Thursday 28 July 2016

HISTORY OF HERNIA SURGERY



Friends, I hope you remember one of my most favourite senior colleagues Dr. H.S. Adenwalla. He has an unique ability of recreating the history of medicine in front of our eyes by his outstanding story telling abilities. This time he is telling us about Edoardo Bassini and the History of the Evolution of the surgery of the Inguinal Hernia. Enjoy it!
Edoardo Bassini was born in Pavia in Northern Italy and came from poor peasant stock. After he received his medical degree he joined up as a soldier under the revolutionary leader Giuseppe Garibaldi. During the war he suffered a saber cut in his right groin which led to a foecal fistula. This mishap is what focused this young surgeon’s attention on the anatomy of the groin. After he recovered from this injury he studied under Theodore Billroth in Vienna and then under Bernhard von Lagenbeck in Berlin and Joseph Lister and Spencer Wells in London. With Lister he learnt the principles of antiseptic surgery, which at age of 39 he brought to the famed university hospital at Padua. There he was given the chair of Pathological Anatomy. His first act was to convince his Superior Prof Tito Vanzatti that antiseptic surgery was of prime importance if surgical patients were to survive. When Vanzatti retired Bassini was elevated to Prof. of surgery at Padua.

Bassini was a tall well knit and athletic man, it is said he rose every morning at 4 AM to ride for an hour and a half and entered the hospital at 6 AM, where he worked late into the night. In his early years he lived in the hospital a Spartan existence.

The history of Inguinal Hernia therapy is a long one. The mummy of Pharoah Merneptals who reigned in 1215 BC showed a large scar in the groin with a scrotal swelling. The mummy of Ramesses V 1157 BC also showed evidence of a large inguinal Hernia. Three thousand years ago both operation and trusses were employed. The Babylonians advocated the ingestion of wolf’s bile in urine. The ancient Hindus laid heated cow dung upon ruptures. Celsus was a strong advocate of surgery but he worked on a wrong premise, he believed that the hernia resulted from a rupture of the peritoneum. There is no doubt that of all the workers of that age Celsur showed an advance in the knowledge of anatomy. He separated the sac from the cord structures and ligated the sac at its neck. His hernias however, recurred and he did not report as to how many of his patients died of shock or sepsis. Ambroise Pare after giving surgery a good try turned to the truss. With Pares’ abdication of surgery all responsible physicians gave up trying to operate on the inguinal hernia. All they had to offer was the truss. As a result millions of young otherwise healthy young men all over the world lived miserable lives. After a time Celsus’ operation was revived by Pierre Franco in France, Czerny in Heidelberg and John Wood in London. All their patients wore a truss after the operation and more than 90% of their hernias recurred. The results of surgery were obviously distressing.
Anaesthesia and antiseptic surgery set the stage for Edowardo Bassini’s monumental work, which was so simple that one wonders why no one had thought of it before. Bassini had devised his operation in 1884, by 1886 he had operated on 123 cases with a two year follow up and a 94% success rate. He however, refused to publish till he had operated on 250 cases, which he did in 1888.
A German physician by the name of Peter Gallman, a student of Virchow has left behind a firsthand report of what he saw at Padua in Bassini’s unit where the hernia operation evolved…. I quote from Gallman “A few days ago I arrived in Padua and visited the University Hospital. Things were different from what I had seen at Pavia and other Italian hospitals. I felt as I was breathing a different kind of air, clean and fresh, with a strong smell of carbolic acid and eucalyptus oil. When I asked to see Bassini I was guided to a plain white washed room with a few simple pieces of furniture. A tall strong looking man was seated behind a large desk. On the desk were a few open books and a couple of surgical instruments strewn around. He was in the act of writing something. His face was deeply tanned, his hair and beard dark with a few scattered threads of grey. As he rose to shake my hand his deep set sad eyes lit up with just a flicker of a smile. He spoke to me in fluent German without an accent. He said “I am pleased that you are interested in my work on the inguinal hernia. We are a young nation and it is difficult for people from the outside world to take us seriously” I noticed two things about him, that for an Italian he was sparing of gestures and unlike the German professors in my country he was soft spoken and was not at all formal. He continued “I have three patients with hernias for surgery tomorrow. I would be happy to have you witness them. Today you must see their antiseptic preparation that is most important.””Why today? I asked.” Bassini replied, “The day before the operation I put my patients in an isolated room, no visitors or unauthorised persons are allowed.” “I saw the patients being placed on rubber sheets and then after shaving began the most rigors sponging from neck to toe, first with soap and warm water and then with a carbolic solution, after this the patients were wrapped in a sheet dipped in carbolic solution and there they would remain till the next day when the operation would take place”. “This preparation was more stringent than what I had seen with Lister”. When I questioned Bassini he smiled and said”one can’t be too careful if infection sets in all is lost. ”
“Next morning I found a seat near the operating table. The first patient Ernesto Calzavare, was carried in still wrapped in the carbolic sheet. The patient was soon brought under chloroform anaesthesia. Bassini with one clean sweep of the knife opened the skin and the external oblique exposing the inguinal canal. The hernial sac bulged out. The vas and cord structures were separated. The contents of the sac were returned to the abdominal cavity. The sac was tied at the base and excised. I said to myself nothing new so far. Now came Bassini’s simple innovation. His assistant Tansini lifted the cord structures. Bassini then stitched the lower edge of the oblique abdominal muscle to Poupart’s ligament. Bassini had thus created a strong abdominal wall along the posterior region of the inguinal canal. He then nodded to one of his assistants, the doctor took a feather and tickled the patients throat, the patient gagged and coughed violently. The posterior wall of the inguinal canal remained firm. Bassini looked up and smiled. “That is all that there is too it, Gentleman. This patient can go back and dig in the fields or carry heavy loads, they will not be wearing a truss, and they will never get a hernia again”.

I stayed on in Padua for a month, saw many more hernia repairs and at least 40 patients operated on by Bassini a year or two ago, all of them doing hard manual work. Before I left Padua Bassini told me a poignant story. He said, “You remember Arturo Malatesta one of the operations you saw on the first day, after he was admitted there was an ugly scene in the ward which I was witness too. The girl he was betrothed to a slim beauty was standing over his bed and shouting at him and was telling him that she would not marry him. When she saw me approach she shouted “”I have told him time and again that it is all over between us. What do I want with a man who can’t even dance because his guts are falling out of his belly? A nineteen year old cripple! Does he think that I am going to spend the rest of my life buckling on his wretched truss?” “Isabella!” The poor man groaned and turning to me he said “Professor, tell her that you are going to cure me.” Bassini said, “I was so upset I placed my hand on the poor boy’s head and said. If she laughs at you son because you have this trouble, my boy, she isn’t worth marrying, you will find a better girl. I assure you. We shall do everything possible to cure you”.
Two years later Edoardo Bassini reached his first international audience. He published his method in the 40th volume of “The German Archives of Clinical Surgery” a report of 262 cases. It was a well documented paper, with a description of the method advocated and tabulated results. It was as though a long closed door was opening. Maccewen in England and Halsted in the United States were developing the same method more or less on the same lines. Padua became the Mecca for surgeons who were eager to follow the path that Bassini had blazed. Like most great innovations it was a simple one, but it required a genius who with single minded devotion gave mankind an answer to a problem that had defied the finest surgical minds of the world for centuries.
Edoardo Bassini died a celebrated surgeon immortalised by his hernia operation. He lies buried in his home town in Pavia in a family tomb in the “Cimitero Monumental” where are buried other renowned scientists like the Nobel Laureate Camillo Golgi, a neuro-scientist of great fame, Bartilome Penizza, a student of the great anatomist, Antonio Scarpa, who discovered that visual function lay in the posterior cortex, and Adelgi Negri, a pupil of Golgi a great pathologist renowned for his work on the pathology of Rabies. It is strange that all these men like Bassini studied and worked in the Universities of Pavia and Padua. The Anatomy museum at Pavia I believe is worth visiting. You will see the head and index finger of Scarpa in a jar, how it came about is another story.
There were six great Universities in the world Taxilla, Nalanda, Banares, Padua, Oxford and Cambridge. Taxilla and Nalanda perhaps the two oldest do not exist. It is said that the Government of India is trying to revive the University of Nalanda.

May I now add my bit to this lovely story. Every time I read these wonderful write ups, bejewelled with anecdotes and stories, I am amazed by your style of presentation and by your memory! How can you manage to remember so many finer details and then bring them out so eloquently and interestingly? My professor of General Surgery, Prof. P.C. Dubey also was a great history buff and told us stories about the surgeons of yesteryear and how surgery developed. I remember him telling us that Hernia comes from a Greek word ‘hernios’, which means bud or offshoot. He told us that in XIX century Heaton was performing injection of the mixture of white oak and morphine into the hernia sac to obtain its fibrosis! Czerny was performing the high ligation of the hernia sac and complete closure of the internal inguinal ring with sutures and Wood was double ligating the hernia sac to perform a natural plug and use it to close internal inguinal ring! Needless to say they all failed and recurrence was a rule along with very high mortality too! 

Bassini's landmark contribution in 1887 is written in golden letters in the history of hernia surgery and many surgeons copied his style. William Steward Halsted, after reconstructing the inguinal canal, left the spermatic cord in the subcutaneous position. It allowed for closure of the posterior wall of the inguinal canal with a very strong, transfixing sutures but he managed to perforate the urinary bladder in one of his patients and had a urinary fistula from the repair site! Zdzisław Sławiński in Warsaw did something even more peculiar - dissecting only the neck of the hernia sac, ligating and cutting it and leaving the cut sac in situ! It was McVay from Ann Arbour popularised his concept of inguinal hernia repair using Cooper’s ligament instead of inguinal ligament as a lower edge of sutures aimed at reconstructing posterior wall of the inguinal canal. Edward Earl Shouldice from Toronto advocated meticulous dissection, complete incision of the transverse fascia, sutures with monofilament rather than silk, oversewing of the posterior wall of inguinal canal by four layers of fascia and aponeuroses of oblique muscles and finally rapid ambulation of the patient. The Shouldice repair or the Canadian repair, as it was named, can be seen as a final, close to perfect state of Bassini method. It incorporates succinct changes, but the underlying concept is surely Bassini! 

Friday 22 July 2016

HIGHER EDUCATION IN INDIA - OPEN THE DEADLOCK

When it comes to the quality of higher education in India the mushrooming of medical colleges, engineering colleges and management schools has certainly not provided a solution and the products they continue to push out at the end of every academic session are neither employable nor useful for nation building. If this is the state of affairs in these new institutions then what are the old and established ones doing? Are they any better? Do they stand a chance to compete with the best in the world? Let us get a reality check.

India has five institutions in the top 50 and nine in the top 100 among the top 350 Universities across 17 countries, as per the QS University Rankings Asia 2016. In the BRICS Rankings 2016, India continues to hold its position in the top 10 with IISC at Rank No. 6. India has eight institutions in the top 50 which is the same as Russia and one more than Brazil. From 31 institutions in the rankings last year, India today has 44 institutions in the top 250 of the QS BRICS Rankings 2016. The University of Delhi has taken a lead by rising from 46 last year to 41 this year.

So, the established institutions are not exactly trail blazing success stories. The question is ‘Why’? We have poured in resources but why have we not got the value for our money? Our past Prime Minister, Dr. Manmohan Singh summed up our higher education system as sea of institutionalized mediocrity with a few islands of excellence. I cannot agree more. The problem is multi-dimensional and there are four factors which need our attention – students, teachers, syllabus and the system.

Students: The students who are graduating from our primary and secondary education system are either a product of mass copying and cheating or experts in cramming up and regurgitating for examinations.  Rote learning still plagues our system, students study only to score marks in exams, and sometimes to crack exams like IIT JEE, AIIMS or CLAT. The colonial masters introduced education systems in India to create clerks and civil servants, and we have not deviated much from that pattern till today. If once the youngsters prepared en masse for civil services and bank officers exams, they now prepare to become engineers, doctors and lawyers. The mind numbing competition and rote learning do not only crush the creativity and originality of millions of Indian students every year; it also drives brilliant students to commit suicide.

Teachers: Teachers are Nation builders but do they get the recognition for being that. In a materialistic world, where success is gauged only by the size of the bank balance, where is the poor teacher today? Money, power and position in society have all bypassed him/her and barring a few exceptions, he / she stands stripped of all dignity and prestige. If we continue to pay our teachers peanuts we will only attract monkeys for these jobs. Gone are the days of Prof. Sarvapalli Radhakrishnan and Prof. A.P.J. Abdul Kalam, the best in a class aspire to be administrative officers, engineers, doctors but not teachers any more. Higher education is heavily dependent of excellent teachers, who can guide high quality research, and it is not surprising to find that in this system ‘research’ is the worst victim. If teachers cannot imagine it their students will never become it and so it is absolutely essential to attract the very best in this profession. Good teachers need not be restricted to their own small institutions, we can, in this day and age of internet, share them not only with all those institutions which lack good teachers, but virtually with the rest of the world! We need leaders, entrepreneurs in teaching positions, not salaried people trying to hold on to their jobs by marking their attendance.

Syllabus: What we teach today will decide how we compete tomorrow. The syllabus should have two distinct parts – a fixed section of hard core basics and an ever changing section of what the market demands. The market is dynamic, it is always changing and if the graduate programme is unaware of the market place it will invariably produce a bunch of unemployables. The goal of our new syllabus should be to create entrepreneurs, innovators, artists, scientists, thinkers and writers who can establish the foundation of a knowledge based economy rather than the low-quality service provider nation that we are turning into. Why should we be happy Bangaloring jobs from the U.S? When will we start outsourcing our not so smart jobs to the not so smart countries? Why do we spend billions of dollars buying ammunitions, fighter jets and radars from U.S, France, U.K and Israel? How come their syllabus and their system taught them to make all these smart stuff, while our system was busy in campus politics and succeeded in producing only ‘netas’?

System: Education system in India is failing because of more intrinsic reasons. We live in a country where the people see education as the means of climbing the social and economic ladder. My tailor has paid Rs. 21 lacs for a degree in dental sciences for his daughter, not to make her practice dentistry but to make her more eligible for marriage. If the education system is failing – then it is certainly not due to lack of demand for good education, or because a market for education does not exist. There are systemic faults that do not let our demand for good education translate into a great marketplace with excellent education services.

We may have the most number of engineering graduates in the world, but that certainly has not translated into much technological innovation here. Rather, we are busy running the call centres of the rest of the world – that is where our engineering skills end. This is not excellence. We have set the bar so low that we will never be able to compete with the world. Until and unless we encourage innovation and research, creativity and originality and go out hunting for patents we will remain copiers and assembly workers for the world. We have to encourage risk takers, they will not succeed always, but when they will they can create Internet, Smart phones, Facebook and Hotmail!

Still India is in the top 10 Research producing nations globally. In a decade and a half, India has produced over 1.4 million Research Papers attracting a massive 8.5 million citations (7.4 citations per paper). During the same period, the Indian Scientific Community filed 4.6 Lacs Patent applications. A total of 1, 29,481 scientific papers were published by Indian authors in 2015, but the question is of quality......how many of them were path breaking?

We have tolerated mediocrity for far too long. Our education system will remain sub-par or mediocre until we make it clear that it is not ok to be mediocre. If we want excellence, mediocrity cannot be tolerated. Mediocrity has to be discarded as an option. We have to put some fire under the seat of mediocre students and mediocre teachers and make them function to their fullest potential. Accountability should be non-negotiable. With internet reaching our villages, for a country as big and as varied as India, distant learning is the way to go ahead. This will make good education, imparted by good educators, universally available and this is the only way reservation will become irrelevant. If a religious preacher in Middle East, by his hateful teachings can pollute the minds and hearts of so many young men and women in this sub-continent using distant learning of sorts, why can’t the good, the useful, the precious use the same medium and make India more imaginative, more inquisitive, more purposeful and more educated?

President Pronob Mukherjee is of the opinion that "Education as the alchemy can bring India its next golden age," Our first citizen has given us the key to the key to the next golden age, are we going to use it to open the deadlock?

Wednesday 13 July 2016

ACID ATTACK - AN ABHORRENT CRIME

ACID ATTACK – AN ABHORRENT CRIME



Acid attack or Vitriolage is the most heinous crime known to mankind. The victim usually does not die because of the criminal act but is cursed to live a life of misery, shame and agony. The villainous act is enacted to disfigure, mime, torture and kill the victim socially, psychologically and economically bit by bit every day. The perpetrator usually does not want to kill the victim, but wants to do something worse than murder – make the victim suffer forever.

Vitriolage as a phenomenon is firmly rooted in the crucible of ages bygone. Historically its purpose was vitriol, i.e., hatred, then and now too it is no different. Its scope has nevertheless widened with the passage of time. Innovation is never in short supply when it comes to cruelty. Corrosive acid has now become the weapon of choice for a wide range of individuals determined to inflict life-long suffering on their victims. Acid attacks have been documented in different parts of the world, including Australia, Bangladesh, Cambodia, China, El Salvador, Ethiopia, Italy, Laos, Malaysia, Nepal, Pakistan, Sri Lanka, Thailand, Uganda, UK, USA, and Vietnam. However, incidences in Bangladesh, India, Pakistan, Cambodia and Uganda are much higher and are on the rise.

Acid attacks, like other forms of violence against women, are not random or natural phenomena. They are social phenomena deeply embedded in a gender order that has historically privileged patriarchal control over women and justified the use of violence to “keep women in their places.” Acid attacks in India are a crime of passion. Acid attacks in India have ravaged the lives of thousands of young women whose only fault was that they
ú   Repudiated marriage proposals
ú   Rejected sexual advances from men they didn’t fancy
ú   Were caught in the crossfire of domestic disputes
ú   Conflicts over land and property
ú   Gang violence and rivalry
ú   Socially, politically and religiously motivated

When we try to analyze why acid attacks are so common in our sub-continent three factors stand out prominently:
1.     Gender discrimination - Women allegedly or actually transgress hegemonic gender norms and roles that discriminate against women and keep them in subordinated positions.
2.     Easy availability of Acids - Acid is easily and cheaply available, and no licenses or customer identification is required
3.     Feeble laws - The laxity of certain sections of the law and the delay in delivery of justice allow the offenders to walk away with minimal punishment

The Acid Survivors Trust International (ASTI), a London-based charity, tentatively estimates that some 1,000 acid attacks occur every year in India. However, in the absence of official statistics, campaigners put the true figure even higher: at roughly 400 every month. Governments do not keep data of acid attack. Bangladesh – Acid Survivor Foundation (ASF) recorded 3000 attacks between 1999 and 2013. In India news paper reported 153 attacks between Jan 2002 to October 2010 and only God knows how many go unreported. In Cambodia the Cambodian Acid Survivor Charity reported 271 attacks between 1985 and 2010. When we try to understand why is it that there is so little genuine data we are faced by a bunch of causes: lack of funding for research, hard to gain access to interview the victims, victims are ashamed and may not want to see or talk to anyone other than their doctors or social workers, their refusal to talk about their traumatic experiences to strangers or they are too disabled to participate in any survey.

The problems encountered by these unfortunate victims are medical, psychological and social. Medical problems include horrific disfigurement of facial features – scalp, skull, eyelids, nose, ears, lips, mouth, face and neck and often blindness. Psychologically they suffer from anxiety, depression, loss of self esteem, suicidal tendencies, and distress due to concern for their appearance and increased self consciousness. Socially  they  depend on others for day to day work, are not able to find suitable work, due to impaired vision, physical handicap, lack of social acceptance and the routinely have difficulties with social interactions. There is a negative economic impact on families, frequent divorce or abandonment by their spouse and most of the women are shunned and ostracized by the society.

To combat acid violence, we the people and our governments should address the root cause – inequality and discrimination against women. Every other step is secondary if the individuality and dignity of a woman is not respected. We can then go on and enact laws to
ú  Limit the availability of acid by effectively regulating  the production, distribution, use, sale, handling,  storage, labeling, transfer, and disposal of acid by manufacturers, distributors, and other business and individual users of acid in order to deter the unauthorized use of acid
ú  Unlicensed, over-the-counter sale of acids should be banned immediately and the origin of the chemical should be traced and the vendors prosecuted. Buyer of acids must provide a photo identity card to any retailer when they make a purchase. The retailers must register the name and address of the buyer.
ú  Regulate the safe-handling, appropriately punish perpetrators by enacting and implementing laws that specifically tackle this problem effectively and swiftly.
ú  Support women’s empowerment to enhance their self-confidence and ability to sustain independent livelihoods.
ú  Provide redress to victims, including compensation for healthcare costs.
Often these victims need multiple stages of painstaking reconstructive surgeries and a prolonged professional, personal and social rehabilitation program. For all this they need continuous financial support. Insufficient infrastructural support at most of the remote and non metropolitan cities, does not allow the victims of acid attack to get the quality expertise, which otherwise would reduce not only the complexities of deformities but also help save some of the vital functions like vision, etc. as well as improve the quality of life. This gender based violence against women is so horrific that it is an insult to our nation and we Indians need to take it up very seriously.

Thursday 7 July 2016

HAPPY EID - AN OCCASION TO CONTEMPLATE AND CHANGE COURSE



May I and my family wish you and your family everywhere in the worls a very happy Eid! May the choicest blessings of God be with you, irrespective of your religion, caste and nationality, and may you be blessed with health and prosperity, love and affection, and success in every sphere of life! I do so no only because you are my friend but because I am about to give you a back-breaking burden of responsibility.

This is one world that God has created for us all and it is His desire that we share its bounty and live in peace and harmony. But are we doing so? We are living in difficult times. These are the times that the Prophet described as the times of fitan; crises coming one after another; crises that shake our faith and test our patience. In these difficult times we need to keep alive the spirit and lessons of Ramadan: lessons of self-restraint, patience, forbearance and compassion.

The ignorant will often tell you that the Muslim world is passing through a deep crisis, little realizing that it is no different world than the one in which they too are living. So problems that are raising their ugly head today anywhere in the world are our problems not anyone else’s.

There are two types of challenges facing us today. First and foremost, we are faced with ignorance and extremism. I put them together because they go hand in hand. This has given the opportunity to the affluent west to target us. We know that Islam is peace and yet the actions of many among us show otherwise; we say Islam is mercy and yet there are our brothers who don't hesitate to kill each other as if they were flies. We say Islam is discipline and self-restraint and yet we easily become impatient. Extremism is a disease we must deal with. And this can only be done through education. Our children and youth need to be educated in the morals, character and virtues of our religion – Hinduism, Christianity or Islam; we need to make them exemplars of mercy and compassion. We need to teach them values and principles; we need to nurture them as leaders who shall stand forth as witnesses of justice and compassion for all humanity.

Second and equally disturbing is the silence of the ‘good’. How can we become good Hindus and good Muslims and good Christians if we do not raise our voice against injustice and oppression irrespective of the religion of the perpetrator? How can we allow a handful of mad men and women taint our religion, our culture and our centuries of civilization? When the teaming majority is for humanity, peace and peaceful coexistence then can we remain silent any longer and let these lunatics turn Islam into a faith that is against the world. In face of increasing Islamophobia we need to reach out to all other communities in a true spirit of good will and cooperation on projects of virtue and compassion. We need to demonstrate through our actions that we are for living in peace, in mutual respect with all the people. This is our Ganga-Jamuni tehzeeb, we are products of this society, how can we let offenders, irrespective of their religion, get away with murder, butchery and destruction of our way of life!
Let us all become instruments of peace and good will in a world torn apart by wars, antagonism, racism, and xenophobia. The stage is set for people of this subcontinent to show leadership and broker peace in the world. The usual peace makers have failed miserably, let us do it now!



Dear friend, on this Eid I invite you to be the new ambassador of peace.