anonymous

12th November 2018

PHILOSOPHY OF MEDICINE - 3

PHILOSOPHY OF MEDICINE - 3

DR PRAFUL DESAI

"I have no problems at all and I have no complaints” said the mother, Ms Miriam, nearly 58, but in strapping good health before I could ask the story and before the brothers could begin to describe the emergency situation of the mother.

"The doctor had ordered an X-ray as mother had some cough and wheeze last week”, said the eldest of the brothers. "The report of the X-ray has left us in a daze and our doctor has stated we must immediately go to the Tata Memorial, and so here we are and we have brought her here with the greatest difficulty" said another brother. "Mother has never before seen a doctor in her life" said the third. The mother was blissfully unaware of the name of Tata Memorial and what the institution specialised in. This helps, though it is a rare event that an individual has not heard of the Tata Memorial. She was rustic, reared and grown in rural India, had an adoring family (husband deceased since) and was the apple of her children's eyes. Not surprising that she was quite unaware of the existence of the Tata Memorial. It sometimes make things easier for the patients and for us.

I waded through all important questions. The cough and wheeze were very transient for two or three days, devoid of fever or any other symptoms. The matriarch and five healthy offspring, had lived a very happy and healthy rural life, had no complaints of any sort referable to any body systems.

I asked for the X-ray which I hung up on the viewing box. The ray was very clear and precise. There were tell-tale spots of cancerous nodules in both lungs from 0.5 to 3 cms in size, dispersed evenly in Dom lung fields. An experienced doctor has to learn to suppress emotion during examination and wading through reports and x-rays, particularly in the presence of the patient or the relations. Betraying one’s emotions and expressions of sorrow or concern on one’s face at such a time strips the professional of one great attribute that patients seek in their doctors – confidence. If I deeply value after nearly 34 years in the profession one quality within myself which I can project to my patient adequately, it is confidence. In my presence, in my professional ability, in my overall demeanour and behaviour, bedside manners etc., I have tried hard to cultivate this for many years. I was 25 years younger then, but I believe 1 not express any concern or warning. I proceeded to see the X-rays in a detached manner and very objectively looked at other papers, scanned through the blood reports and then started the conversation. Something which I have learnt to do very carefully and deliberately in a few chosen words. With precision. Without any adjectives or hyperboles. Very matter of fact. Professionally. The truth. May be not the whole Truth. But no false hopes or stories. The patient and the relatives have a right to know. The facts. The problem, the decision and the solution. I strongly believe patients and relatives admire this and lend their total cooperation during the stressful period of difficult treatment procedures.

"Mother's X-ray of the lungs is rather abnormal. With a few shadows. They could be tuberculosis (there was no history) or a kind of blood infection (eosinophilia) or could be even spots of cancer. We have to make sure”, I said. "Since her general condition is as good as any of us here, there is not much cause for concern till we come to some conclusion. I will need to examine her first." I did not expect to unearth any dramatic finding on examination. In my mind were racing the possibilities I have stated above. She was extremely healthy, no contacts with tuberculosis, normal eosinophil count and the X-ray was indeed suggestive that a cancer from somewhere had spread and settled into the lungs. The only symptom was a short episode of cough, and wheeze which also had disappeared since. Where could the cancer have started? Breast, liver, kidneys, ovaries, thyroid - all common places where cancer can start without any symptoms

spread into the lungs. In the presence of a nurse, I examined her derully. There was nothing of note in the thyroid or the breast. The pelvis and the internal examination did not give a clue. The uterus, ovaries, were all normal and compatible with her age. We had no CT Scan or ultrasounds or MRI then and the only methods (and they can compare Temarkably well with the modern high-tech machines) available then were he ability to listen to the patient's story, carefully and painstakingly examine the patient with a caring hand while engaging them in a conversation (this art has now disappeared or is rapidly becoming extinct) and making a mental note of the findings. A wince on the patient's face can often tell you that the liver is enlarged and diseased. But let me cut that short. Going over her abdominal examination I was am thrilled to find an enlargement - a gross enlargement of the left kidney.Large, but mobile. Not tender. Without much ado, I completed the examination and felt elated at what I thought was a good clinical examination which often reaps rich rewards.

"Well, we need to do some more tests", I said. The kidney is slightly enlarged even though there are no symptoms referable to it Th. puzzle fits perfectly. A cancer of the kidney—asymptomatic into the lungs rare, but known. Some lead was established. In the next two days further X-rays-intravenous and ascending pyelography we call it-confirmed that indeed there was a mass in the kidney where cancer began and spread into the lungs.

Very rarely kidney cancers behave unpredictably. Removal of the offending mass can have a beneficial effect on cancer spread elsewhere bones, in lungs or elsewhere. Despite having no symptoms referable to kidney, I suggested that it may be good treatment to remove the organ to prevent future problem like pain, bleeding in the urine, spread to the parts etc. The rationale of the treatment I offered did not appeal to the family, even less to the mother.

"I have no trouble anywhere. I had only cough. What will I gain by operation on my abdomen? It will not help me. And now I have no cough either. I do not want any treatment". The mother pleaded with her sons: "I told you not to take me to the hospital. I have no problem. Let me go back to the village."

All my persuasive powers were reduced to nothing in front of the no-nonsense lady with a lot of native intelligence. It was difficult-nay, unwise--for me to suggest that removal of the offending kidney mass - very likely to be cancer—may hold a chance that the lung spots may resolve. This is known to happen in 1 in 5000 patients. I did not dare to suggest that.

Totally unsatisfied, the family left. The case remained in the files, incomplete in every sense; no proof of what I thought was indeed the problem. One more chart amongst the many when you don't know what is happening in the human system. However, that is the beauty of medical It is not a mathematical model.

We are sorry, doctor”, the brothers said, "but Mama has gone back to the village despite all our requests to have the operation”. She is probably wiser than all of us put together, I thought.

"We supply a lot of milk to the Aarey Colony. Nice, fresh buffalo's milk. Please call on us whenever you need our help - some party-etc. You know, good, healthy milk is not easily available these days!” the brothers said as they left. For many weeks thereafter, every Saturday morning their man would call on my home and deliver fresh 5 to 10 liters of milk, butter and many other goodies. Indirect professional

benefits.

On their last visit, they asked me what is likely to happen. I was young then. I said, rather confidently; "The cancer is likely to grow further in the kidney and the lungs. She will have cough again and when cancer

spreads in the lungs, life is usually measured in months, may be a year. If she ever agrees to come, if she develops symptoms, do bring her along”. Seven months later, when Ms Miriam had long faded away from memory and her case filed into the previous years' records, I suddenly saw the mother and her three sons sitting in the office. With an appointment. In good spirits. The mother looked perfect. May be healthier. A benevolent smile. I was keen to know what was happening. They had new X-rays. New hopes. New aspirations. The brothers were beaming and waiting to see me. I was more keen to see her. What had happened? A lady who had, I was sure, cancer spread in the lung coming after seven months with no sign of distress—in fact as healthy as her sons.

They trooped into the office, related how mother went away to the village, has had no problems at all! In fact the cough and spasms were gone. She worked more than ever before and came to Bombay for some ceremony and the brothers thought it would be a good idea to get a chest X-ray of the mother done and call on Dr Desai again. She came not for consultation but for a social chat!

In quick time I hung up the X-ray-a totally normal lung! The shadows of seven months ago were gone. I wanted to see the old X-ray-the brothers had it ready. It was unmistakable, clear even to the boys and the mother that the diseased spots seen in the previous X-rays were no longer seen! I was amazed, happy, surprised, elated. Are we dealing here with what is described as spontaneous regression of cancer? This happens once in 10,000 patients but is a well-described phenomenon. Body's own defence mechanism-call it immunity or call it resistance-very rarely overwhelms or destroys the cancerous process. Naturally, as before, she had no symptom at all! I could not wait to examine her for her kidney tumour which I palpated with such ease earlier. Surely it must have regressed (or disappeared) too? To my great surprise and happiness, the tumour was still present though smaller by more than 75 per cent. It took me some time to feel the tumour, which I did. I distinctly remember it was so easy to feel the tumour earlier on.

All what I surmised and diagnosed was at best speculation, of course, a good clinical diagnosis, yet I had no proof that she had a tumour which can be decided only by an operation of removal of the kidney and confirming it by microscopic pathology. I conveyed the happy news to the matriarch and her sons that, in fact, the tumour is smaller, but made a strong point that it had not disappeared and that it could possibly be a source of future problems. I was still hinting to them to have it removedby surgery for selfish academic reasons so that I could scientifically record such a case of spontaneous regression of a kidney cancer.

With my persuasion to the fore and in their moment of weakness they—the mother too - agreed for surgery. Of course, she argued the not even the cough and the wheeze of a few months ago and that it is good sense to operate when there is no problem. She was indeed right: nonetheless I wanted a complete case-file. I knew we could pilot her safely through a simple kidney operation. It could not harm her and would only do her good. The danger of such an operation going wrong is less than 2 per cent. The minimal risk was taken, surgery performed and a well-defined kidney cancer-proved by microscopy-was removed from Ms Miriam. She remained well till 1982—fourteen years after she destroyed her own lung cancer nodules and we removed her kidney cancer. The family has since moved away from Bombay and we have lost track of her. Yes, I have no microscopic proof that her lung nodules were also cancerous. However, those who have seen the X-rays—and many medical audiences have seen those X-rays—cannot but be convinced that they were cancerous nodules, regressing spontaneously due to the patient’s own defence mechanism on which we depend to ward off day-to-day

infections which threaten our lives.

This is a lesson to learn. The secrets of the human body and systems. How little we know and how much more there is learn. Realisation that Nature will not give away her secrets very easily. That we have a long way to go. A gentle reminder of Nature which says: "Man, be not proud of your achievements". And yet, human endeavour, in the years to come, slowly but steadily will unravel the mystery of Nature, and of Life and Death!