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MY OBSERVATIONS ON THE CLINICAL PROFILE OF 2000 FEMALE PATIENTS FROM KONKAN WHOSE HUSBANDS WERE SERVING ABROAD
O P Kapoor
Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
0ver the last twenty-eight years of my practice, I have been lucky to have had a chance to serve the above populations, In most of the cases, the husband serving in one of the developing countries would visit home only once a year, in a few cases, once I , n two years (in the latter case, they came for a longer vacation. Of a month or two). In more than ~half the cases, the husband had been staying abroad for more than five years.More than ninety-nine per cent of the, patients have faithful husbands. Like a typical Indian, all of them were very much concerned about ft welfare of wife, children, parents (mother, father) and brothers and sisters. This extraordinary concern is perhaps responsible. For a few functional symptoms which ate more common this population. Many times, nine months after the visit of the husband, a child is born Thus majority of the women had two to three children to be looked after in the absence of their husbands. Nearly hundred per cent of these children were being given good education (husbands expected this, since they were working very hard for the uplift of the family). But the tension of the day-to-day problems is born only by one parent, the mother. Finally how much anxiety, tension, fear, insecurity these women underwent during the absence of their husbands has to be imagined and appreciated by any doctor treating them, not to mention, absence of company and sex life in the years of youth. Average age of these women is between 20 and 25 years. All of them were married at a young age and were Muslims.
Symptoms which are common to most of them are as follows:
a) Giddiness which when evaluated is due to tension and anxiety Some of the patients in this population complain of such severe giddiness that it has to be seen to be believed. A doctor not aware of their background would easily label this giddiness as of organic origin.
b) Migraine headaches, tension headaches or both are a very common presentation.
c) Chest pain due to chondritis is very common in this population. The underlying tension, fear and anxiety seem to keep it up and often they fail to respond to usual treatment.
d) The symptom to "ghabrahat" is an equivalent of "chest apprehension". It is so severe in these patients that the family doctor will surely think of an organic heart disease. Young inexperienced physicians and cardiologists also get convinced and search for a cause like an organic heart disease. "Mitral valve prolapse" syndrome is often diagnosed even in the absence of typical clinical findings because of the report of a 2D echocardiography. The announcement of this disease increases "ghabrahat".
e) Symptoms of gases and aerophagy are extremely common and related to tension.
f) Symptoms of peptic ulcer syndrome or nonulcer dyspepsia are extremely common and are present in majority of them. In fact, this is the single and perhaps the only organic diseases present in this population. Often I wonder whether it should be labelled organic. The fact is that endoscopy shows evidence of oesophagitis and gastritis. Not a single chronic duodenal ulcer is seen in this population. Although the symptoms and the severity of the findings do not correlate with each other, certainly there is response to anti-ulcer line of treatment. However some patients do not respond satisfactorily.
The most significant aetiological factor of this illness is the use of a tobacco paste known as "Masheeri". This is used by all of them and often more than three to four times a day. Whether this addiction is due to the anxiety and the tension of the husband being away, is difficult to guess. Though this is possible, most of them learn to live without this tobacco paste and get relief only after omitting it. Many however continue to use it early morning possibly to help their bowel evacuation. In fact, this tobacco paste mightalso have a role in the presentation of the next symptom which is very common in this population - this is "palpitations".
g) Dyspnoea on exertion is a very common complaint. In very few of them (less than 10 per cent) anaemia is responsible for it. In majority of them, no organic cause is detected and is possibly related to their sedentary life or to attract the attention of the family.
h) Weakness is a universal symptom and is invariably of "mental" origin. Nearly one third of these patients are underweight.
i) Low backache is a common complaint and does not respond to any treatment because it is psychogenic. Osteomalacia is rare in this population, because as compared to the other poor families, they can afford to drink milk and are often consuming multivitamin pills, sometimes brought by their husbands from abroad!
j) Though many of them have menstrual problems, surprisingly, leucorrhoea was less complained of than in a corresponding population of patients from UP in whom it is a universal complaint. How much lack of sex relations is responsible in this discrepancy is difficult to say. The latter may also be the explanation of the lower incidence of urethral syndrome in these women.
Management of these patients is very difficult. They (and their husbands when they come) have to be satisfied that they have no organic disease. Sympathetic attitude is required in the management. Understanding and solving family problems is more important than prescribing drugs. Discard the reports of 2D echocardiography showing mild mitral valve prolapse (often over reported and clinically not important) or the radiologist's report of the X-ray of the lumbar spine showing a disc disease! Pursuade them. To give up "Masheeri", improve the weight or anaemia if required. This is the best advice to the doctors treating such unfortunate patients who are sacrificing their youth in order to promote the welfare of their families.
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