TRAVELLOGUE – PART 1 THE PLANE THAT COULDN’T LAND

We were 15 of us, from as varied sphere of life as we possibly could have imagined! The only common thing amongst us was that we were of Indian origin and we all wanted to go to Kailash and Mansarovar. Our friend Sudipta had planned this trip in very great details with Mr. Prasad Ruparel of Yatra.com and we had mulled over all the possibilities and routes. Finally it was decided democratically that we will not take the Hilsa, Simikot route because it involved some scary rides on twin engine planes and helicopters and Sudipta, our ‘fearless leader’ as he was often called by us, finally decided on the Lhasa route. So it was planned that we will all gather in New Delhi on

September 16, 2016 and proceed to Kathmandu. From Kathmandu we will fly by a Sichuan Airlines commercial flight to Lhasa and then after acclimatizing in the higher altitude of Lhasa for two days we will proceed by road to Mansarovar. This route was much longer but we were thrilled with the prospect of staying two days in Lhasa as we wondered if we will ever be able to visit this city at a later date as it is not easy to obtain a visa for the Tibetan Autonomous Region.

Ghule, Sri Mirle, Nagu, Shyam, Smita, Tanmay, Sanjay, Ravi and Sudipta

Our journey started from various places in the world as we were truly scattered all over. Sudipta flew in from Houston, Texas, Sri Mirle from Cincinnati, Tanmay from Toronto, Canada, Smita Ravishanker and Rajiv Arora from London, and Ravi Uchil, Nagbhushan Gubbi, Nandkumar Ghule, Shyam Nihalani, Sanjay Bhalla, Sharmila and yours truly from different parts of India. Our immediate destination was New Delhi. On September 16, 2016 all of us except me took the morning flight to Kathmandu. The hotel we had chosen was Geje Suite. It was in Thamel and it had thankfully arranged for an airport pick-up. While our friends utilized the afternoon visiting Sri Pashupati Nath temple and shopping in the lanes and bylanes of Thamel, our fearless leader with the local representatives of Yatra.com arranged for our group visa for the Tibetan Autonomous Region. I had an evening Royal Nepal flight from New Delhi to Kathmandu and I joined the group at around 11 PM. The first person I met was my room partner in the hotel Sri Mirle. Tired after a hectic day, he was fast asleep when I knocked the door. He got up rubbing his eyes and introduced himself, gave me my duffel bag, raincoat and Dawn jacket and promptly went back to sleep. I quickly re-packed my stuff in the duffel bag and after a refreshing shower too retired for the day as it was already 12.30 AM.

September 17, 2016. I got up in the morning only to find my partner Sri Mirle in deep meditation. This was followed by a prolong yoga session and all this while I brushed, shaved, showered and got prepared to meet the rest of the team. But the morning did not start well. My friend Sudipta and Tanmay rushed me to a room where one of our team mate Sanjay was very sick all night and was in pain. The fact that he was from Delhi, a place which has recently been in the news for many Dengue and Chikangunia morbidities raised my clinical antennae. He had pain in joints and profound malaise and after an eventful night had already decided that he was returning home. I too felt that he had one of these viral fevers and so his return flight was hastily arranged. Though this was an inauspicious start but the silver lining was that we were still one stop away from Delhi and not in the wilderness of Tibet!

In the breakfast that was laid out on the 5^th floor restaurant of our hotel, I got the opportunity to meet all the other members of our group. The mood was a mix of excitement of the forthcoming trip and somberness as one of us won’t be accompanying us but returning home. I personally wanted to meet Sanjay and talk at length about his passion of growing organic food stuff and breeding a better variety of cattle in his farm in Noida. He is a wellness advisor and has a very interesting website http://thewaywewere.in/Wellness_Advisor.aspx#. I guess this will have to wait for now!

Our travel to Lhasa was by Sichuan Airlines flight 3U 8720 scheduled to leave Tribhuvan International Airport, Kathmandu at 11.10AM and so we all reached the airport at around 9 AM, only to be told that the flight was late by two hours. But during these 2 hours we met three new teammates from Hyderabad who were joining us in the expedition and they simply mesmerized us by their infectious enthusiasm! Bhasker Pendyala, Shyamsunder Reddy and Venu Vavilala were all younger to us and infused the much needed zeal, zest and exuberance of youth in us, who were feeling really down and out after the unfortunate exit of Sanjay Bhalla from the scene.

Sri Mirle talking to a French guy, Sharmila,Venu, Bhaskar and Shyamsunder

We spent some quality time in the airport lounge sipping coffee, interacting with each other, knowing about each other’s families back home. Mirle and Ghule even managed to do some yoga and meditation! We discussed about altitude sickness and how to avoid it by Diamox or a homeopathy medicine Coca. Soon the flight was announced and we were ready to go.

Our plane left at around 2PM and it was a 1 hour 50 minutes flight to Lhasa. Lunch was served and consumed in no time and we were ready to land in Lhasa…………but something was not going right. We had been flying for more than two and a half hours and the flight had been quite turbulent and still there were no landing announcements! Suddenly the captain’s voice boomed in the public address system and he said something in Chinese which was followed by a huge cheer from the plane full of people. His subsequent announcement in English however was a huge disappointment to us – the climate in Lhasa was not conducive for safe landing and so the plane was going straight to its next destination Chengdu, which is the capital of Sichuan province and the hub of Sichuan Airlines. No wonder the Chengdu passengers were all thrilled, they would reach early! Our onwards plan seemed all topsy-turvy.

We landed in Chengdu at around 7 PM and were promptly escorted to immigration. We had a group visa for Tibetan Autonomous Region and not for China, and our visa was in a separate sheet and not stamped on our passports. We were made to stand in a line according to the order our names appeared on the group visa and one by one we were checked in to China. The airlines staff was extremely courteous and despite a language barrier we were assured that we will be sent to Lhasa by a 4PM flight the next day. A bus transported us to a luxurious hotel- Haotian Guotai Hotel where we were treated to a delicious multi course Sichuan dinner.

A sumptuous Sichuan dinner 

The vegetarians amongst us were happy. The non-vegetarians were over the moon with the fish, chicken and pork extravaganza! Our fearless leader was busy on his phone with our tour operator, trying to reschedule our trip as we would now land in Lhasa one day late. It was unanimously decided that we are not cutting down on our Lhasa stay and jeopardizing our acclimatization schedule but would adjust the lost day on our return leg from Kailas.

A Tibetan travel agent, Lepka was also stranded along with us but his company was invaluable. He knew both English and Chinese and that made our life easy. We had in Chengdu airport seen a large signboard saying ‘Welcome to Chengdu – the Giant Panda capital of the World’ and this was our chance to see some pandas. We expressed our desire to Lepka and he arranged for a bus for all of us next day to visit Chengdu Research Base of Giant Panda Breeding.

Chengdu Research Base of Giant Panda Breeding

Two Giant pandas

The giant panda is a rare and beloved animal that only inhabits the six major mountain ranges in Sichuan, Shaanxi and Gansu provinces of China. With a population of less than 2000, the species is included on the endangered list by the Convention on International Trade in Endangered Species of Wild Fauna and Flora and is protected by China’s Wildlife Protective Law as the special-class protected animal. In order to rescue and protect the endangered giant panda species, the Chengdu Research Base of Giant Panda Breeding was established in March 1987 with the mission to further the research and conservation carried out by the Chengdu Zoo. The Base’s geographic location and excellent technological and professional resources allow it to carry out the ex-situ (off-site) conservation efforts and to improve the artificial reproduction procedures to increase the giant panda population. Ours was a very well organized visit and with battery operated vehicles we had the privilege of viewing many pandas in their natural habitat as well as baby pandas in their nursery. This set up was involved in preservation of endangered wildlife, integrating scientific research and breeding of giant pandas, conservation education, tourism education, and panda cultural events. If you want to know about this centre please visit their official website: http://www.panda.org.cn/english/about/about/2013-09-11/2416.html

Panda nursery

 After returning to our hotel we were treated to a sumptuous lunch, almost as enjoyable as our dinner the previous night, and were sent to the airport in a bus. In Chengdu airport we were whisked to Counter No. 78 and the display board on the counter read ‘Sichuan Airlines flight 3U 8720 Kathmandu to Lhasa’! The plane was late by an hour but once on board we were happy to know that the weather in Lhasa was favorable. At around 8PM we landed in Lhasa.

So, this is how our journey to Kailash & Mansarovar started in a thrilling and exiting note. I will be back with the next part of the travelogue soon.

THE HISTORY OF LOCAL ANAESTHESIA

I am once again back with an equally interesting story about the history of Medical Science and my source remains my most favorite senior colleague from Trichy in Kerala, Prof. Hirji Adenwalla. The octogenarian professor is an avid story teller and has, in his illustrious career, interacted with so many 'greats' in the field of medicine, and has such a profound memory, that every time he walks down the memory lane, it is a pure pleasure to walk alongside him.

Though not as tragic, the history of the evolution of local anaeathesia is just as bizarre as that of the history of general anaesthesia and involves the names of many great scientists and research workers and starts with no less a person than the celebrated Sigmund Freud-  immortalized for his work on the human psyche. His role in the discovery of local anaesthesia is forgotten.

In 1532 Pizarro during the conquest of Peru discovered that natives of Peru chewed the leaves of a shrub called Coca and the juice of these leaves enabled them to perform prodigious physical feets. This discovery made no impression on the world in general. In the mid ninth century a traveller and linguist by the name of J J Von Tschudi again got interested in the ability of these leaves to increase physical performance. This prompted Mariani, a Parisian manufacturer to make an infusion of Coca leaves in wine and sell it as a general tonic and a cure for every disease under the sun. This of course smacked of quackery of a high order and made no impression on the medical world. In 1858 a Dr. Scherzer a Ships doctor of the Austrian frigate Novara brought dried coca leaves in quantity and gave them to a German Chemist Wohler Gottengen for analysis. Wohler’s pupil Niemann succeeded in extracting the effective component of the leaves which he called Cocaine.

The word went round in Europe that a Carl Koller, a minor assistant ophthalmic surgeon in the Vienna General Hospital was to read a paper at a major conference in Heidelberg on the anaesthetic properties of Cocaine, and that a cataract could be removed painlessly if a few drops of Cocaine were trickled into the eye. Koller did not have the finance to travel to Heidelberg therefore, he requested his friend Dr. Brettauer to read the paper. The truth of what he claimed was demonstrated to a group of senior surgeons at the conference, and this made a sensation.

However, the twist to the tale lies in the historical fact that it was not Carl Koller, who was the man with whom the story of Cocaine and local anaesthesia begins but with another young Viennese doctor Sigmund Freud who much later was immortalized for his work on the analysis of the human mind and the treatment of insanity. Freud was then 27 years old, the son of an impoverished Jewish textile merchant, marginalized, despised and humiliated as a Jew. Sigmund thought that he could overcome all the disadvantages of birth by becoming a great lawyer or statesman: All doors were closed to this poor Jew and so he turned to the study of medicine. After qualifying, he took a job in Professor Brckes physiological institute and had no idea of going into the practice of medicine.

Then a strange thing happened Sigmund  Freud fell in love with a beautiful 20 years old Jewish girl called Martha Bernays. There was no way her family would agree to the match unless Freud was earning well and so he decided to go into medical practice. Freud did not do well in general practice. At about the time he chanced to read an article by a German Army Doctor called Theodore Aschenbrandt entitled “The Physiological effect and importance of Cocaine”, he claimed that the drug had considerably heightened his soldiers’ marching performances. Freud had never heard of Cocaine before but he was looking for some sensational discovery so that he could become famous and marry Martha. He thought that Cocaine might help in combating nervous diseases. Freud was already getting interested in mental conditions. He approached Merek in Darmastadt and bought some Cocaine and started a series of experiments with the drug. He used it on himself and his depression disappeared. He started using it on Morphine addicts and found that the symptoms of morphine addiction disappeared but did not then realise that the symptoms of Cocaine addiction would be far worse. During his experiments on himself he found that Cocaine aneathetised his tongue and gums and could relieve severe tooth ache. It was Freud who introduce Carl Koller to the anaesthetic properties of Cocaine and he was the first in his monumental paper on Cocaine to mention its aneasthetic properties. But Freud had no surgical interests at all and so it was left to Carl Koller to steal the limelight from his friend Sigmund Freud.

In Hamburg while he was with Martha, he heard nothing of Koller’s success with Cocaine at the conference at Heidelberg. Freud married Martha in 1886 and heard of Koller’s success when he returned to Vienna. Curiously Freud was not at all shaken by the news for he was only interested in what Cocaine would do to neurological diseases. It must however, be mentioned that Koller had the honesty to mention when he next spoke at a major conference that “a careful and interesting  paper by my colleague Dr. Sigmund Freud introduced Cocaine to the physicians of Vienna”. Freud realized that he had missed the bus and took to Cocaine to relieve his depression. It is a miracle that he did not become a Cocaine addict. His role in furthering the research on Cocaine was soon forgotten or relegated to history. Other men spread the use of Cocaine as an anaesthetic to other parts of the body and these men, were William Halstead, Paul Reclus, Carl Ludwig Schleich, August Bier, Leonard Corning and Heinrich Braun. Halstead’s story with Cocaine is full of pathos and great suffering. He was at the time an up and coming surgeon working at the Roosevelt Hospital in New York and passionately taught the principles of antiseptic surgery. This young bold dynamic surgeon was also a fun loving extrovert. By chance he stumbled upon the work of Carl Koller on local aneasthesia and Cocaine and that completely changed his life. Halstead with his searching mind refused to be limited by the local use of Cocaine in the eye and in the mouth. He proved that Cocaine could be injected to provide not only local anaesthesia but one could inject major nerves like the sciatic nerve and cause wide spread regional anaesthesia. During these experiments he started injecting Cocaine on himself and his students and these experiments led to the tragedy of his Cocaine addiction. Halstead in his prime had become a nervous wreck and had to be taken to Providence virtually by force and admitted in an asylum. They tried to wean him off Cocaine by using morphine but it was like from the frying pan into the fire. William Welch, the great pathologist took him under his wing and after several admissions to the asylum moved him to the Johns Hopkins University Hospital in Baltimore. Welch and William Osler slowly pulled Halstead out of his Cocaine addiction. But he was never the same man. The brilliant bold and rather reckless surgeon became slow, meticulous and extremely careful.  A radical mastectomy which he could do in one hour took four to five hours to do. Out of his Cocaine addiction came the three cardinal principles of good surgery- reverence for tissue, complete hemostasis and elimination of dead space. The fun loving Halstead had become a recluse. Cocaine had damaged him for life. Welch said of him “this restless man of action was transformed into a master pedant who brought to American surgery-still coloured by the devil- may-care attitudes of the pioneering days a fool proof system of safe surgery”. Backed by Welch and Osler, Halstead was appointed to the prestigious chair of Professor of surgery at the Johns Hopkins. He never spoke of Cocaine or local anaesthesia or ever used it after that on his patients.

Following on Halstead’s work the year 1886 to 1888 saw a worldwide use of Cocaine for local and regional anaesthesia, the enthusiasm for Cocaine knew no bounds. Then in the summer of 1888 came the crash.  Journals all over the world started reporting “Cocaine deaths” Professor Kolommin, a doyen among Russian surgeons lost a patient after an operation performed under Cocaine. The patient died of Cocaine toxicity. Prof Kolomnin shot himself. Next came reports from Paul Reclus in Paris of deaths due to Cocaine poisoning. Dr. Brouardel reported 30 deaths in Paris due to Cocaine injections. But soon came a ray of hope for Cocaine, Dr. Oberst working in Prof Volkman’s clinic developed a method of preventing Cocaine absorption into the system by tying a tourniquet above the site of injection but this could only work on peripheral parts of the body like the fingers or the hand but the great Volkman was not particularly enthusiastic about it.

In the mean time Paul Reclus did not give up, he analysed Bouardel’s list of 30 fatalities. Only nine had died of Cocaine poisoning. Of the nine fatalities six were due to Cocaine overdosage. He set out to find   out the toxic dose of Cocaine. So far 30% Cocaine solutions were injected. He found that a mere 3% solution was sufficient to produce analgesia, and that the surgeon should inject Cocaine as he went along the operation over a duration of time. With this technique Reclus reported a series of 200 cases without a single mortality. Reclus was a cautious investigator. He was now experimenting on his own infected finger which surgeons wanted to amputate to save his life. He managed to open and drain the infection with a ½ % solution. Reclus brought Cocaine and local anaesthesia back on the scene by proving that Cocaine was safe if used in the correct concentration and in the way that he advocated.

           

Carl Ludwig Schleich was not aware of Reclus’s work but came to the same conclusion. In addition he injected saline into the tissues. The pressure on the nerves dampened the sensations and then he used just 0.1to 1 percent of Cocaine. Schleich and Reclus may be jointly credited for not letting Cocaine and local anaesthesia die a natural death.

           

At Esmarch’s department at Kiel Prof Heinrich Quincke discovered that the spinal canal could be punctured with a needle. He called the procedure “Lumbar Puncture”. He first performed it on a two years old child suffering from symptoms of raised intracranial pressure and he relieved the child’s symptoms by draining the cerebro-spinal fluid. From this August Bier working in the same department concluded that it would be possible to inject Cocaine into the spinal canal to anesthetize the lower part of the body. On the morning of August 16^th 1898, August Bier aided by his assistant August Hildebrandt injected 3 cc of 3.5% Cocaine into the spinal canal. The patient was operated on for tuberculosis of the ankle joint. An extensive debridement of the joint was performed without any pain. Bier recorded that the anaesthetic effect lasted for an hour and a half. This was the birth of spinal anaesthesia now used in every operating theatre of the world. Heinrich Quincke and August Bier must share the honor for this great advance in anaesthesia.

           

At about this time arose a great controversy about spinal aneasthesia. James Leonard Corning, an American claimed that he had discovered spinal anaesthesia 14 years before August Bier. He claimed that he had written three papers on the subject in 1885, 1888, and 1894. In America, patriotic fervor got the better of facts. An inquiry was held and it was found that Corning had injected Cocaine near the spinal canal but not in the spinal canal. The mild anaesthetic effect in some cases was due to permeation of the Cocaine. In his 1894 paper he had injected in the canal various drugs to cure neurological diseases with no success. He never injected Cocaine to produce anaesthesia. He drew no conclusions about Cocaine and anaesthesia. So credit for spinal anaesthesia ultimately went to August Bier. Corning’s story was the repetition of the story of Sigmund Freud all over again. Had not Freud clung to the idea that Carl Koller’s discovery concerned only a minor subsidiary aspect of the use of Cocaine? Had he not, with obsessive stubbornness, clung to the notion of Cocaine as a superlative treatment for neurological diseases? Freud’s thinking on this was one of medicine’s more dreadful errors.

           

Bier worked on to eliminate the side effects of spinal anesthesia. Bier was one of the first surgeons to use Novacaine synthesised by the German Chemist Einhorn, which had virtually no toxic effects.

           

The curtain now must be raised on the last act in this convoluted story. His name is Heinrich Braun working as head physician at the Sisters of Charity Hospital in Leipzig. In his early experiences with Cocaine he had seen that the effects of Cocaine were most lasting when the circulation of the blood was interrupted by a tourniquet thus hindering the removal of Cocaine. Braun had witnessed Oberst’s experiment in anaesthetisng fingers and toes. He worked out a Cocaine -adrenaline formula, the adrenaline caused vaso-constriction and thus delayed the absorption of Cocaine into the general circulation. This made the anaesthetic effect of Cocaine to last much longer. His paper was published in 1903 and Novocaine adrenaline became the combination that was used for all local anaesthesia. Local anaesthesia was no longer a dream but became a reality. It lent a tremendous impetus to thyroid surgery. Many operations were now feasible which before had been ruled out because of the perils of general anaesthesia. New vistas were opened up for surgical exploration. A new dawn had broken on the surgical horizon, soon to be further enhanced by the discovery of antibiotics and the advance in optics.  

PUBLISH OR PERISH!

A

s a junior resident in Surgery I was always tutored by my teachers to document the operation notes accurately, in great details and always with an accompanying diagram. When I rose the ladder of seniority in the residentship programme, I was coaxed, bribed, harassed, tormented and threatened with dire consequences to   publish my clinical and research data, and I often wondered what is all this fuss about? When I became the Editor of Indian Journal of Plastic Surgery when I went through the submissions to our journal I at once realized who all were fortunate enough to be tortured in their formative years and who all are trying to torture themselves today! But it is never late to start publishing!  

So why should we publish? We publish to communicate with a wider audience, to secure recognition of our peers, to promote the work of our team, to document our research data and get it reviewed by our peers, to advance our career and to satisfy our own self. The importance of the immortality of the published work can not be over-emphasized.

Fear of writing or ‘Blank screen syndrome’ is dreadful. It is caused by

• fear of failure
• waiting for an  inspiration - that never comes
• sub-optimal information gathering
• laziness and lack of discipline
• desire to write it all in one go
• the dreaded ‘Perfect Draft Syndrome’.

Stephan King had very correctly said that the scariest moment is just before you start writing. After that things can only get better!

There are various ways of getting over the initial hesitation - 5 tips that I can offer are

• set a ridiculously easy targets
• bribe yourself for finishing small bits
• challenge yourself for completing parts of the paper
• spin a web of ideas in your mind
• when tired or exhausted give yourself a break

The paper need not be written from start to finish in the order it will appear, one should start from the part one knows best, the study plan or the Material & Method perhaps. Tape recording the paper instead of writing it may be an easier option.  One should not fall into the trap of ‘Laundry List Phenomenon’ i.e. cut-paste from 10 papers! This is plagiarism and there are softwares to pick it up even if the reviewers miss it, which itself is highly unlikely.

The ‘Pre Research Stage’ of writing is vital and sites like Google Scholar, Pubmed, SCOPUS all help us with what is current. Instead of accepting all printed text one should question it….. can we do it better?. Recording all performed work as one goes along – data, graphics, videos etc. and discussing with seniors and colleagues helps one to develop and research the thought and eventually formulate a hypothesis. Hypothesis is a testable assumption and every research should have a hypothesis. It is best to write it down – it is key to the research project. Then one should test it and critique it to destruction……..ask “so what?” and “who cares?” and finally one should answer honestly “is it worth publishing?”

Good data speaks for itself – generally we can eyeball a good data. If we need statistics to prove our point we are putting the cart before the horse. Statistics should prove what is obvious, but statistical fishing expedition to somehow prove our erroneous hypothesis is wrong. Statistics should not disguise the hypothesis.

Choice of ‘Title’ is vital as the latter is the critical identifier of the contents of the research we intend to publish. Title only comes up on search and so should be short, catchy and representative of the hypothesis. Abstracts and Conclusions are most read parts of a paper and should entice the reader to read the whole paper. Abstract is what comes up on Pubmed search and is the calling card of the research project. It is like a well decorated display window in a departmental store, if it is attractive then shoppers come inside the store and otherwise they move on to the next store! An abstract should entice the browser to read the complete paper and so is absolutely vital.

The style of writing should be simple with short paragraphs conveying a single idea with a sub-heading. Sub-titles / Sub-headings are important as they are critical to readability, critical for IMRAD structure, they introduce a new subject / idea and the reader is not lost in a long discussion, thus making the paper more readable. Judicious use of images, graphics and tables, properly placed in the text again helps the reader to understand the hypothesis. Printing space is at premium and so one should avoid excesses - excess data does not add intellectual worth and such data overload only baffles the mind; excessive tabulation and statistical wizardry should be avoided and excess colour is an irritant. The look of the page is important and brevity is vital – there is very little useful you can offer beyond 3000 words. Watson & Creeks’ landmark paper on ‘Structure of Nucleic Acid’ was written in 2 pages of ‘Nature’. Lastly one should submit the manuscript when it is ‘good enough’ and not wait for it to be ‘perfect’

Choosing our audience and journal according to our message is also of vital importance. What is the core message? Who needs to hear it? Is the message for local or regional or international dissemination? What is the best format? – Editorial, Review Article, Original Article, Letter to the Editor, Case Report, Ideas & Innovations? Which journal has audience for our message? This can be judged by reading the target journal’s aims, scopes instructions and guidelines and its past issues. Aiming for a high prestige journals is good as it has sound criticism and peer review and that improves the quality of the efferent article. But these journals have low acceptance rates.

Tackling reviewer is a very taxing and tactful part of paper writing. One should be patient and receptive. They are usually experts – been there done that too, they have spent valuable time to read our manuscript and they are trying to help. Good referees act like proxy guides and one should address their queries point-wise and make the alterations in the text in a different coloured font

Lastly claiming what is not true is immoral and can easily be picked up by experts and systems. Other author’s work / diagrams have to be acknowledged and permission obtained for reproducing in any form text can not be reproduced verbatim from a previous publication. Use of pronouns ‘I’, ‘my’ and ‘mine’ has no place in a surgical paper as surgery is a team game and by using plurals ‘we’, ‘us’ and ‘ours’ we are acknowledging the contribution of our team of doctors, nurses, therapists etc. even if the paper has a single author. Language and grammar are non-negotiable factors and help from others should be sought whenever one feels challenged.

We are today not teaching our residents to document properly and this is not only a reason of concern but a matter of shame. How long are we going to keep our heads buried in the sand and stay convinced that nothing is going wrong? To all  Karmyogi Surgeons who are of the opinion that their job is to do the surgery and writing papers is the job of some nerd, sitting in a cold country with no patient-load, I have a news: they may be the Shehenshahs, Badshahs, Emperrors and Kings of their own world of fiction, but the real world does not recognize them, does not know about them and will never come to know about their exploits lest they publish their work. Their vast clinical wealth will be lost in oblivion and posterity will refuse to accept their existence! And this exploitation of our clinical wealth and paying back nothing intellectually in return is a crime on posterity!

Publications are our footprints on the sand of time. While our surgical exploits can fetch us local fame our publications are our calling cards to the world. You have a choice to be in the elite league of Berni O’Brien, Joseph McCarthy, Converse, Graham Lister, Wayne Morrison and Ravin Thatte or you in far bigger and unknown team of Mr. Nobodies. The choice is yours!

HOW MANY TIMES HAVE YOU BEEN TURNED DOWN?

How many times have you been turned down? Is your answer ‘never’? Is it ‘very seldom’? Whether you are an entrepreneur or an employee if you haven’t been turned down many a times, you are not pushing hard, and you haven’t asked often enough! Undermining complacency and challenging the vision of the prevailing best is key to breaking newer frontiers, and these are unchartered roads with no known road signs and maps………so you will get turned down initially. But, if we are contented with the present status quo, too cautious to even question it, and far too late to act, then no matter how good we are today, we will surely fail tomorrow. Nokia was a market leader of mobile phones in the last decade………where is it today? Only they continue to enjoy success all their life, who keep struggling to achieve it.

Too many successful individuals and institutions worry too much about holding on to success when they know in their heart that with the effort that they are putting in, they have more to lose than to gain. That is when they get timid, stop trying new things and start worrying about their image and their appearance. Movie stars of the silver screen are perfect examples – those who were blessed with fathomless talent, may not have been heroes and heroines all their life, but were always raising the bar for themselves, went on to give memorable performances and ensured that their last performance was their best. Thus Sir Lawrence Oliver, Marlin Brando, Audrey Hepburn were geniuses till their last day, while many super-stars of yesteryears only succeeded in becoming cranky old men and women later in life, only to be forgotten with time. 

Feel free to question the norm, debate the usual. Those days are long gone when inflexible adherence to sacred cows was imperative and almost essential for homogeneity and team spirit. A team thrives on multiple inputs from its different members and gathering a bunch of men and women with ‘yes sir’ attitude surely kills the individuality of its members.  Individual brilliance can give a renewed impetus and breathe life into a failing purpose but the team must be receptive to the new ideas. If a leader wants to see his/her carbon copy in every member of his/her team and not encourage effervescence of originality, novelty, uniqueness and freshness, then this team will surely fail, no matter how talented the leader is. Do you think a team comprising of eleven Sachin Tendulkars would have been world champions?

Whether it is an individual or a corporate, or for that matter a country, there should be no confusion between strategy and plan. What we want to be as an individual or as a company or as a country is strategy, and how we become what we want to be is planning. Only enthusiasm does not impress anyone, enthusiasm coupled with a plan is what is required.  If we are failing to plan then we are planning to fail. Then again planning should be optimal and not so elaborate that it saps all the energy required to perform. You do not need to clear the Grand Central Station just to look at the train time table. Too much planning and too much analysis will only lead to paralysis. We have seen this happen in the past in our country. As Nike so correctly screams from every bill board ‘Just do it!’

Warren Buffet once observed: "there will never be a better you than you." That is a brilliant insight. There will never be a better me, than me. And there will never be a better you than you. Some might try to copy the way you think, speak and do. But - no matter how hard they try, they will only be a second best you. This is because you are unique, and that there really isn't any competition. Same is the state of a country. India need not be better than any other country, it simply has to be the best India we can imagine……..and for this we need a plan!

In this politically mundane, economically stagnant and socially volatile world everywhere people are looking for a new leader and a new team. It is too simple to say that antagonism to a particular religious group is adding fuel to the amber of xenophobia and encouraging right of centre politics. No, people are looking for leaders who can march out into a world, with a whole new team of doers, a whole new bunch of performers. These leaders may not have the intellect or the credential but they have the temperament, the persistence and the perseverance. History may have rejected them in the past, but their time has come. A team of people playing boldly with their lives more than ever before, people who are prepared to exert more of their hidden potential, and people who are prepared to take a chance and liberate more of their natural creativity, it is their time now. The political changes in the democratic world – the annihilation of the grand old Congress party by a compulsive workaholic with a track record of performance in a small Indian state, the referendum in favor of Brexit in U.K, the rise of the ultra right in Belgium, Austria, Germany and France and the battle which the over-confident and the provocative ringmaster is giving to the realist, the conventional and the well prepared, for the coveted post of U.S. Presidency…..they all fall in a pattern.

This change must inspire every one of us. The success of those who were once dumped as improbable should pack us with TNT of inspiration, enthusiasm, zeal and zest to take us to the crest of success, which till recently was the exclusive domain of those with privileged pedigree and proud heritage. So, back to my original question ‘How many times have you been turned down? ‘If your answer is ‘never’, bad luck……you have not pushed hard enough. Your time hasn’t come yet!

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.