THE FREEDOM FROM SICKNESS-SARVE SANTU NIRAMAYA

THE FLAG OF INDIAN ARMY MEDICAL CORPS: DULL CHERRY WAS THE COLOR OF THE ROYAL ARMY MEDICAL CORPS. SIGNIFIES POSITIVE HEALTH AND FREEDOM FROM SICKNESS. BLACK WAS THE COLOR OF INDIAN HOSPITAL CORPS. SYMBOLIC OF BIRTH AND DEATH. OLD GOLD WAS THE COLOR OF INDIAN MEDICAL SERVICES WHICH EXISTED BEFORE 1943. IT IS THE SYMBOL OF SUN GOD AESCULAPIUS, THE GOD OF MEDICINE. ARMY MEDICAL CORPS CAME INTO EXISTENCE ON JANUARY 26, 1950. 

SARVE SANTU NIRAMAYA: 

The motto of the Indian Army Medical Corps is “SARVE SANTU NIRAMAYA”. This is an idea expressed in ‘UPANISHADS’. The hymn appears as a benediction to invoke “PEACE” and hence is known as a ‘Shanti Mantra’.

POSITIVE HEALTH AND COMPREHENSIVE HEALTH CARE: 

The ideas of freedom from misery and sorrow and the state of happiness are clearly associated with freedom from sickness and the complete well-being of an individual.

Health is defined as ‘the state of complete physical, mental, and social well-being, and not merely the absence of disease’. The health care program must embrace all the three aspects of a disease; the preventive, the curative, and the restorative care of an individual. These three aspects of physical, mental, and social well-being are interrelated, interdependent and contiguous. The medical care should be ‘patient-centered’ rather than being ‘disease-centered’.

Comprehensive Health Care can be described as the health promotive, health preservative, preventive, curative, and restorative health care of all individuals, at all stages of life from conception to the grave, and in all spheres of life such as home, school, workplace and in the community.

In the Armed Forces, the medical practitioner gives attention to any condition considered responsible for the deterioration in health or likely to affect adversely the health, morale, and welfare of the personnel under his medical care. The Medical Officer in the Armed Forces not only promotes, preserves and protects the health, but also he periodically carries out an assessment of the environmental, living and working conditions of the personnel under his medical care.

The threats to human health and well-being come from several directions and tragically very healthy individuals may sometimes succumb to sickness and the causative factors of several diseases still remain a mystery. Cancer is one such disease that poses a challenge to our motto of achieving ‘freedom from sickness’. 

ONCOLOGY – THE STUDY OF NEOPLASMS: 

The word ‘Oncology’ is derived from the Greek word of mass which denotes a swelling or a new growth. New growth or neoplasm could be ‘benign’ or ‘malignant’. The ‘benign’ growths are relatively harmless and they may not invade other tissues of the body but can contribute to some functional impairment. The ‘malignant’ growths are dangerous to life as they tend to invade other tissues and spread to other distant sites in the body. Apart from this ‘invasiveness’, the malignant cells display uncontrolled growth and could cause a very rapid deterioration in the state of health of a victim.

The term ‘CANCER’ is used to describe a wide variety of malignant diseases. The factors involved in the causation of many of these diseases still remain unknown. Next to Heart Disease, Cancer is the most common cause of death. Cancers could be grouped into three major groups;1. the Carcinomas which arise in endodermal or ectodermal tissues known as epithelial tissues. Breast and Colon Cancers are well-known Carcinomas. 2. the Sarcomas are fleshy tumors, arise from mesodermal tissues, the connective tissues like bone, cartilage, and fat. Sarcomas of soft tissues constitute only 1 percent of all malignant tumors and they may occur at any location in the body. Roughly twenty different types of Sarcomas are described. 3. the Leukemias and the Lymphomas are derived from the blood cells and the cells of the Lymphatic system.

A fundamental principle of Cancer treatment is to establish the pathological nature of any growth suspected of being neoplastic before making decisions about its management. This usually involves a ‘BIOPSY’; taking a sample of the tissue from the suspected lesion and subject it to a microscopic examination and a histological evaluation to determine the nature of the tissue and the cell type involved. While an early diagnosis is very helpful, the survival of the victim mostly depends upon the nature of Cancer. 

TWO RARE CASES OF CANCER IN PERFECTLY HEALTHY INDIVIDUALS: 

I served as the Regimental Medical Officer at the Army Ordnance Corps Centre, Secunderabad, India from December 1978 to January 1984. I would like to narrate the stories about two individuals who served at the AOC Centre in great physical shape prior to becoming victims of Cancer.

The first case in 1979 involved Lieutenant Colonel D’ Souza, the Commanding Officer of No. 2 Training Battalion of the Centre. He was very tall, handsome, with a well-proportioned body built. He was picture-perfect and had no unhealthy habits like smoking. He walked into my office around 10.00 A.M. with a slight expression of concern on his face. He came to ask me about a pea-sized, painless swelling he had noticed on the gum pad of his left upper incisor tooth. The swelling was of very recent origin and could be easily noticed while brushing teeth. It looked reddish and there was no other discomfort caused by it.

I immediately diagnosed it as a neoplasm(new growth) as I could easily exclude all other possible conditions. He had perfectly healthy teeth and gums and had no other medical problems. The Military Hospital and the Military Dental Centre are at a short distance from the AOC Centre. I told him that I would not prefer to refer him to either of those two places. I told him that the only way to know the diagnosis of that tumor would be by getting a Biopsy report and the earliest way to obtain the Biopsy report would be from the Osmania General Hospital, Hyderabad which is a Post-Graduate Medical Institution that conducts medical research. The Military Hospital has no qualified Histopathologist and cannot provide the report that I wanted quickly.

He proceeded to Hyderabad and had undergone the Biopsy test as recommended by me. I remember Col.D’Souza and my meeting him at AOC Centre Medical Inspection Room. He returned to me with the report after two days. Col.D’ Souza fully understood the gravity of the situation and the report that he had in his hand. Apart from the Military Hospital, we had numerous Specialists in the twin cities of Hyderabad and Secunderabad. He never thought of asking anyone or consulting anyone about his illness. He trusted me because he knew that I was truly involved and concerned about his welfare.

The Biopsy Report suggested that the tumor was an ‘Angiosarcoma’, a very uncommon malignant neoplasm derived from the blood vessels, the vascular endothelial cells that line the inner walls of the blood vessels. It is also an extremely unusual
 presentation for this type of tumor. When we discussed the Biopsy Report, he was very calm, very well composed and took my advice without showing off any anxiety. I am very happy for having met a brave man like Col. D’ Souza. On the very same day, I arranged for his admission to the Military Hospital, Secunderabad and an immediate transfer to the Malignant Disease Treatment Centre in Pune. In spite of this early diagnosis and very prompt hospital admission and Cancer therapy, he did not survive and I missed seeing him again. 

The second story involved a very fine athlete who participates in several events both at the national level and at the International level and had won prizes. The top athletes who belong to the Army Ordnance Corps are usually posted at AOC Centre, Secunderabad and the Centre took great pride in having them there.

This had happened in the year 1983. This tall, well-built and muscular sportsman a Junior Commissioned Officer, noticed a painless swelling, about the size of a small orange, on his trunk, on the back near his waistline. He immediately reported his problem to his Battalion Commander at the Centre. The Battalion Commander wanted to get the swelling treated immediately and took this athlete direct to the Military Hospital and showed him to a Classified Surgical Specialist.

The Surgeon whom I knew personally, is a kind and compassionate person, soft-spoken and gentle in his attitude and bearing. This Surgical Specialist who was apparently preoccupied with his plans for retiring from military service somehow failed to arrive at a proper diagnosis. He misdiagnosed the swelling as a pyogenic abscess and immediately performed a minor surgical procedure called ‘incision and drainage’ to empty the contents of that swelling on the back. He made no attempt to send a sample specimen to the Hospital Laboratory to ascertain the nature of infection if any. The Surgical Specialist further prescribed a course of antibiotic injections for seven days and assured the athlete that the problem would be resolved.

The initial case management of this athlete provided no relief or benefit. The lump/swelling in the back was soft like an abscess but the clinical findings suggested that the lump was seated in the muscles and there was no reason to consider it to be of infectious origin. The patient had no underlying problems like Diabetes or infections like Tuberculosis, or poor nutrition or lack of personal hygiene that could have contributed to a pyogenic abscess. If it was an abscess, he still needed admission to the Hospital and a full evaluation of any underlying disease. In my view, it was incorrect to provide out-patient care.

It would be very exceptional for a healthy male adult to suffer from a large abscess. At the end of the 7-Days antibiotic treatment, the Surgical Specialist was gone and was not available for making an evaluation of the patient’s condition.

This fine athlete and his Battalion Commander came over to my residence in the evening to discuss his health problem. The Surgeon had earlier assured them that the swelling would go away and it was not so. The swelling not only reappeared after the surgery but also was growing in its size. When they walked into my living room and as I asked them to be seated, I could immediately recognize that the athlete was in great danger and that was an insight, an impression I got from his facial expression.

He briefly explained his story and the treatment as an outpatient at the Military Hospital. I examined the swelling on his back and could immediately diagnose it as a very serious case of a Cancer, a malignant tumor that had already invaded other tissues and had spread to the nearby lymph nodes. This Cancerous growth was in his back muscles and is often described as Rhabdomyosarcoma.

I was disappointed by the fact that a qualified Surgical Specialist holding the rank of a Lieutenant Colonel at the Military Hospital misdiagnosed the condition and had subjected this patient to unnecessary treatment. The diagnosis of Cancer was so apparent in this case, I did not need a Biopsy report to confirm it further.

I arranged for his admission to the Military Hospital and an immediate transfer to the Malignant Disease Treatment Centre at Pune. Within a few hours of time, after consultation at my home, this great athlete who was in the prime of his Sporting career boarded a train in Secunderabad on way to Pune for his Cancer treatment. Just like Col. D’ Souza, this Junior Commissioned Officer received my advice with a sense of calmness and I take pride in the fact that the Indian Army has brave and courageous people who receive news about life-threatening conditions with a sense of maturity and without the show of any anxiety. 

In both of these cases, I earnestly wished and hoped that they would survive and return to the Unit. Unfortunately, their Cancers were very aggressive in nature and the Cancer won this unfair battle during their initial course of treatment at MDTC, Pune. 

MY RECOMMENDATIONS TO INDIAN ARMY MEDICAL CORPS: 

I reviewed the Manual of Health for the Armed Forces-1968 Edition. Chapter VI – Assessment of Health and Hygiene in the Armed Forces and Chapter X- Health Care deal with the duties of Regimental Medical Officer. We should involve the Medical Officer to a fuller extent in case management. It should be mandatory for the Medical Officer to visit his Unit personnel who are admitted to a Hospital and enter a written report about the case management. The Unit Medical Officer should be officially informed when his patients are placed on ‘SERIOUSLY ILL LIST’ or ‘DANGEROUSLY ILL LIST’. This official notification should constitute the authority for the Medical Officer to visit his patients in the Hospital and if required to proceed on Temporary Duty to the Hospital.

The Medical Officer should be given additional training to provide psychological and grief counseling to his patients and to the immediate family members. The Medical Officer should be able to refer his patients and their family members for further appropriate psychological counseling. The rules for medical evacuation should be amended and we should authorize and provide qualified medical attendants to support the mental, and social well-being of individuals apart from providing routine curative care and management during the journey.

The Army Medical Corps is not a Charity providing Compassionate Care. We have a duty to provide the Health care that we provide and we need to express the spirit of our Motto through our actions. If there is no freedom from sickness and disease, we can still excel in providing mental comfort and social support to our patients and their immediate family members. Kindly share my concerns with others who may be serving in Uniform and Army Medical Corps should deliver in accordance with its Motto. If you have any questions, please contact me sharing your thoughts on this blog post: 

Bhaja Govindam: 

The Art of Diagnosis has no further value apart from knowing the nature of the threat faced by humans and there are several medical conditions where the outcome ultimately depends upon the nature of the underlying problem. However, knowing the reality is equally important and it helps us to face the consequences and in the end, the sweet name of ‘GOVINDA’ is the only consolation we have while preparing to lose the battle against Death. 

Freedom From Sickness. Sarve Santu Niramaya. 

Dr. R. Rudra Narasimham, 

Kurnool Medical College, Kurnool, Andhra Pradesh, India., 

M.B.B.S., Class of April 1970.