Letter from Mumbai

LANGUAGE TO BE USED IN MEDICAL COLLEGES

In earlier Letters, historical evidence from the 1840s onwards has been adduced to show that medicine is best taught in English.

Most states in India, Maharashtra included, teach children in vernacular languages in schools. This is felt necessary to spread literacy widely. Increasing facilities are being provided to tribal children and those from poor households to attend schools. An encouraging trend has been the focus on girls.

An unwelcome consequence has been the dismay among these children when they attend institutes offering higher education in subjects such as medicine and engineering. They struggle to understand and keep up with the curriculum. Repeated failures in mid-term tests and university examinations further demoralize them, especially when the student is inherently intelligent and hard-working.

The Seth Gordhandas Sunderdas Medical College in Mumbai and other institutes in the state are attempting to help such students.

Recently admitted students are evaluated on their competence in English. Those falling short are separated out and helped by teachers to familiarize them with the nuances of English and the understanding of medical terms. Help is also made available in the form of literary works, starting with the simplest, such as the daily newspapers and periodicals such as Readers’ Digest. They are assisted in using the dictionary and the thesaurus. Most students are familiar with the use of the internet. This competence is also utilized, the students being guided to tutorials on YouTube and films with English subtitles.

While medical teachers familiarize students with terms commonly used during lectures and in clinics and laboratories, teachers from other streams also help improve confidence in students and their abilities to converse among themselves, with their teachers and with patients. The help of generous professors of English in our arts colleges has also been sought. They hold sessions during weekends tailored to our purpose. Exercises are set during these sessions and the essays prepared by the students in response sympathetically analysed with constructive comments. Generating a competitive spirit in the student group has been seen to serve as a stimulus.

Familiarity with the written word enables medical students to prepare their own notes during lectures and in creative efforts such as writing essays, stories and poems.

Peer groups including those proficient in English are formed for more help. Students often find it easier to interact with them than with seniors.

Over time, such efforts, modified after obtaining feedback from students, will help ease the transition from education in vernacular language to that in the international language— English.

LATERAL THINKING ON CHRONIC SUBDURAL HAEMATOMAS

Chronic subdural haematomas remain a fascinating entity in neurosurgery. Their clinical presentations range from contralateral hemiparesis to dementia. In the days before the advent of computerized tomographic scanning (CT), it was not uncommon for the neophyte to be foxed till corrected by a wise and experienced senior colleague.

Treatment commonly consists of evacuation through burr holes. While this is simple in most cases, there are occasions when the young neurosurgeon nears exasperation as fresh collections of blood keep expanding the subdural cavity and compressing the underlying brain.

The practice of placing the patient in the head-low position for 24–36 hours after removing the clot often proved useful as gravity brought the brain closer to the dura and shrank the subdural cavity. The major drawback was that this position had to be maintained day and night. This caused discomfort especially during meals and when voiding urine and stools.

In some patients, excision of the parietal wall of the subdural membrane along with as much of the visceral wall as could be removed without damaging the underlying cortex proved effective. The disadvantage was the need for a large craniotomy for effective removal of the membrane.

Several studies were carried out in search of better treatment. Histological examination of the membranes that form around these clots provided a clue. A rich network of abnormal tiny arterioles and capillaries was detected in the membrane, the number of vessels being larger in older membranes. It was evident that this fragile neovasculature was bleeding into the cavity. Since these abnormal vessels are fed through the middle meningeal arteries, their occlusion through selective catheterization was successfully attempted.

Dr Sudheer Ambekar in Mumbai has been using a technique initiated in 2000¹ but not commonly used in India. He treated patients who had recurrent collections of blood into the subdural cavities but had no signs of cerebral compression.

At a recent medical conference in Mumbai he presented his results over the past few years. In each of his patients, the preembolization angiograms through the external carotid artery showed an extensive blush under the dura, demonstrating the abnormal vessels. Post-embolization films showed disappearance of the blush. His patients showed slow but progressive resolution of the subdural clots. CT three months after embolization showed total resolution with the cerebral cortex lying against the dura.

With increasing use of this minimally invasive form of treatment, we may see a disappearance of craniotomies to remove subdural membranes.

‘WHEN SEX IS A HEADACHE’²

Going through long-treasured reprints, I came across one with this fascinating title. The paper was written by the respected Australian neurologist, Dr James Lance (1926–2019). Migraines were of special interest to him. He preferred benign sex headache to coital cephalgia as it could also be brought on by masturbation.

He had provided a subtitle—Not funny but usually not serious. This took care of the ‘age-old avoidance ploy’. Instead, Dr Lance concentrated on the ‘severe, explosive headache at orgasm’ in individuals without any structural neurological lesion. Aware of the reaction that may follow a cursory glance at the title, he wrote: ‘Hearing of sex headaches may bring a smile to the lips of the uninformed, but they are anything but amusing to those who have experienced them.’

Since some of you may find it difficult to access the original text, I take the liberty of providing you the gist.

The abrupt, severe pain could raise the suspicion of subarachnoid haemorrhage—not unreasonably so as sexual intercourse precipitated the event in 6 of 50 cases of such haemorrhage in a published series.

Dr Lance provided clues that help differentiate the two. Benign sex headache starts off as a ‘dull, tight, or cramping sensation in the occipital region. This is probably related to excessive contraction of the head and neck muscles’. Conscious relaxation of these muscles relieves this sensation. ‘The second component, which may follow the first or arise without warning, occurs abruptly at the time of orgasm as a severe occipital or generalized ache, described as explosive or excruciating.’ The explanation for this thunderclap was obvious when the systolic blood pressure was found to have risen by 40–100 mmHg. ‘These increases are comparable with those during the paroxysmal headaches caused by phaeochromocytoma, which they closely resemble.’

His interest in medical history is evident in his answer to the question on whether physical exertion plays any part in these acute vascular headaches. ‘Hippocrates thought so, commenting that “one should be able to recognize those who have headaches from gymnastic exercises, or running, or walking, or hunting, or any other unreasonable labor, or from immoderate venery”.’

He reassured his anxious readers that if clinical features and findings in CT scans showed no abnormality, explanation and reassurance may be all that is required.

He did refer to a variant described by Paulson and Klawans.³ Their patients had postural headaches after coitus. These were brought on by standing and relieved by lying down. Lumbar puncture showed low cerebrospinal fluid pressure. With the benefit of hindsight, this would now be classified under intracranial hypotension.⁴ A search would be made for tear in the spinal leptomeninges and a blood clot used to patch it.

ON WHOM IS THE CHARACTER OF Dr ASOKE GUPTA IN SATYAJIT RAY’S Ganasatru BASED?

Released in 1989, this film made by Mr Satyajit Ray was based on Henrik Ibsen’s play An enemy of the people.

The story in the film can be briefly summarized. In a small town in Bengal, Dr Asoke Gupta (Soumitra Chatterjee) is the head of the local hospital. Dr Gupta shows that the holy water of the temple is contaminated by leakage of sewage into it, causing an epidemic. His brother Nisith, a powerful local politician and other town officials reject Dr Gupta’s suggestion that the temple be shut down and pipes repaired. All his efforts are sabotaged. He is proclaimed an enemy of the people.

Hans Gerhart Kohler (1915–2004), a retired consultant pathologist in Leeds, delved into the innards of Ibsen’s play. He found Dr Eduard Meissner (1785–1868)⁵ to be the model for Dr Stockmann, who, in turn, was the model for Dr Gupta. We are provided a brief biography of Dr Meissner, who was born in Dresden but grew up and studied medicine in Prague. He visited Berlin, schools in the Netherlands and travelled to London, where he was impressed with the care given to patients at Guy’s Hospital. He spent several weeks attending lectures and clinics in Edinburgh. On his return to Europe, he settled in the 1000-year-old spa town and health resort of Teplitz in north-west Bohemia. During the early 1830s, cholera spread through Europe. The Radzivills, a princely family from Poland and their vast entourage visited Teplitz. Meissner diagnosed cholera in a patient in the adjacent Jewish quarter, reported this to the authorities and demanded that the house be disinfected and isolated. The mayor browbeat Meissner and demanded that the diagnosis be changed as news on cholera would stop tourists visiting the spa and health resorts. Attending a lunch at the Radzivill residence, Meissner was asked of the risk of cholera. He disclosed details of the fatal case in the nearby home. The Radzivills left the city the next morning. As this news and the reason for their departure spread, the immediate future of the resort town looked bleak. Meissner became the most hated man in town. His house was damaged by mobs and the lives of his family were in jeopardy. The family eventually moved to Carlsbad and later Prague. Meissner’s story had a happy end. He died of renal failure aged 83, ‘the doyen of the medical fraternity of Prague’.

As Ibsen’s Dr Stockmann faced mob violence and humiliation, he made a statement that commands admiration, ‘Now, I am one of the strongest men in the whole world…The thing is, you see, that the strongest man in the world is the man who stands alone.’

The film should be of great interest to everyone in the field of medicine in India as it poses a crucial question—can a sincere, strongly motivated physician acting on behalf of the people be called a ganasatru? Can he eventually prevail?

Efforts are being made by the humanities division at the Seth Gordhandas Sunderdas Medical College in Mumbai to introduce the arts to our medical students and resident doctors.We were fortunate in having Mr Amrit Gangar as an invited speaker a couple of years ago. He is an acknowledged authority on Mr Satyajit Ray, having known him well. He charged us no fee. He decided to show us an interview with Mr Ray recorded on film, give us an introductory commentary on Ganasatru, and then screen the entire feature film. Imagine our dismay when the entire audience in the large Dr Jivraj Mehta auditorium consisted of just about 20 persons. The apathy was demoralizing. Mr Gangar took it in his stride. He consoled us, ‘Let us continue (with our efforts). Young students need to be told, cajoled, inspired at a time when Home is no longer a great school, Mother no longer a great teacher (as she herself is perhaps burdened with existential problems), School no longer a great crucible for learning, Teachers no longer the idealist and self-less givers...’