LEWIN: EXPEDITIONS DRIVE CLINICAL RESEARCH 
535 
mine-like drug to reverse muscle weakness resulting from myasthenia gi'avis [22-24] and in the 
1970s radioaclively labeled cobra and krait toxins were used to show that myasthenia gi'avis was a 
disorder of the acetylcholine receptor [25-27]. Baneijee first reported using intravenous neostig¬ 
mine to reverse snakebite induced paralysis in 1972 [28] and 20 years later Sghirlanzoni and col¬ 
leagues reported the safe use of nasal spray neostigmine in the treatment of myasthenia gravis [12]. 
The connections were not obvious — very different fields of medicine and science, but much to my 
surprise, it was all there — the final piece of the first puzzle being whether nasal spray neostigmine 
could reverse pai'alysis in the type of experiment Tom Heier and John Feiner had designed to look 
at perioperative complications related to the type of pai*alysis used in the operating theater [14]. 
On April 5^i\ after considerable planning and rehearsal, the experiment was performed at 
UCSF in an intensely monitored setting. The subject was slowly infused with mivacurium until sta¬ 
ble clinical and electrophysio logical deficits were established. 115 minutes after starting the infu¬ 
sion, the nasal spray neostigmine was administered with mivacurium being infused at a constant 
rate such that the only explanation for the subject’s rapid return of muscle function was the nasal 
spray’s effect. As described by Dr. Lance Montauk, one of four physicians present, “the effect was 
so quick and obvious we didn’t even need to measure it.” But, of course, we did [9]. 
To this point, the project was completely un-ftmded — eveiything the product of my and my 
friends’ efforts during our own time. For me, though, it was already a full time job. From the day 
the experiment was approved, I closed my practice to all but neighborhood patients and occasion¬ 
al house calls. The day after the experiment, I started analyzing and writing the data. By coinci¬ 
dence, I had been invited to be one of the keynote speakers at the American Physician Scientist 
Association meeting in Chicago at the end of April. The invitation had come long before the idea 
for a needle-free snakebite treatment matured in my mind, but presented a gi'eat opportunity to dis¬ 
cuss it in front of a knowledgeable audience and see how it would be received. Importantly, now 
that we had data, I could realistically start looking for a collaborator and funding. What better place 
than in front of a large gi*oup of physician scientists? Even so, the manuscript was only submitted 
and not accepted, so I was a little nervous about putting this idea out in the open. Jeriy Harrison, 
who has been the Godfather of the project — details of how and why are outside the scope of this 
version of the story — encouraged me to speak about it and just a few hours before my lecture 
I did end up changing the entire talk to gear it toward the idea of a nasal spray for the early treat¬ 
ment of a broad range of neurotoxic venoms. His main argument was that I had had this idea so 
tightly held for so long that I should just get it off my chest and who knows who might be in the 
audience? In fact, the second part of tlie argument was prescient. Dr. Stephen Samuel of Trinity 
College Dublin, Ireland and a native of Tamil Nadu, India was in the audience. The talk was well 
received and he approached me afterwards to ask some questions and make some comments, 
including that he was jet-lagged and had come to the talk to force himselfout of that state. After 
several hours- of discussion, it seemed pretty certain that we had a serious collaboration in the 
works. From a chance meeting on April 27 ^^^ agreed to meet in India in June. I went to work 
raising funds for the trip and Stephen, in a flurry of unbelievable activity and coordination, 
arranged for us to use a certified animal lab in Hyderabad to perform mouse experiments — includ¬ 
ing all protocol approvals — and reestablished contact with a schoolmate, Dr. C. Soundara Raj, 
from medical school whose specialty is the treatment of snakebites and poisonings. Dr. Soundara 
Raj was a senior student at PSG Medical College when Dr. Samuel was a junior student. Stephen 
immigrated to Ireland for post-graduate studies and Dr. Soundara Raj returned to his hometown of 
Krishnagiri to found his own hospital, TCR Multispecialty Hospital. The motto of TCR Multispe¬ 
cialty Hospital is, “No patient should die from snakebite.” Prior to performing the animal experi¬ 
ments in Hyderabad, I spent two weeks as an observer at TCR and was — and remain — tmly 
