The Secret of diagnosis

The posting in Dermatology was one, as an Intern, I had looked forward to. The full name of the specialty was Dermatology, Venearology and Leprology. In addition to diseases of the skin, it dealt with sexually transmitted diseases and leprosy.

It was one of those cooler departments that an intern desperately looks forward to. I should add, with sleep-deprived, dark-circled eyes. The consultants were chilled out and – spiritual.

When we say that the orthopaedic surgeons are spiritual, we mean that generally speaking, they are interested in the leisure time imbibing of alcoholic spirits.

But here, I meant it literally. The professor, Dr. Rama Murthy, was particularly inclined to tangential ramblings of a spiritual and philosophical nature.

We started the first day with a class from the great man. We listened keenly. Rama Murthy was known to be an astute clinician. He had that mysterious knack for diagnosis.

Patients with difficult problems flocked to him. Other doctors sought his opinion.

He talked about common diseases that are usually treated by the specialty. He mentioned that sun exposure led to some problems of the skin.

The he looked up suddenly. He surveyed us interns with a sharp eye, like the sweep of a sharp sword. We cowered.

‘Does the sun have consciousness?’ he asked. Most of us looked back, perplexed. Neeko, an impulsive chap who is constitutionally incapable of silence when faced with bait like this, spoke up:

‘No, sir.’

‘Have you studied the problem in detail?’ Prof. Rama Murthy asked. ‘Did he confide in you?’

‘No, sir.’ Neeko gave up, reluctantly.

‘Hey, you – tell me. Do you think the sun has got consciousness?’ he demanded, pointing to me.

‘I don’t know, sir,’ I answered promptly. The response that came to my mind was: ‘I don’t bloody think so.’ But five years of medical education had taught me what to say and what not to.

The professor was pleased. He smiled broadly.

‘That is the correct answer. I congratulate you.’ He beamed. I beamed. Neeko scowled. Some laughed nervously.

Although our reactions were different, all of us were thinking the same thing: was the professor’s consciousness alright? Was he, to put it in plain speak, a nutcase?

The next patient walked into the OPD. He was smiling. He showed his forearm, which had a fading brown rash the size of a large leaf.

‘It is almost gone,’ he said. Rama Murthy turned to us. ‘What do you think it is?’

‘A fungal infection,’ I replied. We had two months of posting in Dermatology as undergraduates. Now I was an intern. I was supposed to know these things.

‘No. It is a vitamin deficiency. Niacin cures it, as you can see.’ He smiled.

After a few more patients, another one walked in, with a rash on the forearm that looked exactly similar to the one on the first patient. The professor looked up quizzically.

‘Niacin deficiency!’ I announced triumphantly. Rama Murthy looked at me with amusement.

‘It is a common fungal infection,’ he said.

‘But –’ I stammered.

‘Just imagine,’ he cut me off, ‘that you are staying in our hostel. You step outside at night to have a pee. You see the vague outline of an animal running away. Would you assume it to be a stray dog, or would you think it was a black panther?’

‘Er –a dog,’ I replied.

‘Exactly. Rare diagnoses are rarely correct. Niacin deficiency is rare. A fungal infection is common.’

I nodded obediently. Neeko piped up rebelliously.

‘Then how did you diagnose that rare condition?’

‘In the example that I told you, imagine that you had a powerful torch with you. You could use it to see the animal clearly. You could recognise it unmistakably as a black panther in the powerful light. Then?’

‘Where can we get the light, sir?’ Neeko persisted.

‘The light is diagnostic acumen. Common clinical sense. One gets it by keeping one’s eyes and ears open.’

‘Just that?’

‘Yes. For fifteen or twenty years,’ he said.

Another patient walked in, with a lot of tiny warts all over his body. It started as a prominent wart on his hand that had been there for a long time.

Suddenly he had an eruption in different parts of his body. Professor Rama Murthy took the patient to the procedure room and gave local anaesthesia to the wart in the hand.

Then he took an electrocautery and cauterised the wart.

‘The small burn will heal in a week,’ he told the patient.

‘But what about the other warts?’ he asked.

‘We will try pranic healing.’ Rama Murthy made the patient sit on a stool. Then he put his open palm over each wart, closed his eyes and seemed to concentrate intensely.

‘I am directing my “pranic” healing energies to each wart. Let us see. Come after one week.’

We decided that the professor, though brilliant, was a nut. He may not be an actual lunatic, but was definitely an eccentric. But then sanity was such a relative term.

Was I totally sane? Or was it an elaborate act? What if I became a brilliant clinician and diagnostician in the future, respected by many?

Society gives such people some leeway to act as they pleased, to an extent. It might free me from the social pressure to act normally. What would happen then? I shuddered at the thought.

The first week was interesting. Early in the second week, the wart man came back. All the warts had vanished. He was very happy. Rama Murthy had a sly smile.

‘The flies will get into your mouths,’ he said. Only then did we realise that all of our jaws were hanging open. Our eyes must have protruded impossibly, like in the comic books.

Professor Rama Murthy did not give any explanation. I decided to go to the library and read up on viral warts. Then I saw all.

Warts were a kind of viral infection. The first wart was called the ‘herald’ or the mother wart. Once you remove the mother wart, sometimes all the other warts disappeared spontaneously.

No one knew why. Warts were also one of those rare diseases that were occasionally cured by hypnosis, or strong suggestion. It had a peculiar mind-body impact.

‘I read everything about pranic healing yesterday. I still don’t understand how it worked,’ Neeko told me the next day. I felt a sneaky pride. I at least knew what to read.

A young man walked in and complained of recent hair loss. Hair loss was a common complaint in dermatology.

This man had early male pattern baldness. I felt sure about that. I stroked my own thinning pate. Rama Murthy examined him and asked him a few questions.

‘You had some major illness, about three and a half months back.’ Rama Murthy looked at the man. It was more a statement than a query.

The patient was astonished. We went into the mouth opening, eye bulging routine again.

‘How did you know that, sir? I had a severe attack of pneumonia and was hospitalised for a week,’ the young man said.

‘Clinical sixth sense,’ the professor said. But this time, I caught hold of the patient as he was walking out. Rama Murthy was busy with the next patient.

I had seen him look carefully at the patient’s nails.

The patient had a horizontal fine line on each of his nails. These lines were called Beaus’s lines. Whenever one had an episode of severe illness or stress, the nails will stop growing.

When they restart, it leaves behind a line of stagnant growth. The line slowly moves from the base of the nail to the apex.

If one knows the rate of growth of each nail, he can calculate the time before which the stress occurred.

A severe sudden stress can stop the hair follicles from growing, and convert a lot of them into resting phase. They will fall out a few months later. That explained the recent hair loss also.

Eighteen years later, I was sitting in my OPD. A patient came in. He had a swollen joint near the tip of his index finger. He had visited many doctors.

The orthopaedic surgeon had referred the case to me. My residents were watching.

I examined the joint. It was hyper mobile, but there was no pain. I felt the ulnar nerve at the back of the elbow. It was thick and cord-like.

There was a patch of lighter skin on his forearm, the size of a coin. I touched it with a pin. There was no pain.

‘We will send him to Dermatology. He probably has Leprosy. The joint is a ‘Charcot’s joint’. Joint changes due to loss of sensation,’ I told my junior doctors.

They were impressed. The patient will get the correct treatment. It was a curable disease.

Later that day, another patient came in. He had swelling in one of the fingers. Sunil, one of the resident doctors, was looking over my shoulder.

‘Leprosy?’ he asked.

I turned to him. ‘Suppose you were staying at the hostel. You stepped out at night for a pee –’

We doctors do seem wise sometimes. It is only an appearance handed down from one generation to another. One had to keep the eyes and ears open, however.

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