This book is a labour of love. It is also an account of the life and work of Professor R Venkataswami (RV) who set up the plastic surgery department at Stanley Medical College and Hospital, and later added to it the hand surgery service. These have served countless patients, most of them poor and deprived. They have also been recognised as excellent teaching centres not only by students in India but also from other countries. Such achievements in an institution run by the state government deserves applause.
The volume places before its readers a mentor par excellence whose qualities of mind and heart merit emulation. Appropriately, it is dedicated to the gurus who teach by example. Dr Subramaniam is a graduate of the same institution and, while working on an essay on the demand-supply gap in tertiary healthcare in poor countries, was reminded of the days when he had interned in this hand surgery service. He recalled that the contrast with the rest of the hospital was so stark that it was difficult to believe that the service was part of the same hospital. He had been struck by the efficiency and discipline inculcated into each staff member and the systems in operation. “World-class healthcare was delivered to patients with compassion”. He decided to study how RV had achieved this transformation.
The book starts off with two patients, one in 1970 and the other in 1981 – both serving in the small industries proliferating in north Madras. In both instances, a chance event led to severe hand injury in the fast-moving machines they were operating. The outcomes were vastly different. In the earlier patient, relative neglect by the vastly overloaded doctor in the emergency service led to infection and scarring. These led to inability to return to his job and destitution. In the latter instance, the patient’s immediate examination and salvage operations restored function to the thumb and three fingers. Eventually he could return to his job. The prologue highlights the vital importance of time taken to get to the hand surgeon. In the first instance, the relatives and friends of the patient had to enquire of several hospital attendants on how they could reach the relevant department. In the second instance, as soon as he was seen in the emergency section, he was shown a broad red band painted on the wall. “Just follow this and you will reach your doctor.” This is just one of the practical, common-sense and inexpensive measures that RV had put in place for the benefit of the patient.
The initial chapters describe RV’s childhood and scholastic development from “a simple village fellow” onwards. Born on November 20, 1932 in an isolated village in the former Madras Presidency, he was fortunate in having a father who had come under the influence of Gandhiji and took pains to inculcate his values into his son. RV grew up with the ambition of serving the common man rather than the colonial government. Growing up in a rural environment meant a simple childhood. One example: he learnt how to swim by being pushed into a well where elders already in the water taught him how to paddle and stay afloat. He was also fortunate in having a school teacher who enforced discipline. His innate qualities were recognised by his teachers, and he was helped to move to the Sri Ramakrishna Mission Vidyalaya in Coimbatore. His teachers there and the principal, in turn, helped him to go to Alagappa College in Karaikudi. It is salutary to learn that till he got a room in the hostel, he stayed in a village whence he walked barefoot in his pyjamas all the way to and from the college. Seeing his potential, his father insisted on further education and purely by chance, applied for admission to the Madras Medical College. The interview panel was headed by Sir Lakshmanaswamy Mudaliar. Again, accidentally, he chose Stanley Medical College and so was launched on his long association there.
At this early stage, RV encountered “petty corruption that corrodes government institutions like a cancer”, when a clerk in the admissions office made his father travel unnecessarily all the way to his village to obtain a tahsildar’s certificate.
The author provides a brief history of the Stanley Medical College, named after the Governor of the Presidency when the college introduced the five-year course in medicine and surgery. (A list of eminent alumni from this college is provided on page 147). Poverty necessitated borrowing books from seniors and colleagues in the college but the teaching at home and in the Ramakrishna Mission stood him in good stead: “There is nothing wrong in being poor as long as long as you live carefully within your means.” He proved a diligent student but was not an academic star. His cultural activities in the student council and taste for drama are detailed in the book.
In his final year as a medical student, RV was able to attend a lecture by Sir Harold Gillies and this may have played a role in his choosing plastic surgery as a specialty. It was also during this year that RV’s father died from a cerebral haemorrhage.
The incident when RV had difficulty inducing general anaesthesia for the reduction of a Colles’ fracture is interesting (p 23) as is the occasion when he was asked to streamline the protocol in the septic operation theatre (p 24).
He was awarded the MS. in 1959. After a stint with Professor C Balakrishnan in Nagpur at the only department in India recognised for training for the M Ch in plastic surgery, he persuaded the Dean of Stanley Medical College to forward and recommend a proposal to create a plastic surgery department in their hospital. An interesting incident demonstrating the magnanimity of the Dean is to be found on pages 34-35.
Having been warned not to ask for the moon when he proposed setting up the department, he faced several handicaps that hampered function. How he overcame them one by one using simple and inexpensive means is described on pages 37- 47. The ready and willing cooperation of his colleagues was a great help. It also helped that RV enforced discipline by example, arriving well before his scheduled time and not leaving before 4 pm when his duty hours had ended at 2 pm. Eliminating corruption, making all members of the staff behave courteously with the poorest of patients and their families, and ensuring careful and thorough documentation on every patient were slow and time-consuming but rapidly yielded dividends. RV’s personal attention to every detail – including inspection of the toilets for the patients – also helped.
It was soon evident that patients with hand injuries outnumbered those needing plastic surgeries. Loss of the function of the hand almost inevitably led to destitution of the breadwinner’s family. This influx led to the addition of a hand surgery service to the plastic surgery department. As facilities improved and more talented consultants joined the team, microsurgery, surgery to correct handicaps from injuries of the brachial plexus, and other procedures were added on. Eventually, the department evolved into the Institute for Research and Rehabilitation of the Hand and Department of Plastic Surgery. It was soon one of the busiest hand surgery units in the world.
Visitors such as Drs Guy Pulvertaft, Eric Peet, C Balakrishnan and BB Joshi applauded the progress within the department. RV was invited to visit the famous AO Foundation facility in Switzerland. It is also of interest that Dr Mohammed Rela, later famed for his expertise in liver transplants, attributed his love for surgery to the experience in RV’s department. Honours followed. RV’s delivery of the Lt Col. KG Pandalai oration is described on page 68 and speaks a lot about RV’s attention to detail and infinite capacity for taking pains.
By 2005, when RV retired on superannuation from Stanley Medical College, the department that had started with a handful of beds scattered in different wards and a makeshift operation theatre had grown into in institute with 80 beds, 107 staff members and 6 operation theatres. The narrative headed ‘The car that would not start’ describes RV’s retirement and adds a humorous twist (pp 74-75).
RV has since set up the Department of Plastic Surgery at Apollo Hospital in Chennai, edited a multi-authored book on hand injuries and attends to an ashram set up by his father-in-law in a village near Madurai.
Pages 82-113 summarise his principles and practices and his consequent achievements. Chapter 7, entitled Reflections has been written by RV at the request of the author. These sections will inspire our younger colleagues.
Cicero (106 – 43 BCE), the respected Roman statesman and philosopher, was driven, even in his times, to exclaim, ‘O tempora, o mores!’ as he witnessed deteriorating social and political norms. The author, viewing the institute at present and comparing it with the period under RV’s direction, regretfully, notes: “…the attitudes he had fostered were getting diluted and the department increasingly resembled other departments in Stanley – a natural regression to the mean” (p 85).
Despite the sad, final, observation – not uncommon when analysing the fate of departments and institutes set up by a remarkable, far-sighted and dedicated individual – the book leaves us with hope. RV demonstrated that much can be achieved under difficult circumstances to improve the lot of the person central to his focus at all times – the poor, helpless patient. And heaven knows, we have innumerable patients in this category who are desperately in need of kindness, compassion and expert medical help.