O Cancer! Where is thy claw?

CONQUEST OF DEATH 8

 “Doctor, my mother has a tumor in her breast,” said her son.

“Tumor?,” I asked.

“Yes,” she replied. 

“How old are you?” I asked the old lady.

“I am an illiterate peasant. For the last seven-eight years, I stopped my menses. So....,  may be I am fifty six, fifty eight. Well, you only judge.

“How did you notice it?”

While taking a bath”

“When did you first notice it”

“May be two-three years back,” interrupting me she said, “It does not pain, nor do I get a fever,  but for a few months it is ‘growing’"

“What have you done for that?,” I inquired.

“We are farmers staying in a remote village on the coastal line of the state of Maharashtra, India. We do not have good medical facilities, no x-ray machine, not even a laboratory for blood-testing. We took her to a lady doctor nearby, she gave her some medicines for a few days but the ‘tumour’ did not subside. She suspected a ‘growth’, so she recommended your name for medical advice,” replied her son.

I examined her. She had a tense, cystic, vascular swelling about eight to ten centimeters in diameter in her left breast. It was warm but non-tender. It was freely mobile. Lymph nodes in the axilla and in the neck were not enlarged.

To ease their anxiety, giving assurance to them, I said, “Your maa (mother) has a small ‘growth’ in her breast. Let us get her chest x-ray and blood reports done. Thereafter, we shall decide the plan of treatment. Okay?”

Breathing a sigh of relief, her son and daughter in law said, “Okay!”

Two days later, they brought me her reports. Her chest x-ray and blood reports were normal. 

“Maa, to remove this ‘growth’ you are required to undergo a small operation.” I told her.

“I shall be guided by your advice. I am willing for it,” she replied. 

“On the operation table, I shall put in a needle in the swelling and aspirate, if there is a clear fluid I shall remove the swelling, but if the blood is aspirated I shall remove the swelling and the whole breast,” I explained my plan to them.

“Whatever is required to be done, you do. We are willing to face it,” came the reply.

To begin with, I gave her local anesthesia. As per plan, I aspirated. It was blood. I showed her and her relatives the aspirated blood and took their consent for mastectomy (removal of the breast). I removed the breast and got the tissue tested. It was a ’non invasivecarcinoma in situ’ (an early cancer).

Since it was a very well localized, non invasive cancer and the lymph nodes were not enlarged, I did not give her radiotherapy or chemotherapy. For fifteen years, she attended my clinic for regular follow up.

Thereafter, she did not attend my clinic. Is she alive? Did she pass away? Who knows? I did not get any follow-up from her relatives either.

For fifteen years, she was symptom free, disease free and had no relapse of cancer.

Can I not say then, that at least for her, the dreadful, life threatening disease like cancer was ‘cured’?

Non- invasive cell

 There is another similar case that I encountered during my clinical practice.

Many years ago accompanied by husband, a lady visited my clinic. 

“Doctor, I have a small, hard lump in the left breast. It is not painful.”

“How did you notice it?” 

“For so many years, while bathing, I used to examine my breasts. About six to seven months ago, I felt a small nodule in the upper outer quadrant of my left breast. It was mobile at that time. Now it is increasing in size and becoming harder too,” she said.

“You are giving your case history so... accurately, what is your academic background?”

“S.S.C. (high school graduation exam). I wanted to go for graduation in chemistry but..”

I examined her. She had the lump that she described. The lymph nodes in the left axilla were enlarged, non tender, mobile.

“She is unnecessarily worried for the ‘growth’ to be ‘cancer’. Is this cancer, doctor?,” asked her husband.

“We will investigate.” I said.

Advanced investigations like ultrasound, CT, MRI scans etc. were not available in India then...

 

“Let us get her blood reports and chest x-ray done and then decide the plan for treatment,” I explained them.

Two days later, they brought her reports. They were normal. 

“Let us do a fine needle aspiration biopsy and according to the histopathology report, plan our treatment”

They agreed. I took tissue for biopsy. The report was positive. Cancer!

“She requires a radical operation, i.e. removal of the breast, the muscles and the axillary lymph nodes!”

“Go ahead,” they said.

I performed the surgery and got the tissues tested. The cancer was localized to the breast; the lymph nodes were free from the disease. I, therefore, did not advise radiotherapy or chemotherapy.

She used to come for follow-up regularly. I followed up this case for twenty years. She was symptom free. The cancer did not relapse nor did it spread.

She died of ‘heart attack’ but not of cancer!

Can I not say then at least in this case the cancer was ‘cured’?

Even today whenever doctors say ‘cancer is cured!’, they mean that a patient is symptom free or the cancer has not relapsed for a period of five years. In predicting the progress of a cancer patient, the doctors talk about ‘five-year survival rate’. Is breast cancer an exception then? Maybe some types of breast cancers are!! 

Today, worldwide, millions of women who were once victims of this insult but have taken treatment for it, are not only surviving for more than twenty five years, but are symptom-free, disease-free, show no signs of relapse and are living a very good quality of life!

                                          

May I say a bit more (too much?) in optimism though, no cancer is so trivial as to be ignored or neglected nor so severe as to be despaired of!

 

Tomorrow, with better understanding of the disease process underlying cancers, with the availability of better and safer surgical procedures, with the availability of cancer-specific, tissue targeted anti- cancer drugs with very few or practically no untoward effects or side effects, may be, may be, doctors will be able to say,

Mother Nature, we’ve understood your law

O Death! We’ve corrected our flaw

Tell us o cruel, killer cancer!

Where is thy crooked claw? 

A True Story in Real Life!!

A Drama in My Life!!

Tragedy of ‘Father of God’

CONQUEST OF DEATH 7
 

 “Stand erect…why are you bending?”

Said I to a young boy who came to me for consultation.

“Why should I stoop? I am ‘Father of God’! But when my son starts troubling me“

“Ignore his gestures doctor,” interrupted his father, and said “I hope you are not offended!”

“No, no go ahead” I said.

“He is a loquacious, mischievous boy! His name is John. Hence with a gesture and pride, he proclaims himself to be a ‘Father of God’!! For the last three, four days, he has pain in the stomach and fever” his father started narrating.

“Is the pain continuous or comes in throes?,” I interrupted and asked.

“It is more or less continuous, but sometimes very severe, and----”

“Does he vomit?” I interrupted and asked.

“Only twice he vomited”

“Is he constipated?”

“Yes”

“Did you give him purgatives, or massage his tummy?”

“No, no--- we gave a doctor’s medicines but in vain. Our doctor suggested your name for consultation. So here we are!”

I examined John and said, “John has a bad attack of appendicitis he requires an urgent operation”

“Well! What is required to be done should be done! We will be guided by your advice!” said John’s father.

I performed the operation. He had appendicular abscess. I could remove the appendix and drain the abscess. He had peritonitis. He was toxic. His post-operative care including selection of antibiotics and administration of intravenous fluids, administering of pain killer drugs, etc. was managed by a well known pediatrician and friend of mine, Dr. Jayant Karve. He took time to settle and recover. Thereafter, his progress was very good. He came to me for follow up for three months. He picked up good health.

Years later, one day early morning, my door-bell rang. My wife opened the door. John’s family was at the door. They introduced themselves. My wife let them in. His father and mother had brought him to me. They had traveled more or less forty kilometers to reach my house. 

“Did you recognize us doctor?” asked his father.

“Yes! Certainly yes!” I replied in a lean voice.

Seeing me on death bed, his parents could not contain their sentiments. They burst out in tears.

His father screamed, “Nnn nooo  doctor- nnnooo you savior of many patients, you can’t die!”

------ and there was a sudden restless hush in the room!!! 

After a while his father prayed aloud, “Jesus! Save our doctor. He can’t die”

To lighten the mood I said, “Why is John bending again?”

“Again he has developed stomach-pain!” Replied his father.

“He is developing intestinal obstruction! Take him to a hospital specialized for pediatric surgery as early as possible.”

“Please examine him doctor,” Requested his father.  

“Unfortunately I am unable to help you this time!” earnestly I was telling them.

“At least touch him once, even your touch can save him doctor!” ardently requested his father. I examined him perfunctorily and said, “Please take him to a specialty hospital.”

They went away.

I did worry about John’s condition for many days to come. However with lapse of time, the incident was forgotten.

I recovered from a life threatening illness and restarted my practice. One evening, unexpectedly this family came to my consulting room.

“Good evening. Come----come----come,” I greeted them. 

The absence of ‘Father of God’ was conspicuous.

“How is ‘Father of God’? Where is he?” I asked yearningly.

“He is in Heaven!” replied his father.

“Well! Gods revel in Heaven only” Said I in a lighter vein.

Suddenly there was a hush. There was a restless calm. The eyes of all the members of the family were brimming with tears. 

father broke the silence and said, “Nnnnoooo doctor, he is no more”

I recollected the incident long forgotten. I asked a bit annoyed, “Did you not take him to a specialty hospital?”

“We did! We followed your advice. The doctors gave him good treatment. The trouble was over. He had recovered very well.”

His father started narrating ----“We are grateful to you for saving his life again. We will never ever forget your obligations. We always remember you, more so when in need”

“I always help everyone if and when I can.”

“Indeed! You certainly do”

“You were telling about John,” I asked very anxiously.

“One evening, he went with his friend to a remote place for flying kites. Suddenly three, four adversaries of his friend arrived there, stabbed his friend repeatedly, cut his throat and slew the friend. Those boys bogged his slain friend in the quagmire in the vicinity. Perplexed, confused, John was dumbfounded. Because of fear, he could not shout for help. He was eye witness to the incident. Hence the boys threw John also in the quagmire. John was devoured alive by the mire!!!!!!

“We lodged police complaints in various police stations; we requested the fire brigade to assist us in his search, but in vain.

“The agitated, restless soul of ‘Father of God’ is crying for help. I can clearly read the SOS message on the ripples of the bog generated by the mute sentiments of the agitating soul of John ‘Father of God’ is gone for good, never ever to meet us--never to meet again----”

I sat mute in my chair in the consulting room. I could not contain my sentiments. I wiped my eyes and asked, “Did the story appear in the news paper? I think I read this!”

“It did,” Replied his mother” You don’t know doctor, how much sorrow and misery we are enduring in our life!” She was wiping her eyes. Pointing to a girl sitting beside her she said,” She is our daughter. Against all odds we are determined to make her a good, great doctor like you.”

“Great” I interrupted “Good? Yes! Noble? Certainly yes!”

“We have brought her to your feet. Please bless her”

Her daughter bowed to my feet.

“Your daughter is my daughter! I promise you, I shall teach her. She shall become a good, noble, great doctor. A thought crossed my mind, why me alone, the whole world shall sing a Song of Beauty

               
She is a lotus in mire,
A rose amid thorns,
A cactus in a desert,
A creation in derision,
A song of beauty
Born in adversity!!

A True Story in Real Life!!

A Drama in My Life!!

The Cloth Tourniquet

CONQUEST OF DEATH 6

As a corollary to the anecdote of “The Swollen Leg,” it would not be totally out of context to narrate an incident that happened in my family. My wife is from Pune, a city about three hours away from Mumbai in the State of Maharashtra, India. Her father became stable after having sustained a heart attack. He started his routine. To meet him and relax during the vacation, she went to Pune.

One day while on a routine walk, he suddenly developed cramps in his calf. He limped, somehow managed to come home. Anticipating a clot, but not knowing whether in the artery of the leg or in the vein, she fastened a cloth tourniquet above the level of the calf. The physician treating her father was called. 

Soon he came.

Seeing the tourniquet he asked, “Who fastened this?”

“I” Replied my wife.

Not knowing her relation to the patient in question, he asked, “What is your name doctor?”

“I am his daughter. I am not a doctor, my husband is! He is a surgeon. I have heard him teach his students: ‘sudden pain in the calf muscles while walking is claudication.  It can be due to a clot. The clot can be in the artery or in the vein. If the clot slips and enters into general circulation, the complications can be horrendous.’ So to avert a debacle, I fastened it!” she replied.

“Brilliant prudence! By giving important first aid, you have certainly averted a life threatening debacle. Not all house wives of surgeons are curious enough and possess a sense of presence of mind! Kudos to you!!,” the attending physician lauded my wife. 

“Let us shift you to a well equipped hospital and take a vascular surgeon’s opinion” said the physician, to my father in law.

“Well, we will be guided by your advice.” He replied.

My father in law was shifted to a hospital. Soon a vascular surgeon was consulted. He assessed the case and came to the conclusion that the clot was in the important artery of the leg.

So he advised an operation for removal of the clot. He and all the relatives around agreed.

The operation was successful. My father in law’s recovery was uneventful.

There is a well-known saying: “Behind every successful man there is a woman”

I beg to modify it and say, juxtaposition to a man, however successful, there is a woman!!

A True Story in Real Life!!

A Drama in My Life!!         

  

The swollen leg

CONQUEST OF DEATH 5

“Do you perform fibrin degradation products or D-Dimer test?,” I asked a pathologist friend of mine.

“Not in my laboratory, but I can get it done” He replied.

“In which laboratory can I get it done urgently?”

“I can arrange to get it done urgently for you! What is the problem?”

“A middle aged lady, traveled from the U.S. to Mumbai. She was sitting in the plane for a long time. Now she has developed ‘white leg’. I suspect deep vein thrombosis. I got her Doppler sonography done. It is not very conclusive. So I thought of laboratory evidence to prove----”

“Searching for proof, you are wasting a valuable time,” he interrupted me, “No laboratory test is a cent percent proof. There are some false positives and some false negatives. Clinical evidence is also an evidence. In some quasi emergency situations like the one you have encountered now, it is better to depend on your clinical judgment.

“When you were a house surgeon, you used to advise such a patient ‘bed rest with elevation of his leg’, give perfunctory treatment with antibiotics and some so called clot dissolving drugs and wait for  nature to heal. Many patients would improve. But remember you have witnessed ‘white leg’ (phlegmesia alba dolens) turn ‘black leg’ (phlegmesia cerulea dolens), venous gangrene??

“As a surgical registrar, you had better drugs to treat such patients. But those measures had an intrinsic threat of embolization, rarely though patients have died!

“Time has changed now! Today intensive care units can manage such patients better. Instead of wasting time in proving your diagnosis, admitting the patient thereafter into a comparatively under equipped hospital and managing her, better admit her right away into a hospital with a well equipped ICU attached!”

“Thanks for your genuine, honest advice for the well being of the patient,” I said.

I admitted the patient into an ICU. The doctors in charge managed the patient very well. Her recovery was uneventful. A debacle was averted! 

Was it not prudent on my part then to shun my ego and boast of managing a life threatening case and take the credit of saving a life than to obey my friend’s genuine, patient friendly advice?

May I modify a well known Sanskrit saying ‘शिष्यात् इच्छेत पराजयं’ (wish your disciple or pupil to defeat you!), and say ‘मित्रात् इच्छेत पराजयं’!! (wish your friend to defeat you!!)

A True Story in Real Life

A Drama in my Life!