating leading to failure, the very illness for which it is given!

Madam A had classical Digoxin toxicity! The drug was stopped and it took 48 hours for her to eat her first solid meal in three weeks. Her heart’s beating returned to normal and the deathly pallor was replaced by a cheerful expression. She began moving around the third day and was able to walk up and down the stairs of her home. Yesterday she made a long car journey to her other son’s place to a town some 6 hours away!

Mrs A escaped from certain death [if she had continued with digoxin].

This story has taken too much of time. Will do the other one sometime next week.