THE STORY OF CORTISONE

I am once again back with another story that I heard from my senior colleague Prof. Hirji Adenwalla of Trichi in Kerala. As you will appreciate, while reading this blog, he is a treasure trove of knowledge and his story telling ability will keep you enthralled. He is the Head of Charles Pinto Centre of Cleft Lip, Palate and Cranio-facial Anomalies, and in his eighties he remains one of the senior most plastic surgeons of our country.

The story of the discovery of cortisone began in 1928 nearly 20 years before it was really discovered. A 65 years old doctor suffering from severe rheumatoid arthritis was admitted to the Mayo clinic under Dr. Philip Hench with an acute attack of jaundice. The doctor in passing, as an aside mentioned to Hench that his rheumatoid condition had almost disappeared with the onset of jaundice. He could now walk a mile without pain when before the jaundice he could walk only a few steps. Any other doctor would have put this aside  as mere coincidence. But not Hench he noticed the same phenomena in other patient with the same problem. In 1933 Hench who himself was suffering from a  wide unrepaired cleft palate wrote a paper which was published in the proceedings of the Mayo Clinic that there must be some substance that was produced by the jaundiced patient that caused the crippling symptoms of rheumatoid arthritis to abait. He accepted his ignorance and called this substance substance X.

Hench in desperation started hitting in the dark. He started feeding his rheumatoid arthritis patients with bile salts, liver extracts and he even injected blood taken from jaundiced patients but to no avail. He published his failures in the British medical Journal of 1938. Hench was a dogged clinician and would not let go he observed that it was not only jaundice which caused this remission but it also happened in pregnancy and he noted that it did not only cause remission in the rheumatoid condition but also in asthma, myasthenia gravis and in other autoimmune diseases. These were masterly observations. But here Hench met with a brick wall. What was this substance X?

He got Professor Edward Kendall professor of physiological chemistry at the Mayo clinic to try and identify this substance X. Kendall was already well known for his isolation of thyroxin which was curing    Myxoedema. As luck would have it Kendall was working on the hormonal secretions of the adrenal glands. Everyone knew of the clinical condition called Addison’s disease caused by destruction of the adrenals by tuberculosis. These patients with Addison’s disease died within 6 months. Patients with Addison’s disease were treated with extracts made from cat’s adrenals Kendall set out to identify this hormone. In 1932 Kendall isolated several compounds from the adrenal glands and called these compounds A, B, E, and F. Hench and Kendall working in the same institution became friends. They wondered if Hench’s substance X could be either A, B, E or F.

Then came the Second World War, and as often happens wars act as a catalyst for great medical and surgical advances, US intelligence reported that Nazi Germany was purchasing large quantities of adrenal glands from cattle in Argentina and extracts of these glands were injected into Germen pilots who as a result could fly high attitudes without distress. This was of course not true but it motivated a strong research programme in the United States which culminated in 1948 with the synthesis of a few grams of compound E which was identified as Hench’s substance X. This compound E was named cortisone. This break through took place at the Merck laboratory Dr. Lewis Sarett was responsible for it. Dr. Lewis Sarett was working in the Merck laboratory.

           

Now the scene shifts back to the rheumatology ward of Dr. Philip Hench. On the 26th of July 1948 a Mrs. Gardner suffering from severe rheumatoid arthritis was admitted under his care, she was confined to a wheel chair and was in severe pain. Hench, spoke to Kendall and Kendall requested Merck to send him some compound E now called cortisone for trial. Injections of 100 mg every day were started, four days later Mrs. Gardner who could hardly hobble a few steps went shopping. Dr. Hench treated 13 more cases with cortisone which was really the substance X that Hench had been talking about for years. The results were dramatic. He presented these cases at a clinical meeting at the Mayo clinic in April 1949. I quote from Albert Marel’s book “The Hormone Quest” “The lights were turned down and a color film began flickering on the screen. First came the before treatment pictures in which patients struggled to take a few steps.” Suddenly an electrifying gasp, swept through the audience as the after treatment scenes appeared and the doctors saw the very same patients jauntily climbing steps, swinging their arms and legs and even doing a little jig as if they had never been crippled. Even before the film ended, the watching physicians had filled the hall with wave after wave of resounding applause. When the lights went up Dr. Hench approached the lectern, he was greeted with a standing ovation”. No man deserved it more for his insight and his perseverance. It took 21 years for Philip Hench to prove what was first just a suspicion. A year later Hench and Kendall were awarded the Nobel Prize. Hench donated a part of his prize money to serve Sr. Pentaleon the nun in-charge of his rheumatology ward, so that she could fulfill her wish to travel to Rome and meet the Pope. But alas, Dr. Lewis Sarett who made the end possible was forgotten.

           

Like Penicillin cortisone did not fulfill its full expectations and was certainly not the answer to rheumatoid arthritis. But cortisone is today used to ameliorate the symptoms of a legion of diseases. “It generally does not ever cure but when correctly used, relieves, alleviates and controls several disease processes” and often saves lives. James Le Fanu in his book the Rise and fall of Modern medicine says “Hench got it right but for the wrong reasons”.

  

THE STORY OF PENICILLIN

Let me, at the very outset, introduce you to this wonderful story-teller. Prof. H.S. Adenwalla is in his late eighties and is one of the most senior Plastic Surgeons in India. He is the Head of Charles Pinto Centre of Cleft Lip, Palate and Cranio-facial Anomalies in Jubilee Mission Medical College & Research Institute in Trichur, Kerala. The learned professor is an encyclopedia of knowledge and yet an epitome of modesty. Trained under the famous Plastic Surgery Guru Charles Pinto in K.E.M. Hospital, Mumbai, when the octogenarian professor chooses to walk down the memory lane, you are distinctly lucky if you are accompanying him! This is one of hise several stories which I am going to share with you all from time to time!

In the history of the growth of science it is difficult to lay any clear watersheds, but we can say that the era of modern medicine roughly started with 1880’s- many good things had happened before, for instance Jenner had begun his war on Small Pox, and Louis Paster had conquered the horrors of Rabies. Dogmack had synthesized salvarsan which was a sulphoamide. But otherwise medicine consisted of purging, bloodletting and starving and more people died of the treatment than the disease. There were a few useful drugs which became the physician’s carthorse, digitalis for the heart, Quinine for malaria, salicylates for fever, sarol for intestinal infections, hexamine for urinary tract infections and opium for pain. Insulin for diabetics, thyroxine for myxoedoema and salvarsan (arsenic) for syphilis, came later.

Our story of Penicillin begins with a young Scottish student of Medicine who wanted to be a surgeon. In 1906 he took a temporary job in the bacteriological department of the St. Mary’s hospital, London under Sir. Almroth Wright, his intention was to stay on the hospital’s rifle shooting team. That as Udwadia says in his book “The forgotten Art of Healing” was a quirk of destiny for both Fleming and the world.

His first discovery of importance was that he proved that there was in tears an enzyme called lysozyme which destroyed organisms that existed in the nasal tract. It showed why the eyes resisted infections so effectively. He then turned to the study of staphylococcus a common organism which infected wounds and caused fatal septicaemia and death.

Now starts a Cinderella story never surpassed in the annals of medicine. Fleming retiring from a holiday found that one of the Petri-dishes that he had left open by chance had been contaminated by a mould, and the bacteria round the mould had been destroyed. He presumed that this mould may have floated up the stairs or through an open window from a laboratory where a research worker was studying fungi. The genius of Fleming was that he did not just throw away the Petri-dish. He was intrigued by the pneumonia and so he studied what lay before him and found that a powerful substance had emanated from the mould that had killed the bacteria. What was this substance? He believed that the mould was Penicillium rublem. It was really Penicillium notatum and hence he called the lethal substance Penicillin. His further research showed that this Penicillin destroyed a whole range of gram positive cocci and a few gram negative ones too. He also showed that Penicillin did not affect healthy tissue or the leucocytes in blood. Why did not Fleming try Penicillin on infected animals? This was because he found that if Penicillin was mixed with blood it lost its potency. He failed to realize that what happens in vitro does not necessarily happen in vivo. Disappointed at this road block he turned to other areas of research. Strange to say other workers who thought Fleming had given up too easily could not duplicate Fleming’s observations. When they dropped penicillium mould on to an agar plate full of colonies of staphylococcus nothing happened. A year later Robert Hare solved the riddle. Robert Hare consulted the meterological records for London at the end of July 1929. When Fleming was away, London had a very cold spell of a week, which favored the growth of the penicillium mould. After that the temperature rose which favored the growth of the staphylococcus. Robert Hare succeeded in duplicating Fleming’s experiment in conditions of controlled temperature. But there the research died. It must be noted here that without that cool period when Fleming went on leave he would not have discovered penicillin at all.

For six years no one spoke or heard of penicillin. In 1935 Howard Florey a brilliant Australian who headed the Dunn School of pathology at Oxford hired a German Jew who had just escaped from the Nazis in Germany, he was a biochemist, they both set out to find a powerful antibacterial substance. By chance they stumbled upon a paper by Alexander Fleming on penicillin but they just could not isolate the active substance from the mould. It was Norma Heatley another biochemist on the team who succeeded. On Sunday the 25^th of May 1940 Florey’s team inoculated 8 mice with lethal doses of streptococci four were then put on penicillin. By 1.45 AM the next morning the mice who were not treated with penicillin died the other four survived. Florey exclaimed “This gentleman looks like a miracle.”

The Second World War was going badly for Britain. France had already capitulated. Florey then made a desperate decision, he decided to convert his department into a manufacturing plant for penicillin. Heately was put in-charge and he at last had enough penicillin for a human trial. A police man Albert Alexander had developed septicaemia following a scratch while pruning roses. Dr. Charles Fricher on the 12^th of February 1941 administered penicillin three hourly to the patient. By the fourth day the patient’s temperature dropped and he became lucid but unfortunately they ran out of penicillin and Alexander died. They had no doubt that if they had enough Penicillin Alexander would have lived.

Florey appealed to the British pharmaceutical industries for help but they said they were too busy due to the war, so in July 1941 Florey and Heatley flew to the USA to get the help of Andrew J. Moyer. Moyer it is said sapped Heatley of all his knowledge but gave nothing in return. Moyer succeeded in manufacturing penicillin in large amounts.

Now in 1942 Fleming asked for some penicillin for a dying friend, he has given the drug and his friend survived. This was reported in the Times. It was then that Almroth Wright wrote to the Times giving credit to his pupil Fleming for the discovery of Penicillin. Fleming, Florey and Chain shared the Nobel Prize for Medicine. As often happens in life Norman Heatley and Robert Hare were forgotten. Penicillin became the wonder drug which opened up the phenomenal era of antibiotic therapy. For a moment man thought that he had conquered diseases caused by infective organisms but it was not to be, nature always has the upper hand and as Udwadia says “Microbes like man evolve, when threatened they mutate to form resistant strains. And so the battle for survival goes on.”

CAN WE OVERCOME THE TWIN TROUBLE OF CASTE AND RELIGION?

The largest state of India, Uttar Pradesh, goes to the poll next year. Political parties have started preparations, but what preparations you may ask. They are trying their level best to get the caste equation right. For a majority of the voters the performance or the non-performance of the government does not matter and the performers / non-performers know this pretty well. 

The ‘caste’ unfortunately influences political activity in our country from Panchayat right up to Parliament. While the Caste System is breaking down in social and cultural fields; conflicts between castes are intensified by party politics. Numerically large castes have become important pressure groups in local as well as state politics. Political Parties in India sponsor candidates having social base, which is nothing but the numerical strength of a caste of candidate in the constituency. Their service to the society is unimportant and their criminal background usually does not matter.

U.P is not the only state which suffers this malady. In Karnataka state politics there is rivalry between Okkaligas and Lingayats, the two leading present castes. In Andhra Pradesh the chief contesting castes are Reddies and Kamas, in Bihar, Bhumidars, Kayasth and Rajput. Dravida Munnetra Kazngam (D.M.K) emerged as a non-Brahmin party of break the Brahmin cal dominance in Tamilnadu state politics. Bihar and U.P. are champions of caste based politics. The traditional caste rivalry between the Rajput, Kayastha and Bhumindar is found today among the political parties in Bihar. The emergence of Kanshi Ram and Mayawati as Dalit messiah and that of Mulayam as the benefactor of Yadavs have polarized the post Mandal politics in U.P. and will continue to do so till a charismatic leader emerges who can, more by his deeds and less by his words offer employment, progress and prosperity across the caste divide.

Political parties utilize the support of caste for their functioning and seek their support in winning elections. The involvement of these castes organization in politics has changed their position in hierarchical pattern of Hindu society. Caste solidarity and political power have helped them to achieve higher social, economic and political success and become one of the most formidable elements of group formation within political parties in India.

 Incidentally political process has a dual effect on the caste system. To the extent that caste and sub-caste loyalties are consistently exploited, the traditional structure is strengthened and to the extent that it leads to new alliance cutting across caste, it loosens the traditional structure. Caste enters the political process by making appeals to caste loyalties and thus engineering power shifts from one dominant caste to another or one caste/sub caste combine to another by articulating caste interests in an organized manner. From Kanshi Ram and Mayawati for the Dalits to the new kid on the block Hardik for the Patidars the pattern has remained unchanged.

Religion too enters the political chess in a very unique way and with almost one out of five votes belonging to a Muslim, they can be expected to be wooed by all and sundry. Appeasement of a particular caste and religion combine may lead to a winning combination and every political party will strive for this divine match making. But in the midst of all this the state of Uttar Pradesh has swung like a pendulum between corruption and lawlessness since almost last three decades. Much is expected from the aspirational India of today but in states like Uttar Pradesh and Bihar the thought process is still medieval and so the situation notoriously remains status quo.  Whether this is good for the nation or not only time will tell. But if good and honest politicians fall victim like Abhimanyu to this chakraview of caste and religion and I wonder how it can be good for our future.

KIDNEY TRANSPLANT ………..HOW DID IT ALL START?

In the late 40s, during the ward rounds at this Boston hospital, the residents were very concerned at the young comatose patient who had been wheeled in. The consultant looked at the patient at her and said "the only thing that can save her is a new kidney. Else she will not last more than a day or two"

During the evening after the consultant had gone, another patient in the ward died and the young residents took his words seriously. They felt that they could try to give her a new kidney. They went to the mortuary and removed the kidney, brought it back to the ward and using a wick lamp worked till late at night stitching the renal artery and vein to the most easily approachable vessels - Brachial artery and cephalic vein in the ante-cubital fossa.

At the end of the anastomosis they realized that the ureter was hanging free. Too tired they just placed it in a kidney tray and covered the donor kidney with a wet gauze and headed back to sleep.

Next morning when they came back the patient was awake, sitting up. The kidney tray was full of urine and had dripped all over the floor.

Obviously there is no mention about long term survival and the kidney must have been rejected later but the ball was set rolling. Joseph Murray, a Plastic Surgeon did the first proper kidney transplant. It needs a Plastic Surgeon to think out of the box!

Experimental studies to transplant a kidney in animals started in 1902 in Vienna Medical School in Austria. In 1909 the first kidney transplant experiments were performed in humans in France using animal kidneys – a brave surgeon inserted slices of rabbit kidney into a child suffering from kidney failure.  Although “the immediate results were excellent” the child died about 2 weeks later. Scientists blamed such failures to unknown ‘biochemical barriers’. The first human to human kidney transplant was attempted in 1933 by Yuri Voroniy from Kherson in the Soviet Union but the donor kidney never produced urine and they blamed it to the fact that the donor had a different blood group!

On June 17, 1950 a successful transplant could be performed on Ruth Tucker, a 44-year-old woman with polycystic kidney disease, at Little Company of Mary Hospital in Evergreen Park, Illinois. Although her transplanted kidney was rejected eventually as there were no immuno-suppressants available then, before rejection it gave sufficient time for her own remaining kidney to recover and she lived for another five years!

The first kidney transplants between living patients were undertaken in 1952 at the Necker hospital in Paris by Jean Hamburger although the kidney failed after 3 weeks of good function. However, by now people knew that new approaches were needed to prevent the body from fighting off a “foreign” donor kidney. Sir Peter Medawar at the University of London was experimenting with the immunologic basis of organ rejection in the late 40s and in early 50s Cortisone like medications were used to protect the donor kidney from the recipient’s immune system!

Two days before Christmas in 1954 Joseph E. Murray and his colleagues J. Hartwell Harrison, John P. Merrill performed the famous Boston Transplantation, which changed the course of history. The procedure was done between identical twins Ronald and Richard Herrick to eliminate any problems of an immune reaction and so was done without any immunosuppressive medication. For this and later work, Dr. Murray received the Nobel Prize for Medicine in 1990. The recipient, Richard Herrick, died eight years after the transplantation. More importantly, this opened the door to many more kidney transplant between identical twins, both in Europe and in America.

After scientists more accurately understood why our bodies fight off foreign organs, they experimented with ways to combat these defenses.  Surgeons used X-ray, bone marrow infusion, immunoparalysis, donor-recipient matching, and drugs to stop rejection. The 60s came with rapid advances and better techniques for matching donor and recipient blood and tissue types. Improvements in preserving cadaveric (from recently deceased donors) kidneys, were developed and today’s solutions and cooling methods can be safely preserve kidneys for up to 48 hours, there were times when surgeons rush organs from decapitated prisoners!

A procedure, which today is practiced with effortless ease in almost every country, has developed because of the determination and dedication of countless men and women of medicine who were not happy with status quo, and challenged the prevalent norms.

THE HISTORY OF THYROID SURGERY

I am once again back with an outstanding account of history of medicine from the pen of my senior colleague Dr. H.S. Adenwalla. Besides being one of the most respected senior Plastic Surgeons of our tme Dr. Adenwalla is Head of the Charles Pinto Centre for Cleft Lip, Palate and Craniofacial Anomalies in Jubilee Mission Medical College and Research Institute in Trichur, Kerala.

Physicians hundreds of years ago had learned by observation that eating roasted sponges sometimes reduced goitrous swellings. In 1820 the Swiss scientist Jean Francois Coindet had discovered that iodine was the effective component of sponges and ever since then iodine became the sheet anchor of all therapy for goiters. It was rubbed into the gland, taken by mouth and even injected into the gland. The treatment had some effect and is still used in iodine deficient areas to prevent goiters. But it did nothing for the large goiters that either killed their victims with asphyxiation or, in cases of toxic goiters, with ultimate heart failure. A tracheostomy was performed as a last resort for asphyxiation. No one really knew as to what was the function of the thyroid gland, which unlike other glands had no duct to carry away its secretions. Scientists made the most fantastic speculations about its function.

The Roman physician Celsus had written an account of his experience with thyroid surgery. He enucleated the nodules and most of his patients either died of sepsis or severe hemorrhage.  Two hundred years later Galen described an operation on a child. The patient survived the hemorrhage but lost the ability to speak. Galen described a nerve behind the thyroid gland, the slightest disturbance of which would affect speech. This nerve was later called the recurrent laryngeal nerve which controlled the vocal cords.

A thousand years after Galen, Paracelsus issued dramatic warnings against a surgical solution of the thyroid problem. Roland, a noted surgeon, burned holes with hot iron and drew threads of horse hair to tie off chunks of thyroid tissue hoping that those parts would necrose and die. Desault and Dupuytren tried surgery but with no success. Until by 1877 some hundred and fifty operations were performed on the thyroid resulting in death due to haemorrhage or pyaemia and the few that survived lost their speech.

Then came the work of Semmelweis, Pasteur and Lister and the advent of antiseptic surgery, anaesthesia and the creation of the artery forceps, the stage was now set for the epic speech delivered by Edmund Rose, a fourty year old surgeon from Zurich at the annual congress of German surgeon in 1877. Rose said that “total extirpation of the thyroid was the only remedy for this condition and it could be done without undue haemorrhage and without  damaging the vocal nerve if the surgeon took pains to study in detail the anatomy of the thyroid gland.” Rose’s lecture focussed the attention of European surgeons on the thyroid gland. In his talk, he acknowledged the work of Theodore Billroth of Zurich and Theodore Kocher of Berne both of whom had successfully done total thyroidectomies as early as 1872, a good five years before his presentation. Both Billroth and Kocher described a method whereby they systematically tied off the major vessels that supply the thyroid gland, and carefully avoided touching the recurrent laryngeal nerve. However, there came up at the time a few reports of the patients developing spasms, no one knew why and no one knew what to do for them. This neglected “tetany” killed a few patients due to severe spasm of the thoracic muscles. We know today that this was due to the inadvertent removal of the parathyroid glands and all that one has to do is give calcium to control it, but no one knew anything about the parathyroids at that time.

Theodore Kocher was now at the height of his fame. The world was talking about how he had mastered the operation on the thyroid gland, and how he had saved hundreds of young women from a ghastly death and then suddenly his world came tumbling down. It  was Reverdin who first pointed out to Kocher that one of his fourteen cases on whom he had done a total thyroidectomy had become a cretin and he suspected that the cause was the total removal of the thyroid. Kocher made Roux his assistant write to everyone of his patients to come for a checkup, and when they came, it was the saddest day for this great surgeon. He realised that he had created a generation of Cretins. Roux reports that he found the Professor sitting in his room with his head in his hands and when he looked up at me he said, “Roux have you ever known the moment when God suddenly hurls you down from a peak of self-complacency and lets you recognize what small bungling creatures we are?” The history of Medicine has given a full account of what this meant for the new born science of thyroid surgery. They described the nature of the mistake, how it came to be made and what its consequences were and how it was gradually amended. But they did not name the victims and they do not tell you what Theodore Kocher felt when he first recognized the terrible thing he had done by totally removing the thyroid gland. So what did this great surgeon and scientist do? He went before the Congress of German surgeons in Berlin on the 4^th of April 1885 and told them what he had done and the result of his mistake. He strongly advocated that the total gland should never be removed otherwise they would have many of their patients end up with what he called “cachexia strumipriva” later on labeled as myxoedema or cretinism.

Kocher was not the type of man to accept defeat. He went back and experimented on animals and ultimately came to the conclusion that if a small portion of the gland was conserved the horrible complication would not occur. Many surgeons without proper training took to doing thyroid surgery. They did not have the dexterity and expertise of men like Kocher, Billroth and Reverdin and so many complications kept occurring until the great Lahey at the Lahey clinic wrote his monumental paper on thyroid surgery and the recurrent laryngeal nerve. The complications of damage to the parathyroid was recognized and surgeons learned the use of calcium to treat tetany. In 1891 George Redmayne Murray in England extracted desiccated thyroid extract from pigs. Edward Calvin Kendall of the Mayo clinic extracted the pure form from hog thyroid glands. The hormone was synthesised by Charles Robert Harrington and George Barger British chemist in 1927. In 1960 Levothyroxine was synthesised and with these advances total thyroidectomy for cancer became a safe operation and both myxoedema and cretinism if detected early could be treated.

Today when we race through a subtotal or total thyroidectomy we little realise what the great surgeons of yore went through to give us simple answers to our problems in this, and other fields of surgical endeavor. 

A FRIEND FOR LIFE …..AND EVEN BEYOND!

Today was my friend, Mohan Chand Pant's varshik shradh. We, his batch-mates, friends and relatives, gathered at his home in Lucknow remembered what a wonderful friend he was and met his lovely family.

At Mohan's home today: Mukul, Veneet, Atul, Vinay and myself

We were batch mates in King George’s Medical College and so knew each other since our first day in college in the hot summer of July, 1975. Freshers, as we were then called, we were the easy target for ‘activity’, which was a politically correct name given to ragging. Mohan was a clean shaved lad who had not yet lost his baby looks and in the hostel he was paired off with another baby faced boy from the hills, Mukul. They were both very studious but Mukul was an accomplished sports person too. And they were very sporting and Mukul was crowned the T.G. Queen, an age old custom in which a boy is dressed up as an ‘Apsara’ every year!

Roommates Mohan and Mukul in S.P. Fair

After completing his M.B.B.S, Mohan chose to do his post-graduation in Radiology. This was when, for the first time he realized that life is going to be tough. He hailed from a very modest background and there was no hope of being supported by parents while doing post-graduation, and to his horror he found that this department had no paid residency posts! His professor told him that despite his best efforts he had not been able to convince the government about this demand for paid residency scheme. Mohan took it up as a challenge and pursued the losing cause all by himself. Every day he would go to the Secretariat or the Medical Directorate with applications and documents and request everyone –chaprasis, babus,  clerks, officers, ministers…..whoever he could reach to help him out. He would make them realize that Radiology is much more than taking X-Rays and perhaps for the first time the people in power understood that Radiology was a vast subject with two wings – investigative or Radiodiagnosis and therapeautic or Radiotherapy. Now with this understanding and new vigor he managed to convince the people in power that a residency scheme was very vital for the success of this branch of medicine and the residency scheme was sanctioned. Needless to say, this struggle made him very popular with everyone in the government and the hill people in particular adopted him as their future pride! Mohan never disappointed them.

The door at the beginning of the corridor led to Mohan’s humble room in the Department of Radiology  in his early days

The struggle for financial existence also taught Mohan a very important lesson – the art of man-management. He knew how to convince people and get things done. He would dream a future and make others believe in his dreams. His persuasive skills were so genuine that one was easily convinced by his simplicity. Dreaming big was his passion; he never asked for a job for himself, he insisted on a residency scheme!  His efforts were so selfless that right from that time and that early age he was in ‘Institution building’ mode!

Mohan never forgot those who helped him and even if a peon fell sick he would personally see to it that he or she would get the best treatment in the Medical College. A small hand written note from a friend or a batch-mate to a patient, with only his name scribbled on it was enough for Mohan to get up from his office chair, personally escort the patient to the concerned department, get an out of turn appointment from a busy consultant and ensure that the sick person is fully satisfied! I have been at the delivering end on many such occasions, and when I saw the concern on Mohan’s face for a complete stranger I could never gather the courage to say no, no matter how busy I was.   

Mohan was a big name in the field of Radiotherapy and he had students chairing many premier Radiotherapy departments all over the country, but he was never satisfied with what he was doing. He would often ask me why was it that our patients were coming to us so late when the cancer had spread so much that neither he nor I were able to be of any help. He was of the firm opinion that we needed to prevent cancer and all our efforts should be aimed at prevention and early detection. How do we do this was our next concern. Not to be undaunted Mohan thought of a multi-pronged approach:

1.       Write chapters for text books in regional language for school children, making them aware of cancer and its association with tobacco and chemicals

2.       Conduct audio-visual presentations in the village panchayats and village schools and make people understand the ill effects of tobacco – smoked, chewed or sniffed

3.       To use every available public platform – school function, social and cultural functions, drama festivals, Ramleelas and talk about cancer prevention and early detection.

4.       To use media – radio and television and in simple and understandable language talk about these issues

5.       Write newspaper articles, preferably in regional language to spread the message of early detection and prevention of cancer

Today when I look back, I am amazed at the passion with which he went about doing all this, and that too without ignoring his students, his staff members, his friends and family! There have been evenings when we have met in marriage functions and I have seen 7 more gift envelopes in his pocket and a list of ten destinations to visit that evening with only 3 ticked till then! Not only did he befriend people easily but he had a passion to cultivate friendship, garden it, nurture it and give it back in his own unique way.

Mohan with batch-mates

My mother was 79 years old when she was diagnosed with a urinary bladder cancer. She was investigated and was offered the best treatment that was possible and as we had made an early diagnosis she recovered completely to live for another three pain free years. Mohan was with me all throughout this ordeal and that was a big help. With my younger sister however we were not so lucky. She neglected her breast lump and when we diagnosed her she had an advanced disease. Mohan was very angry with her and asked her whether she had ever thought what would people think….he could not make an early diagnosis in the case of his own sister? She was operated and later Mohan planned radiotherapy for her under his guidance in his own institute, of which he was then the Director. During all this my brother in law was very uncomfortable with one issue which he found strange. In Delhi, where they lived, he was told that the therapy will cost Rs. 2 lacs and here no one was asking him to make a deposit. He asked me where was he supposed to make the payment, and how much? I told him to ask Mohan directly. So next day he went to Mohan’s chamber and asked him. Mohan conveniently ignored the question and flooded him with a ton of other questions of his own about my sister’s health and how my young nephew and he were coping. But my brother in law was insistent; he needed to make a payment. So when refused to let his query be brushed aside Mohan looked into his eyes and said ‘ jis din meri behen se tumhari shadi hui thi us din ye hisab kitab ho gaya tha.’ My brother in law was stunned and he returned home to tell me the story. It took me quite a bit of persuasion thereafter to repay Mohan – two trips to his office and 7 cups of tea to be exact!

A crusader against cancer and a champion of early detection, nothing could be more ironical than the fact that on December 25, 2014 when he was diagnosed for the first time with cancer, the disease was already advanced and incurable. It was a bolt from the blue and though he fought bravely till the last it was all over in eight months! That evening with a very heavy heart when I was sitting in front of his mortal remains though there are hundreds of his other friends and well wishers all around him, in the same somber mood as I was, I could feel his gaze penetrating the glass case and smiling at me as he had always done in the last forty years. Mohan was my friend, a friend for life. It was only then, when the eternal sole had left his body that in his smile he told me death was just a milestone that our friendship had to cross; we were not just friends for life but even beyond! May his aatma rejoin with paramatma and rejoice for some time but promptly return to earth because his fight against cancer is incomplete and Mohan never left things half done!

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!