Late in the afternoon one day in the seventh month, in the year 1147. Falma was about to head off to college from a pharmacy but accidentally bumped into a boy that was pushing a cart across the pharmacy. The boy slipped and fell over, and the cart was tilted with part of the carrying load turned over.
“Well now! Look where you’re going you fucking kid! … Geh!“
The boy yelled at the other person without looking closely, and he discovered that the person was the owner of a different world pharmacy.
“Avoid using such words, you rude person!“
The knight acting as the gatekeeper of the pharmacy is stunned, but Falma calms the knight down.
“No, it’s my fault. I was certainly because of my carelessness, and it was my bad. Are you injured?“
“More than that, my load!“
The boy mentioned his loss to Falma as Falma observe the cart that the boy was pushing, and the impact of a collision caused the neatly oriented bottles of milk meant for sale to spill.
“Aah, I have to compensate for this.“
Falma and the boy knew each other a little bit. The boy sold milk on the streets of the Imperial City early each the morning, and Falma noticed the boy always appeared to be tired as he passed by when Falma took his lunch break. Falma saw him went by from time to time.
“That’s right, this needs compensation!“
The boy checked the load and shouted after he got up. The boy is around the same age as Falma, a commoner in a poor situation.
(From the look of it, this child lost weight quite sudden. I wonder if he hasn’t enough eaten enough for his meals.)
Falma got straighten his inner clothing around his neck while looking at the boy standing in front of him.
“I didn’t mean to make fun of you. To apologize for the collision, I’ll buy them all.“
Falma took out his wallet and tried to reimburse the goods.
“Anyway, are you throw it away!?“
“No. I’m drinking it.“
“…Does the noble of the court pharmacist drinking milk?“
Falma replied nicely to the boy that was instigating him so that the gatekeeper could not hear.
“I’ll drink it. You’re going to drink it too, right?“
Falma comes with the idea of eating it with cereal.
“This is sour.“
“It’s really is. Well good, I’ll make yogurt.“
Falma didn’t exchange any word about buying the milk and he bought all the milk that was in the cart. Falma gave the entire content of his wallet as an exchange instead. The content of Falma’s wallet contained several years’ worth of the boy’s annual income.
“I don’t need the change.“
“Aah!? You’re playing around me! Can I receive this doctor!“
The boy is already in an argumentative stance. Falma wondered if there was any good reason he’s like this while observing the boy rubbing torn pants.
“This is because your clothes were torn and you’re in need of new clothes. And if you pay attention to your hygiene, your sales will also increase. It’s for your extra care, though.“
“It’s for my extra care!“
“What’s the fuss? Falma, what are you arguing about?“
Ellen heard a loud voice and went out to remediate the situation.
“I just bought milk.“
It’s not a quarrel between children, so to speak, and Falma finds out that the boy is still a child. In the end, the boy pulled out the amount to cover the cost from Falma’s wallet and threw the rest back the pharmacy before he went home.
For a few days after, Falma watches the boy that’s selling milk passes by outside the pharmacy and purchases the milk each time.
Pharma watches a milk-selling boy pass by outside the pharmacy,
I stopped and bought milk each time. But, he doesn’t show up this day.
“He’s a bit late today.“
“That milk-selling boy, right? I’ll watch the street for him.”
Lotte also lends a helping hand. The boy that passed by the pharmacy last time finally arrive at the pharmacy, and Lottes goes in to call for Falma.
“Falma-sama! He’s here! I told him to wait! I’ll buy the milk ~!“
When Falma approaches the boy to buy the milk, the boy is visibly depressed.
“…Oh it’s you again.“
The boy is much more slender than a few days ago. Falma becomes more worried about the sudden change in the boy.
“You’re late. Why don’t you take a few days off from work? You appeared to be sick.”
Falma is concerned for the boy while buying and paying for the milk.
“Aah…I’m thirsty, and I feel sick. I can’t touch the items for sale.“
“Yes. I’ll give you water, and I’ll take that empty bottle.“
Falma washes the empty milk bottle and now fills it with divine water, and chills the filled water to hand to the boy. He mutters and drinks the water.
“Do you still want to drink?“
After two bottle worth, Falma observes the boy as he’s drinking his third one.
“I can’t help feeling thirsty all day today.“
“Isn’t that weird? It’s not hot today.“
(He’s dehydrated…his breathing is odd.)
He has abnormally deep breathing as he continues to breath regularly. Falma has a bad feeling.
(Inhalation is better, longer than exhalation…Isn’t this Kussmaul breathing[1]?)
This is unusual. Falma feels suspicious of the situation and uses [Diagnose Eye]. Then, the boy’s entire body fluid is glowing blue.
(What is this!?)
Falma is gasping at the serious condition as soon as he observes the conditional state. Even though there s dehydration, however, that alone cannot explain it. Smelling the scent from the boy’s sigh, there is a unique fruity odor. There’s also abnormal breathing along with the breathing. .
” ‘Diabetic ketoacidosis’ ” [2]
There was a reaction.
Diabetic ketoacidosis (DKA) is acidosis (a complication that makes the blood acidic) caused by a deficiency of insulin, the only hormone that lowers blood sugar (which promotes the blood sugar into tissues). When insulin deficiency occurred the blood sugar level in the blood rises because it cannot be transferred into the organs, as each organ becomes starved due to lack of energy, then the body breaks down the muscles attempting to obtain the necessary energy. As a result, the ketone bodies, which are metabolites of proteins and lipids, increase in the blood (or known as ketosis as in the keto diet), the pH of arterial blood tends to be acidic.
(It means that you are progressing to ketoacidosis!)
” ‘Type 1 diabetes’ “
It was a hit.
Type 2 diabetes progresses gradually, so it is not likely to develop into ketoacidosis. But in type 1 diabetes, it can progress rapidly due to the lack of insulin secretion. By the way, Type 1 diabetes is different from Type 2 diabetes due to lifestyle-related factors.
It is caused by the breakdown of autoimmunity. Therefore, it develops in both the wealthy and the poor. Regarding the onset of Type 1 diabetes, it’s not the fault of the person.
In Japan, diabetes is often misunderstood as a lifestyle-related disease, and Falma recalls the patients around him occasionally suffering from the misunderstandings.
(In erasing the ketone bodies…I may be able to do it.)
All ketone bodies are simple compounds. It can be erased by Falmama. Falma can improve the body of ketoacidosis by erasing all the ketone bodies in the boy’s body with his erasing ability. But, his body is absolutely deficient in insulin, and using the ketone body for nourishment, not sugar. If the ketone body is rapidly erased, he may fall into a coma. Falma couldn’t get rid of that concern, and for temporary first aid, he erased some of the ketone bodies — that is, he’s using the ability to eliminate the acetone not being used for metabolism. This should calm down the condition is a little.
“What is Type 1 diabetes?“
Ellen listens to Falma. The patient appears not to hear what being said.
“Falma-kun may be intuitive if you observe he patient. How do we find it?“
“Ketoacidosis can be detectedby Ellen and others if you are tested. It’s a poor method to use pH testing paper and prick your fingertips with a needle to measure the pH of the blood.“
There is also a way to measure the blood sugar level, but it has not been put to practical use in this world yet.
“What a mess…“
“He needs to be hospitalized immediate! It’s a serious illness.“
Falma begins to to persuade the boy.
“What? If I go home and sleep it off, I’ll be fine…“
The boy tried to respond something back, but Falma screams at him.
“…No, you’ll die! Ketoacidosis is occurring in your body. In other words, your blood is becoming acidic.“
The boy was obliviousvacant, so Falma’s sense of crisis rages.
“Like milk becomes yogurt?“
“Correct dead-on.“
“I don’t like it, and I wonder if I can sprinkle expensive medicine so easily!“
The boy was trying his best to refuse.
“The charge for the treatment’s fee is 3 bottles of milk! I’m not taking more than than, and there will be a written agreement!“
Falma wrote the agreement and shown it to the wary boy.
“Damn, I can’t read what was written.“
When Cedric hears it, he reads out his contract.
“In accordance to what it indicated, the medical fee charged to the patient is three bottles of milk, and the pharmacy will bear all additional costs without charging any extra cost to the patient. The agreement was formalized with the seal of the pharmacy. It becomes validated when you sign.“
“Shii~, I can’t believe it. I’m signing it! You have the confidence to cure it, right? Doctor, ya tell me alright!“
“What do you know about Falma?“
Instead of getting angry, Ellen frowns at him.
“I don’t care what you know, as long as this illness is cured. When is cured, the symptoms can be relieved. By the way, you’ll really die in a few more days. You do not want to leave untreated! Do you want to die?“
“Oh~, oh…“
“Then you’re going to be hospitalized! You just barely able to stand like that at the moment!“
Falma received the consent, but is it too late? He moves about and takes him to the treatment room upstairs.
“Falma-kun was observant.“
Ellen’s glasses slipped.
“I’ve never seen Falma screamed. Really, is it that urgent?“
Cedric mutters while preparing the documents.
In the treatment room on the second floor
After the boy weighs his height and weight
He was lying in bed and rampaging.
During that time, Pharma calculated the plasma osmolality based on the results of eye examination and estimated the estimated dehydration amount.
He completes all the necessary calculations for fluid correction.
“Release me! I didn’t ask you to stick a needle in me! I don’t want what you’re doing to me!! I can’t believe the pharmacist at all!“
“I see, but it’s dangerous if this child goes wild so keep him restrained.“
Falma called on Roger for a man’s (strength) assistance.
“It’s just an infusion. It’s harmless.“
Born in Nedale, Roger is a young pharmacist working part-time job and a type that uses his muscles to solve problems.
“Falma-kun, what in the infusion?“
Ellen prepares the infusion solution. Falma is ready in using the prepared solution into several packaged IVs.
“0.9% saline. Take your time since it’s going to be about 2 hours. After that, it’s reduced to 0.45%. Afterward, I will supplement it with potassium as appropriate while examining his condition.“
“If I die, I’ll turn into a demon and curse you guys!“
As the boy is waving his left hand in his rampaging, Falma speculates that is the boy’s dominant hand.
“His dominant hand is on the left. I’ll insert the needle on his right hand.“
After wrapping a rubber band around the boy’s arm, he inserts an indwelling needle into the boy’s right hand. Attached to the indwelling needle is an extension tube with the dripper.
“Isn’t it necessary for the flow velocity to be fast? It’s better to eliminate acidosis as soon as possible.“
Ellen’s question was logical.
“It’s likely to be better in speeding things up when you’re dehydrated, but the rapid rate can cause cerebral edema[3]. You have to be careful and manage it properly.“
Since the sudden correction of acidosis and lowering of blood sugar can cause cerebral edema, Falma added to the explanation while recalling that sodium bicarbonate should not be used for corrective method. Children are especially prone to cerebral edema, resolve the dehydration issue first, follow by the insulin administration.[4]
“Death with a swollen brain, that will be the day.“
Falma, Ellen, and Roger discuss about the infusion.
When the needle was inserted into the boy, the three pharmacists tightly packed beside his bed.
“Don’t let him pull out the needle. He’s be hospitalized today, no, he’ll be hospitalized for about two weeks. If he doesn’t have a parent or someone to contact with, please let me know because I’ll be the one to contact them on behalf of the pharmacy.“
“This will be left only to the high official.“
“Alright.“
Falma sent a messenger to the high official in requesting for the boy’s address, and to inform the official about the boy’s medical condition along with the long term hospitalization.
“Falma-kun. The drug for Type 1 diabetes was…insulin. When ketoacidosis begins to improve, shouldn’t it also be administered?“
Ellen inquires with Falma’s textbook in one hand.
“Aah, yes … that’s right.“
Pharma nods, but response is loud and clear.
“Maybe, and is there any insulin?“
Ellen’s face turned pale.
(…Finally, is it time?)
Falma clasps his fist tightly.
“I can’t say there isn’t any, and there is some speaking of which.“
“Which one is it then?“
“There are several doses, but it’s not enough. However, it doesn’t mean it’s something you can’t make right away…“
Yes, insulin is a drug that cannot be created simply by Falma’s ability [Create Substance].
Historically, insulin preparations have been purified from pigs and cattle for practical uses[5]. However, historical early extraction method and the refinement technology was immature in creating the unstable volume, and when it was administered to patients, it caused severe allergies. The research equipment in Falma’s laboratory for extraction purposes is is no different than that from the early modern period, and he cannot be overconfident in the refining technology. It would be too late to search for cows and pigs to grind them up readily. Also, when it comes to continuous extraction, not even once where Falma is out of options. It is not impossible to genetically engineer Escherichia coli and the like to synthesize a large amount of insulin and use the reagents he brought back from a laboratory from the other world. Even if the sequence of production is known, it will take several days. If you don’t know the synthesizing sequence, this method cannot be used.
He needs insulin now.
“Insulin is not a simple compound.”
“It’s just a protein though.“
Ellen opens Falma’s textbook and shows the amino acid term to the part-time pharmacists. For a general overview, it is. The two part-time pharmacists finished prescribing the patients in the pharmacy and came up to the treatment room.
“Yes. This is an amino acid used in the human body.“
Falma has a grimacing face while looking at the list.
“Proteins use each of these amino acids, where a string of beads in a fixed order consists of peptides. Simply put, it’s a protein if you connect amino acids in a fixed sequence and fold it…“
Falma explained to the pharmacists and Ellen kept on talking. Ellen reads a lot of his textbooks while learning things by herself.
“The problem is that sequence. Do you know the order of insulin?“
There are dozens of insulin amino acid sequences. As expected, Falma couldn’t remember the complete sequence.
(It’s gotten a bit sidetracked, but I should have analyzed the sequence even if the DNP was able to reproduce by the structural analysis done by Sanger.)
It’s too late to regret it.
“I don’t remember.“
Falma frowns as he touches his forehead.
(If I can go to the laboratory again, I can check the insulin sequence, but…)
It’s a waste of time right now to visit the laboratory in a different world behind the sacred spring.
“I wonder if there is any way to know the sequence. Insulin may not be visible under a microscope.“
Falma sudden notices it after Ellen’s statement.
“However…I may be able to comprehend it. Just a moment.“
Thank you for the hint, Ellen! Falma shouted and darted out of the room.
Falma runs up to the laboratory on the 4th floor. Thanks to Ellen, he was inspired. When Falma visited a laboratory in another world, he brought back only one vial of insulin with a number of reagents. However, it was just one. If he administers it several times, it will all be gone. If insulin cannot be synthesized within a few days, the boy dies.
The insulin vial was removed among the reagent storage in the laboratory on the 4th floor. Falma rolls up his lab coat to reveal the bandaged arm, and he removes the divine seal given by Salomon. If he doesn’t fully open his abilities, he will not be able to find it.
“I see it!“
He uses his special abilities that he hasn’t been using for a long time now. The ring formed on his right hand can be used as [Magnifying Vision] when activated for observing the object, and he directly observes the amino acid sequence of insulin with his own eyes. He feels as if this is pretty absurd, since it can’t be done without an atomic microscope to perform the structural analysis similar to an x-ray of the atomic structure. There is a threshold of the maximum magnification that can be reached, but here, it can be magnified by means of an optical microscope (aka the fingers’ ring).
“It’s observable!“
Falma reads amino acids one by one, and he started writing the sequence in his notebook. It may sound easy, but even when you can read it, there are exceptions to the identifiable structurals, but some amino acid sequences are very similar and are almost indistinguishable to the naked eye. So he uses the dinitrophenolation method to label only the leading amino acid and then combines with [Remove Substance] to guess by connecting the eliminated ones, similar in solving a puzzle through the decided arrangement. And finally, he confirmed the synthesizing of the insulin was successful through [Erase Substance] and compilation of amino acid sequences.
Falma came down from the lab about an hour later.
“I’m done…this here is insulin.“
“There is so much! How did you manage to synthesize it?“
“In principle, through the peptide solid phase synthesis method…In other words, affixing one amino acid at a time until I achieve the result.“
“But you made it in a different way than the mentioned.“
It’s all due to the medicinal crest on his arm that can be seen through from under the lab coat, which Salomon had seal it before. Ellen suspects that Falma used the power of the medicine god. He appears to have forgotten to put the seal back.
“Because it’s urgent. I thought I’d run out of concentration and die as a result.“
“I can tell that it was not a small task. Your eyes are bloodshot, Falma-kun.“
Ellen pointed at Falma.
“Good work.“
Lotte gently hands over a steamed towel to Falma, as she has been waiting for him at the corner of the room during the intense verbal exchange with all the pharmacists. While being thankful in his eyes, Falma only had one thought in his heart.
(I have to use that after all.)
For this time, it was all good because there were dozens of amino acids connected by peptide bonds, and Falma has no long term concentration to deal with hundreds of sequences. On top of that, there could have been mistakes. The way how Falma sweated just now, there is something that cannot be done so easily…
(Since there is no chemical synthesis, we have to proceed with the development of biopharmacy.)
If you use biotechnology, it enables a number of drug discoveries that was not possible with chemical synthesis alone. Falma was a pharmacologist and he knew all the know-how.
“Falma-sama. Aren’t you administering insulin?“
Falma returns back to himself when he heard Rebecca’s question.
“Aah, I’ll do it.“
That day, the boy with type 1 diabetes received the administered insulin, the first peptide drug in Another World Pharmacy.
“He is safe for the time being…“
The pharmacists take turns in observing the boy’s condition while talking to him. Falma and Ellen will take over as part of the turns. It is a rule for the full-time pharmacists. By midnight, the boy’s head official also came to visit him, and he encouraged the boy to cease his job in selling milk a while before heading home.
“Is that head official a good person?“
That evening, Falma turns to the boy when they are both alone.
“I don’t want to talk to you.“
“I want to listen…You have a lot of resentment towards the pharmacist. Why?“
From the conversation, he indicated that the drug which they obtained from third-class pharmacist didn’t work and he lost his mother.
(It’s a common story…)
Such a story was accounted everywhere in this world not just this boy’s case. Before Falma began supplying modern medicines to the Imperial citizens, the commoner’s medical situation was dire.
“Can you believe the pharmacist?“
The boy appeared to be fuming as he swayed away.
“If you don’t trust me, that’s fine. What if it becomes easier to obtain this medicine? That’s the question.“
“…“
The boy bites his lips, and remains quiet from his regrets.
“From now on, you can manage this medicine and administer it by yourself. Every day. Yes, you can be the chief pharmacist yourself.“
Falma taught the boy how to administer the insulin. He instructed as many times as needed in how to dissolve insulin, how to handle syringes and needles, the timing of administration, and various knowledge that the boy needs. He also hands over a disposable syringe and needle to the boy. Because the boy can’t measure his blood sugar himself, he determined the dose of insulin based on the calculated amount of carbohydrates. He also taught the boy about the method after handing over the food list.
“How can you understand it all? It’s a difficult thing. What is this injection? Think of it as a lifelong relationship. It may be possible to reduce the amount, but, it’s basically can’t be done to stop the injection completely.“
“Lifetime heh…“
The boy who was tapping his mouth without stopping while thinking about the long duration required, and not to make any mistake.
“But, I will teach you first if I can find another way. I will definitely find it. It’s a promise until then.“
“You…You really are a good guy.“
The boy mutters a sound that seems to be loud to him but Falma cannot hear it.
“Has there been any relief?“
Ellen asks.
“I can’t agree yet, and I’m pretty worried about it. I have to make a simple blood glucose meter. Super fast-acting and long-acting insulin analogues should be prepared for the future as well.“
The issues were piling up.
Two weeks later, Falma received three bottles of milk as the payment from the energetic boy that was released from the pharmacy.
“He certainly paid off the cost of treatment, but the real treatment starts here.“
He has to protect his own health and life at his own risk. The boy was aware of that.
“I was taken care of…by the court pharmacist. Was it insulin? Don’t forget to obtain your medicine.“
“Your mother, was she also a court pharmacist? It’s an improvement in calling me a doctor since the beginning.“
“Shut up!“
“If possible, come to see me daily. I’ll give you the medicine at that time.“
“I gotcha.“
The next day, another three bottles of milk arrived at the pharmacy. Every day there after, three bottles each time. This is in addition to Falma’s examination. Falma gives glucose in a stick style in exchange for the milk the boy brings, so that the boy can take it immediately to prevent hypoglycemia[6]. Insulin is also prepared and handed over for the day.
“I told you to come to see me, but you also bringing milk every day.“
In which case, the pharmacy staff drank before their work, and sometimes Lotte used it for flavorful cooking.
Falma taught the boy on how to manage raw milk through pasteurization, so that the people of the Imperial City can drink milk safely. The boy talked to his head official to make a uniform for the job, and he took care of his appearance in giving him a sense of cleanliness. It’s Falma’s guidance as a sale merchant. Falma’s recommendation of the milk’s pasteurizing method reached the empress, and the Empress really liked it.
The milk sold by the boy is considered as “high-class milk for court purveyors” and became popular with the people. The boy is getting busier as he pushes a nicely renovated wheelbarrow, and is energetically running about the Imperial Capital.
Footnotes:
[1] Kussmaul breathing: s a condition in which abnormally deep breathing continues regularly. Similar breathing may be seen during exercise . It is found in diabetic ketoacidosis, uremia associated with renal failure, and during coma.
[2] This is a serious diabetes complication where the body produces excess blood acids (ketones).
This condition occurs when there isn’t enough insulin in the body. It can be triggered by infection or other illness. Symptoms include thirst, frequent urination, nausea, abdominal pain, weakness, fruity-scented breath, and confusion. Hospital treatment to replace fluids and electrolytes and provide insulin therapy may be needed.
[3] Cerebral edema is when fluid builds up around the brain, causing an increase in pressure known as intracranial pressure. Swelling or inflammation is part of the body’s natural response to injury. Edema refers to swelling due to trapped fluid, and it can happen anywhere in the body.
[4] Sodium bicarbonate cause an ineffectiveness and result in synergistic effect with insulin and glucose in acute therapy of hyperkalemia in ESRD patients for mild metabolic acidosis. This is common in patients on maintenance hemodialysis, which may contribute to tissue insensitivity to the action of insulin on transcellular potassium shift. In other words, more complications than you want.
[5] Pig’s and cattle’s pancreas were used to extract insulin, as they are very closely related to human. Do you wonder why it costs so much for those insulin shots? Yes, you can also create synthetic insulin as well, but the prices for those also climb astronomically.
[6] Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than normal. Glucose is your body’s main energy source. Hypoglycemia is often related to diabetes treatment. But other drugs and a variety of conditions — many rare — can cause low blood sugar in people who don’t have diabetes.
Late in the afternoon one day in the seventh month, in the year 1147. Falma was about to head off to college from a pharmacy but accidentally bumped into a boy that was pushing a cart across the pharmacy. The boy slipped and fell over, and the cart was tilted with part of the carrying load turned over.
“Well now! Look where you’re going you fucking kid! … Geh!“
The boy yelled at the other person without looking closely, and he discovered that the person was the owner of a different world pharmacy.
“Avoid using such words, you rude person!“
The knight acting as the gatekeeper of the pharmacy is stunned, but Falma calms the knight down.
“No, it’s my fault. I was certainly because of my carelessness, and it was my bad. Are you injured?“
“More than that, my load!“
The boy mentioned his loss to Falma as Falma observe the cart that the boy was pushing, and the impact of a collision caused the neatly oriented bottles of milk meant for sale to spill.
“Aah, I have to compensate for this.“
Falma and the boy knew each other a little bit. The boy sold milk on the streets of the Imperial City early each the morning, and Falma noticed the boy always appeared to be tired as he passed by when Falma took his lunch break. Falma saw him went by from time to time.
“That’s right, this needs compensation!“
The boy checked the load and shouted after he got up. The boy is around the same age as Falma, a commoner in a poor situation.
(From the look of it, this child lost weight quite sudden. I wonder if he hasn’t enough eaten enough for his meals.)
Falma got straighten his inner clothing around his neck while looking at the boy standing in front of him.
“I didn’t mean to make fun of you. To apologize for the collision, I’ll buy them all.“
Falma took out his wallet and tried to reimburse the goods.
“Anyway, are you throw it away!?“
“No. I’m drinking it.“
“…Does the noble of the court pharmacist drinking milk?“
Falma replied nicely to the boy that was instigating him so that the gatekeeper could not hear.
“I’ll drink it. You’re going to drink it too, right?“
Falma comes with the idea of eating it with cereal.
“This is sour.“
“It’s really is. Well good, I’ll make yogurt.“
Falma didn’t exchange any word about buying the milk and he bought all the milk that was in the cart. Falma gave the entire content of his wallet as an exchange instead. The content of Falma’s wallet contained several years’ worth of the boy’s annual income.
“I don’t need the change.“
“Aah!? You’re playing around me! Can I receive this doctor!“
The boy is already in an argumentative stance. Falma wondered if there was any good reason he’s like this while observing the boy rubbing torn pants.
“This is because your clothes were torn and you’re in need of new clothes. And if you pay attention to your hygiene, your sales will also increase. It’s for your extra care, though.“
“It’s for my extra care!“
“What’s the fuss? Falma, what are you arguing about?“
Ellen heard a loud voice and went out to remediate the situation.
“I just bought milk.“
It’s not a quarrel between children, so to speak, and Falma finds out that the boy is still a child. In the end, the boy pulled out the amount to cover the cost from Falma’s wallet and threw the rest back the pharmacy before he went home.
For a few days after, Falma watches the boy that’s selling milk passes by outside the pharmacy and purchases the milk each time.
Pharma watches a milk-selling boy pass by outside the pharmacy,
I stopped and bought milk each time. But, he doesn’t show up this day.
“He’s a bit late today.“
“That milk-selling boy, right? I’ll watch the street for him.”
Lotte also lends a helping hand. The boy that passed by the pharmacy last time finally arrive at the pharmacy, and Lottes goes in to call for Falma.
“Falma-sama! He’s here! I told him to wait! I’ll buy the milk ~!“
When Falma approaches the boy to buy the milk, the boy is visibly depressed.
“…Oh it’s you again.“
The boy is much more slender than a few days ago. Falma becomes more worried about the sudden change in the boy.
“You’re late. Why don’t you take a few days off from work? You appeared to be sick.”
Falma is concerned for the boy while buying and paying for the milk.
“Aah…I’m thirsty, and I feel sick. I can’t touch the items for sale.“
“Yes. I’ll give you water, and I’ll take that empty bottle.“
Falma washes the empty milk bottle and now fills it with divine water, and chills the filled water to hand to the boy. He mutters and drinks the water.
“Do you still want to drink?“
After two bottle worth, Falma observes the boy as he’s drinking his third one.
“I can’t help feeling thirsty all day today.“
“Isn’t that weird? It’s not hot today.“
(He’s dehydrated…his breathing is odd.)
He has abnormally deep breathing as he continues to breath regularly. Falma has a bad feeling.
(Inhalation is better, longer than exhalation…Isn’t this Kussmaul breathing[1]?)
This is unusual. Falma feels suspicious of the situation and uses [Diagnose Eye]. Then, the boy’s entire body fluid is glowing blue.
(What is this!?)
Falma is gasping at the serious condition as soon as he observes the conditional state. Even though there s dehydration, however, that alone cannot explain it. Smelling the scent from the boy’s sigh, there is a unique fruity odor. There’s also abnormal breathing along with the breathing. .
” ‘Diabetic ketoacidosis’ ” [2]
There was a reaction.
Diabetic ketoacidosis (DKA) is acidosis (a complication that makes the blood acidic) caused by a deficiency of insulin, the only hormone that lowers blood sugar (which promotes the blood sugar into tissues). When insulin deficiency occurred the blood sugar level in the blood rises because it cannot be transferred into the organs, as each organ becomes starved due to lack of energy, then the body breaks down the muscles attempting to obtain the necessary energy. As a result, the ketone bodies, which are metabolites of proteins and lipids, increase in the blood (or known as ketosis as in the keto diet), the pH of arterial blood tends to be acidic.
(It means that you are progressing to ketoacidosis!)
” ‘Type 1 diabetes’ “
It was a hit.
Type 2 diabetes progresses gradually, so it is not likely to develop into ketoacidosis. But in type 1 diabetes, it can progress rapidly due to the lack of insulin secretion. By the way, Type 1 diabetes is different from Type 2 diabetes due to lifestyle-related factors.
It is caused by the breakdown of autoimmunity. Therefore, it develops in both the wealthy and the poor. Regarding the onset of Type 1 diabetes, it’s not the fault of the person.
In Japan, diabetes is often misunderstood as a lifestyle-related disease, and Falma recalls the patients around him occasionally suffering from the misunderstandings.
(In erasing the ketone bodies…I may be able to do it.)
All ketone bodies are simple compounds. It can be erased by Falmama. Falma can improve the body of ketoacidosis by erasing all the ketone bodies in the boy’s body with his erasing ability. But, his body is absolutely deficient in insulin, and using the ketone body for nourishment, not sugar. If the ketone body is rapidly erased, he may fall into a coma. Falma couldn’t get rid of that concern, and for temporary first aid, he erased some of the ketone bodies — that is, he’s using the ability to eliminate the acetone not being used for metabolism. This should calm down the condition is a little.
“What is Type 1 diabetes?“
Ellen listens to Falma. The patient appears not to hear what being said.
“Falma-kun may be intuitive if you observe he patient. How do we find it?“
“Ketoacidosis can be detectedby Ellen and others if you are tested. It’s a poor method to use pH testing paper and prick your fingertips with a needle to measure the pH of the blood.“
There is also a way to measure the blood sugar level, but it has not been put to practical use in this world yet.
“What a mess…“
“He needs to be hospitalized immediate! It’s a serious illness.“
Falma begins to to persuade the boy.
“What? If I go home and sleep it off, I’ll be fine…“
The boy tried to respond something back, but Falma screams at him.
“…No, you’ll die! Ketoacidosis is occurring in your body. In other words, your blood is becoming acidic.“
The boy was obliviousvacant, so Falma’s sense of crisis rages.
“Like milk becomes yogurt?“
“Correct dead-on.“
“I don’t like it, and I wonder if I can sprinkle expensive medicine so easily!“
The boy was trying his best to refuse.
“The charge for the treatment’s fee is 3 bottles of milk! I’m not taking more than than, and there will be a written agreement!“
Falma wrote the agreement and shown it to the wary boy.
“Damn, I can’t read what was written.“
When Cedric hears it, he reads out his contract.
“In accordance to what it indicated, the medical fee charged to the patient is three bottles of milk, and the pharmacy will bear all additional costs without charging any extra cost to the patient. The agreement was formalized with the seal of the pharmacy. It becomes validated when you sign.“
“Shii~, I can’t believe it. I’m signing it! You have the confidence to cure it, right? Doctor, ya tell me alright!“
“What do you know about Falma?“
Instead of getting angry, Ellen frowns at him.
“I don’t care what you know, as long as this illness is cured. When is cured, the symptoms can be relieved. By the way, you’ll really die in a few more days. You do not want to leave untreated! Do you want to die?“
“Oh~, oh…“
“Then you’re going to be hospitalized! You just barely able to stand like that at the moment!“
Falma received the consent, but is it too late? He moves about and takes him to the treatment room upstairs.
“Falma-kun was observant.“
Ellen’s glasses slipped.
“I’ve never seen Falma screamed. Really, is it that urgent?“
Cedric mutters while preparing the documents.
In the treatment room on the second floor
After the boy weighs his height and weight
He was lying in bed and rampaging.
During that time, Pharma calculated the plasma osmolality based on the results of eye examination and estimated the estimated dehydration amount.
He completes all the necessary calculations for fluid correction.
“Release me! I didn’t ask you to stick a needle in me! I don’t want what you’re doing to me!! I can’t believe the pharmacist at all!“
“I see, but it’s dangerous if this child goes wild so keep him restrained.“
Falma called on Roger for a man’s (strength) assistance.
“It’s just an infusion. It’s harmless.“
Born in Nedale, Roger is a young pharmacist working part-time job and a type that uses his muscles to solve problems.
“Falma-kun, what in the infusion?“
Ellen prepares the infusion solution. Falma is ready in using the prepared solution into several packaged IVs.
“0.9% saline. Take your time since it’s going to be about 2 hours. After that, it’s reduced to 0.45%. Afterward, I will supplement it with potassium as appropriate while examining his condition.“
“If I die, I’ll turn into a demon and curse you guys!“
As the boy is waving his left hand in his rampaging, Falma speculates that is the boy’s dominant hand.
“His dominant hand is on the left. I’ll insert the needle on his right hand.“
After wrapping a rubber band around the boy’s arm, he inserts an indwelling needle into the boy’s right hand. Attached to the indwelling needle is an extension tube with the dripper.
“Isn’t it necessary for the flow velocity to be fast? It’s better to eliminate acidosis as soon as possible.“
Ellen’s question was logical.
“It’s likely to be better in speeding things up when you’re dehydrated, but the rapid rate can cause cerebral edema[3]. You have to be careful and manage it properly.“
Since the sudden correction of acidosis and lowering of blood sugar can cause cerebral edema, Falma added to the explanation while recalling that sodium bicarbonate should not be used for corrective method. Children are especially prone to cerebral edema, resolve the dehydration issue first, follow by the insulin administration.[4]
“Death with a swollen brain, that will be the day.“
Falma, Ellen, and Roger discuss about the infusion.
When the needle was inserted into the boy, the three pharmacists tightly packed beside his bed.
“Don’t let him pull out the needle. He’s be hospitalized today, no, he’ll be hospitalized for about two weeks. If he doesn’t have a parent or someone to contact with, please let me know because I’ll be the one to contact them on behalf of the pharmacy.“
“This will be left only to the high official.“
“Alright.“
Falma sent a messenger to the high official in requesting for the boy’s address, and to inform the official about the boy’s medical condition along with the long term hospitalization.
“Falma-kun. The drug for Type 1 diabetes was…insulin. When ketoacidosis begins to improve, shouldn’t it also be administered?“
Ellen inquires with Falma’s textbook in one hand.
“Aah, yes … that’s right.“
Pharma nods, but response is loud and clear.
“Maybe, and is there any insulin?“
Ellen’s face turned pale.
(…Finally, is it time?)
Falma clasps his fist tightly.
“I can’t say there isn’t any, and there is some speaking of which.“
“Which one is it then?“
“There are several doses, but it’s not enough. However, it doesn’t mean it’s something you can’t make right away…“
Yes, insulin is a drug that cannot be created simply by Falma’s ability [Create Substance].
Historically, insulin preparations have been purified from pigs and cattle for practical uses[5]. However, historical early extraction method and the refinement technology was immature in creating the unstable volume, and when it was administered to patients, it caused severe allergies. The research equipment in Falma’s laboratory for extraction purposes is is no different than that from the early modern period, and he cannot be overconfident in the refining technology. It would be too late to search for cows and pigs to grind them up readily. Also, when it comes to continuous extraction, not even once where Falma is out of options. It is not impossible to genetically engineer Escherichia coli and the like to synthesize a large amount of insulin and use the reagents he brought back from a laboratory from the other world. Even if the sequence of production is known, it will take several days. If you don’t know the synthesizing sequence, this method cannot be used.
He needs insulin now.
“Insulin is not a simple compound.”
“It’s just a protein though.“
Ellen opens Falma’s textbook and shows the amino acid term to the part-time pharmacists. For a general overview, it is. The two part-time pharmacists finished prescribing the patients in the pharmacy and came up to the treatment room.
“Yes. This is an amino acid used in the human body.“
Falma has a grimacing face while looking at the list.
“Proteins use each of these amino acids, where a string of beads in a fixed order consists of peptides. Simply put, it’s a protein if you connect amino acids in a fixed sequence and fold it…“
Falma explained to the pharmacists and Ellen kept on talking. Ellen reads a lot of his textbooks while learning things by herself.
“The problem is that sequence. Do you know the order of insulin?“
There are dozens of insulin amino acid sequences. As expected, Falma couldn’t remember the complete sequence.
(It’s gotten a bit sidetracked, but I should have analyzed the sequence even if the DNP was able to reproduce by the structural analysis done by Sanger.)
It’s too late to regret it.
“I don’t remember.“
Falma frowns as he touches his forehead.
(If I can go to the laboratory again, I can check the insulin sequence, but…)
It’s a waste of time right now to visit the laboratory in a different world behind the sacred spring.
“I wonder if there is any way to know the sequence. Insulin may not be visible under a microscope.“
Falma sudden notices it after Ellen’s statement.
“However…I may be able to comprehend it. Just a moment.“
Thank you for the hint, Ellen! Falma shouted and darted out of the room.
Falma runs up to the laboratory on the 4th floor. Thanks to Ellen, he was inspired. When Falma visited a laboratory in another world, he brought back only one vial of insulin with a number of reagents. However, it was just one. If he administers it several times, it will all be gone. If insulin cannot be synthesized within a few days, the boy dies.
The insulin vial was removed among the reagent storage in the laboratory on the 4th floor. Falma rolls up his lab coat to reveal the bandaged arm, and he removes the divine seal given by Salomon. If he doesn’t fully open his abilities, he will not be able to find it.
“I see it!“
He uses his special abilities that he hasn’t been using for a long time now. The ring formed on his right hand can be used as [Magnifying Vision] when activated for observing the object, and he directly observes the amino acid sequence of insulin with his own eyes. He feels as if this is pretty absurd, since it can’t be done without an atomic microscope to perform the structural analysis similar to an x-ray of the atomic structure. There is a threshold of the maximum magnification that can be reached, but here, it can be magnified by means of an optical microscope (aka the fingers’ ring).
“It’s observable!“
Falma reads amino acids one by one, and he started writing the sequence in his notebook. It may sound easy, but even when you can read it, there are exceptions to the identifiable structurals, but some amino acid sequences are very similar and are almost indistinguishable to the naked eye. So he uses the dinitrophenolation method to label only the leading amino acid and then combines with [Remove Substance] to guess by connecting the eliminated ones, similar in solving a puzzle through the decided arrangement. And finally, he confirmed the synthesizing of the insulin was successful through [Erase Substance] and compilation of amino acid sequences.
Falma came down from the lab about an hour later.
“I’m done…this here is insulin.“
“There is so much! How did you manage to synthesize it?“
“In principle, through the peptide solid phase synthesis method…In other words, affixing one amino acid at a time until I achieve the result.“
“But you made it in a different way than the mentioned.“
It’s all due to the medicinal crest on his arm that can be seen through from under the lab coat, which Salomon had seal it before. Ellen suspects that Falma used the power of the medicine god. He appears to have forgotten to put the seal back.
“Because it’s urgent. I thought I’d run out of concentration and die as a result.“
“I can tell that it was not a small task. Your eyes are bloodshot, Falma-kun.“
Ellen pointed at Falma.
“Good work.“
Lotte gently hands over a steamed towel to Falma, as she has been waiting for him at the corner of the room during the intense verbal exchange with all the pharmacists. While being thankful in his eyes, Falma only had one thought in his heart.
(I have to use that after all.)
For this time, it was all good because there were dozens of amino acids connected by peptide bonds, and Falma has no long term concentration to deal with hundreds of sequences. On top of that, there could have been mistakes. The way how Falma sweated just now, there is something that cannot be done so easily…
(Since there is no chemical synthesis, we have to proceed with the development of biopharmacy.)
If you use biotechnology, it enables a number of drug discoveries that was not possible with chemical synthesis alone. Falma was a pharmacologist and he knew all the know-how.
“Falma-sama. Aren’t you administering insulin?“
Falma returns back to himself when he heard Rebecca’s question.
“Aah, I’ll do it.“
That day, the boy with type 1 diabetes received the administered insulin, the first peptide drug in Another World Pharmacy.
“He is safe for the time being…“
The pharmacists take turns in observing the boy’s condition while talking to him. Falma and Ellen will take over as part of the turns. It is a rule for the full-time pharmacists. By midnight, the boy’s head official also came to visit him, and he encouraged the boy to cease his job in selling milk a while before heading home.
“Is that head official a good person?“
That evening, Falma turns to the boy when they are both alone.
“I don’t want to talk to you.“
“I want to listen…You have a lot of resentment towards the pharmacist. Why?“
From the conversation, he indicated that the drug which they obtained from third-class pharmacist didn’t work and he lost his mother.
(It’s a common story…)
Such a story was accounted everywhere in this world not just this boy’s case. Before Falma began supplying modern medicines to the Imperial citizens, the commoner’s medical situation was dire.
“Can you believe the pharmacist?“
The boy appeared to be fuming as he swayed away.
“If you don’t trust me, that’s fine. What if it becomes easier to obtain this medicine? That’s the question.“
“…“
The boy bites his lips, and remains quiet from his regrets.
“From now on, you can manage this medicine and administer it by yourself. Every day. Yes, you can be the chief pharmacist yourself.“
Falma taught the boy how to administer the insulin. He instructed as many times as needed in how to dissolve insulin, how to handle syringes and needles, the timing of administration, and various knowledge that the boy needs. He also hands over a disposable syringe and needle to the boy. Because the boy can’t measure his blood sugar himself, he determined the dose of insulin based on the calculated amount of carbohydrates. He also taught the boy about the method after handing over the food list.
“How can you understand it all? It’s a difficult thing. What is this injection? Think of it as a lifelong relationship. It may be possible to reduce the amount, but, it’s basically can’t be done to stop the injection completely.“
“Lifetime heh…“
The boy who was tapping his mouth without stopping while thinking about the long duration required, and not to make any mistake.
“But, I will teach you first if I can find another way. I will definitely find it. It’s a promise until then.“
“You…You really are a good guy.“
The boy mutters a sound that seems to be loud to him but Falma cannot hear it.
“Has there been any relief?“
Ellen asks.
“I can’t agree yet, and I’m pretty worried about it. I have to make a simple blood glucose meter. Super fast-acting and long-acting insulin analogues should be prepared for the future as well.“
The issues were piling up.
Two weeks later, Falma received three bottles of milk as the payment from the energetic boy that was released from the pharmacy.
“He certainly paid off the cost of treatment, but the real treatment starts here.“
He has to protect his own health and life at his own risk. The boy was aware of that.
“I was taken care of…by the court pharmacist. Was it insulin? Don’t forget to obtain your medicine.“
“Your mother, was she also a court pharmacist? It’s an improvement in calling me a doctor since the beginning.“
“Shut up!“
“If possible, come to see me daily. I’ll give you the medicine at that time.“
“I gotcha.“
The next day, another three bottles of milk arrived at the pharmacy. Every day there after, three bottles each time. This is in addition to Falma’s examination. Falma gives glucose in a stick style in exchange for the milk the boy brings, so that the boy can take it immediately to prevent hypoglycemia[6]. Insulin is also prepared and handed over for the day.
“I told you to come to see me, but you also bringing milk every day.“
In which case, the pharmacy staff drank before their work, and sometimes Lotte used it for flavorful cooking.
Falma taught the boy on how to manage raw milk through pasteurization, so that the people of the Imperial City can drink milk safely. The boy talked to his head official to make a uniform for the job, and he took care of his appearance in giving him a sense of cleanliness. It’s Falma’s guidance as a sale merchant. Falma’s recommendation of the milk’s pasteurizing method reached the empress, and the Empress really liked it.
The milk sold by the boy is considered as “high-class milk for court purveyors” and became popular with the people. The boy is getting busier as he pushes a nicely renovated wheelbarrow, and is energetically running about the Imperial Capital.
Footnotes:
[1] Kussmaul breathing: s a condition in which abnormally deep breathing continues regularly. Similar breathing may be seen during exercise . It is found in diabetic ketoacidosis, uremia associated with renal failure, and during coma.
[2] This is a serious diabetes complication where the body produces excess blood acids (ketones).
This condition occurs when there isn’t enough insulin in the body. It can be triggered by infection or other illness. Symptoms include thirst, frequent urination, nausea, abdominal pain, weakness, fruity-scented breath, and confusion. Hospital treatment to replace fluids and electrolytes and provide insulin therapy may be needed.
[3] Cerebral edema is when fluid builds up around the brain, causing an increase in pressure known as intracranial pressure. Swelling or inflammation is part of the body’s natural response to injury. Edema refers to swelling due to trapped fluid, and it can happen anywhere in the body.
[4] Sodium bicarbonate cause an ineffectiveness and result in synergistic effect with insulin and glucose in acute therapy of hyperkalemia in ESRD patients for mild metabolic acidosis. This is common in patients on maintenance hemodialysis, which may contribute to tissue insensitivity to the action of insulin on transcellular potassium shift. In other words, more complications than you want.
[5] Pig’s and cattle’s pancreas were used to extract insulin, as they are very closely related to human. Do you wonder why it costs so much for those insulin shots? Yes, you can also create synthetic insulin as well, but the prices for those also climb astronomically.
[6] Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than normal. Glucose is your body’s main energy source. Hypoglycemia is often related to diabetes treatment. But other drugs and a variety of conditions — many rare — can cause low blood sugar in people who don’t have diabetes.
