B. Dayananda Rao: No ugly scars. The autobiography of a surgeon.
Author : B. Dayananda Rao.
Book : No ugly scars. The autobiography of a surgeon.
Publishers : Hyderabad: Booklinks Corporation
Year of publication : 1993
Type : Paperback
(I have referred to Dr. Dayananda Rao as ‘Dr. Rao' throughout).
Dr. Rao is an unsung hero of neurosurgery in India. As you read this book, you will see the rationale for this claim. His plain speaking, honesty and courage when dealing with difficult situations and individuals (including those ‘worthies' called ‘very important persons' [VIPs]) have been exemplary. He appears to have taken to heart a quotation he provides in the book: ‘Be grateful to the man you help, think of him as God. Is it not a great privilege to be allowed to worship God by helping our fellow men?' – Swami Vivakananda.
When he wrote this book, Dr. Rao was 77 years old. He reminisced, ‘All through my life…circumstances beyond my control have driven me to work for pre-determined targets. I endeavoured to put heart and soul into the effort. The fact that I could often succeed what I had set for is the basis for my successes. But I had to pay a price for this.’ The setbacks he suffered on the way are described in fair detail in the book.
Dedications occasionally provide important clues both on persons cherished by the author and on the author himself. Dr. Rao dedicated his autobiography humbly to his parents using the theme of the uses of adversity and grief. The dedication to his mother carries lines 61 and 62 from William Blake's Auguries of Innocence.
59 Joy and Woe are woven fine,
60 A Clothing for the Soul divine;
61 Under every grief and pine
62 Runs a joy with silken twine.
As you will have noted, the lines preceding these, not quoted by Dr. Rao, are also of interest.
Already, we learn of Dr. Rao's love of literature and familiarity with the works of Blake, the English poet, painter and printmaker (1757-1827). Each chapter is preceded by quotations from sources as varied as Gandhiji, Cowper, Tennyson, Samuel Johnson and Swami Vivekananda. The explanation is found on page 3: ‘One of my earliest ambitions was to make a mark in the study of English literature, a subject to which I am devoted even today… As a first-year medical student, I appeared for the B.A. examination with English as my main subject.’ But then, that was the age when professors in medical colleges were erudite in literature as well. He provides us the examples of Dr. Krishna Rao, his professor of Anatomy, Dr. P. Kutumbiah, professor of medicine and Dr. Iswaraiah, professor of pharmacology. (Dr Kutumbiah later went on to write a classic text entitled Ancient Indian Medicine. Dr. Iswaraiah wrote the popular Textbook of Pharmacology and Pharmacotherapeutics with Dr. J. C. David).
I suggest careful attention to the foreword written by Professor Iyyanki Venkata Chalapati Rao (1923-2016) – whose felicity with the English language rivals his affection for Dr. Rao. This renowned educationist, scholar, public speaker, teacher and editor reminds us that Dr. Rao's ‘stethoscope and scalpel were as sensitive as a seismograph to record the slightest tremors of the suffering poor as he followed Caraka's exhortation – not for money, not for any earthly object should the doctor treat his patients…' He also explains the dedication referred to above, pointing out that ‘as shadows lengthened around him (Dr. Dayananda Rao), his loving mother, dear father and dedicated wife passed away one after another, making him feel lonely.’
Dr. Rao introduces us to his parents in the preface itself. ‘Whatever I have achieved in life was because of them.’ His father, Dr. B. Tirumala Rao, lost his mother early in life. He graduated from Madras Medical College is 1913 and worked in hospitals in towns such as Narsapur and Narsaraopet. In 1924, he was helped to travel to Edinburgh by the Raja of Panagal. He qualified L.R.C.P., D.L.O., F.R.F.P. and S. and finally F.R.C.S. He was appointed the first professor of E.N.T. surgery in the Andhra Medical College and King George Hospital in Vizagapatanam in 1927. ‘It may be said that almost all the practicing E.N.T. specialists in Andhra Pradesh are either his own students or grand-students.’ The account of Dr. Rao's childhood is enlightening as it describes some of his arduous duties and also refers to what he learnt from his father: Dignity of labour, ethical values of life and a love of Carnatic music.
His mother was equally admirable. When she saw her father marrying off her elder sisters to wealthy land-owners, she was audacious enough to ask him, ‘Why do you always seek the rich and not look for education?' When she was married to Dr. Tirumala Rao, her ‘relations were in tears to see such a fine village belle given to a poor and motherless boy.’ There is much more on her that deserves study.
In the preface, Dr. Rao also explains why he wrote this memoir. Having lived and worked in India before and after independence, he had experiences worthy of narration. His children and grandchildren greatly enjoyed his accounts of ‘the good old days.’ The loneliness and depression following his wife's death in 1988 prompted his children to request him to put on paper what he had told them orally so as to create a permanent record. The final stimulus flowed from his friend Professor I. V. Chalapati Rao. We are blessed as a consequence.
As he starts Chapter 1, the quotation, again from William Blake, reads:
'Piper, sit thee down and write
In a book that all my read'
So he vanished from me;
And I plucked a hollow reed.
Dr. Rao's hollow reed, dipped in ink, starts his account in Machilipatnam in Krishna District, where he was born on 25 June 1916. When he applied for admission to the medical college where his father was professor, there were only 46 applications for the 50 available seats. Brilliant students from South Canara filled up the remaining 4 seats. Vizagapatanam was then in the Madras Presidency. Andhra Pradesh was formed in 1956.
His remarks on examinations in medical colleges make one nostalgic for a return to those practices from the current pattern. ‘No candidate or even assistant professors knew who the examiners were till the day of the assessment… It was impossible to contact them in any manner. Nothing counted except the day's performance of the candidate… Major Shone, the internal examiner in medicine never let the candidate guess how he had fared with him. Every candidate was shown the same relaxed approach and smile. When asked why he was so undemonstrative, he replied, “Why should he know how he has fared with me? He may do well with the other examiner and may get through the examination.” The examiner in ophthalmology would ask the same set of questions to every candidate after making sure that they were effectively isolated… (when examining candidates on the long and short cases) as the examiner himself knew only as much as the candidate about each case, the main stress was always upon clinical findings.’
Dr. Rao obtained his M.S. degree in 1946. The average working day for a surgical resident was from ‘early in the morning to … midnight and sometimes to 2 a.m… Though my father and myself were working in the same hospital, we hardly ever met each other for days or even weeks…'
As he completed his studies in 1941, the Second World War engulfed the east as well. Studies abroad were not feasible. He sought an academic appointment in his own hospital. His experience with the Public Service Commission when he appeared for the post of assistant professor is described on pages 7 and 8 and is a blot on the administration of the time.
The move to Hyderabad was auspicious. On reaching there, he was asked to meet Colonel Dabholkar, who was recovering from a stroke that had caused hemiplegia. The Colonel welcomed him and said, ‘I have selected you against opposition from local politicians as you are not a mulki. I have deep faith in you. Please do not let me down.’ Other officers were equally considerate and helpful, leading Dr. Rao to exclaim, ‘What a heavenly change from the faceless Madras Government.’ He was soon to be disillusioned about the quality of work expected from him as he was posted to places where lack of facilities and interest made it difficult to conduct any surgery.
He was appointed Civil Surgeon and Health Officer. He took both responsibilities seriously. ‘Surgery may be spectacular and glamorous but its impact is limited to an individual and his ailment. On the other hand, public measures …impact the whole community… If at all a place is reserved for me in Heaven, it will be for my work as a Health Officer rather than my achievements as a surgeon.’ Details on this work are provided on pages 41-67. There is much to learn and admire on these pages. The incidents concerning Dr. Mrs. Ponnoose (page 58) and Dr. Rao's observations on and experiences with the Deputy Director of Medical Services, Dr. S. Raghavendra Rao (pages 63-67), are touching examples.
His description of an eye camp organized by him where, whilst the eye surgeon dealt with cataracts, he repaired a vesicovaginal fistula, can be read on page 47. Incidentally, his views on religion are included in this section (page 50-52).
At the end of his experiences as a Civil Surgeon, he endorsed the advice he was given, as he started, by his chief, Dr. Ramanamurthi, in Vizag: ‘In government service you should be an accountant first, then a clerk and lastly a medical man. If you do not keep your accounts properly, you will get into serious trouble immediately. If you are not prompt in your correspondence, you will be pulled up by your Director. No one will care if you are good or bad as a medical man.’ The example of how he dealt with a pernickety auditor is both amusing and useful (page 54). On this page, you will also find eminently practical advice on human relations.
On page 149 is this hidden nugget that follows a discussion on vasectomies: ‘I operated on myself when I was on night duty in King George Hospital, Vizag.’
His comments on the absurdity of the Five-Year-Plans where details were decided in air-conditioned government offices in Delhi without any inkling of ground realities, and on the terms ‘war footing' and grassroots' are trenchant (pages 60-62).
His descriptions of conditions in Nalagonda vividly describe the very difficult conditions under which he and his family lived and worked. When his younger son, then two-year old, died of diphtheria, he had to request the Superintendent of Police to send a messenger on a motorcycle to the nearest telegraph office, 40 miles away, so that he could inform his parents of his loss. ‘There were murders in the villages every day… it was not safe to move out of the town limits…'
His narrative of how he worked in his ramshackle hospital, which did not have electricity or an x-ray machine, will shock most doctors today. Patients needing x-ray studies had to be sent 84 km. away to Osmania General Hospital in Hyderabad. The single nurse worked only during the day, and at night, the patients were left unattended. ‘There was no proper lavatory for the patients so they relieved themselves all over the area.’ It is a pity that almost 70 years later, doctors in several hospitals in tribal and forested areas continue to work in conditions that are only marginally better than those faced by Dr. Rao.
His successes under such circumstances were due to his ingenuity and dedication. As there was no suture material, he sterilised fine silk threads from parachutes freely available in the market after the war. Dr. Rao had to treat a patient with fracture of the olecranon using the sterilised tochan (used to make holes through bundles of papers to be filed) from his office to bore holes through the fractures so that he could anchor them using catgut sutures as there was no surgical awl. He also removed huge ovarian cysts and performed Caesarian sections under local anaesthesia (as there was no general anaesthesia). The account of the woman with an abdomen full of pus, after surgery by a medical officer with no surgical experience, is an eye opener and a tribute to Dr. Rao (pages 28-30).
His management of the annual epidemics of smallpox is illustrative of his enthusiasm and innovative capabilities.
On one occasion, it became necessary for him to inspect vaids in the district. His findings boggle the mind. One vaid demonstrated how he made his own injectables. When the patients thus treated developed the inevitable abscesses, he explained to them that all the poisons in his system were coming to the surface and would be eliminated as the pus was drained.
The two chapters ‘Nalagonda and Warangal' must be required reading for all those who have never experienced life in villages and districts, where there is no respect for the law and anything goes.
His future appeared to be restricted to practice in such godforsaken places but details of his achievements against odds had reached Dr. Khatri, the Director of Health Services in Hyderabad. When the far-sighted Nawab Mehdi Nawaz Jung decided to send two doctors to the U. K. for training in cardio-thoracic surgery and neurosurgery, Dr. Khatri chose Dr. Rao for the latter. As he pondered this choice, Dr. Rao was disheartened by a letter from his old professor of surgery, now settled in Birmingham. Writing to Dr. Rao's father, he asked why Dr. Rao was entering a ‘branch of surgery where hours and hours of patient and most painstaking surgery is more often rewarded with the death of the patient'. Dr. Rao turned to Dr. B. Ramamurthi who had started neurosurgery in Madras and found not only encouragement but also an introduction to Dr. Ramamurthi's guru in Newcastle, Mr. G. F. Rowbotham. His father supported his choice by saying, ‘My dear son, I am an E.N.T. surgeon and have fixed my level at the ear. I see no reason why you should not go further up.’
Dr. Rao's attitude towards lucre is very evident in his description of the problems faced as he prepared to travel to Britain (pages 69-72). On pages 72-73, we also read the poignant parting of a son from his mother, whom he knew he was never going to see alive again and of the touching kindness of the airport officer in Bombay.
He traveled to England in September 1955. Chapter 5 describes his general experiences in England, and as on earlier pages, has us engrossed by his personal experiences. His descriptions of Mrs. Pauline Cross and Mrs. Twizzel – two ladies who provided him shelter in their homes – are fascinating. His description of the kindness, courtesy and honesty displayed by two aural surgeons (pages 85-86) provide object lessons for all of us.
Life as an Honorary Registrar and relegation to a very junior status after having been a senior Civil Surgeon and heading an establishment needed adjustments. There is not much information on his neurosurgical experiences in Newcastle in the relevant chapter. There is, however, an interesting experience on how he hoodwinked the Government of India and India House in London (pages 92-96).
The account of the European trip, made at Mr. Rowbotham's suggestion, is principally based on entries made by Mrs. Dayananda Rao in her diary. I am glad this is so, for we see instances of sparkling wit and a lot of affection for those who helped them on this holiday. During this trip, Dr. Rao was able to learn from Dr. Klein, in Paris, the technique of coagulating the choroid plexus in patients with hydrocephalus. ‘I practiced this operation in India for some time before shunt surgery came into the field.’
To learn about neurosurgery in Newcastle we have to turn to chapter 7 entitled ‘Neuro-surgery in Hyderabad'! Mr. Rowbotham was the first disciple of Sir Geoffrey Jefferson, so Dr. Rao calls the centre in Newcastle an offshoot of the Manchester school. Dr. Rao was the second Indian acolyte of Mr. Rowbotham, Dr. Ramamurthi having been the first. Referring to Mr. Rowbotham as ‘Father' – as did Dr. Ramamurthi – Dr. Rao commented, ‘It was strange that such a kindly soul could be extremely rough with his tongue but never with his hands, while operating. He used to swear. It was probably because of a habit he had developed as a National Hockey player.’ After one of his classes, Mr. Rowbotham asked Dr. Rao how he was getting on in his unit. ‘I replied that I was doing very well and learning a lot both in the ward and in the theatre. Mr. Rowbotham then said something that immediately struck me as the very basis of all educational philosophy. “Anybody can learn and anybody can teach. What I want to know from you is if you are enjoying your work.” ‘ In the next paragraph is a fascinating anecdote referring to Professor Learmonth of Edinburgh. ( Sir James Rögnvald Learmonth KCVO CBE FRSE FRCSE [1895–1967] was a Scottish surgeon who made pioneering advances in nerve surgery. One of the tributes in The British Medical Journal after his death stated that Learmonth ‘ranks with William Mayo, Harvey Cushing and Geoffrey Jefferson as one of the surgical giants of our time’).
Dr. Rao also tells us about Mr. Lassman, Mr. Maciver, the irrepressible Dr. Henry Miller and Dr. John Walton. At the Royal Victoria Hospital in Newcastle, Dr. Rao was thrilled at being able to operate in the same theatre as did Professor Grey Turner. (Professor George Grey Turner (1877-1951) gained eminence as a surgeon, especially after his operation for the removal of a bullet from a soldier's heart).
Dr. Rao's lifelong interest in the neurosurgery of head injuries stemmed from Mr. Lassman's request to him to review patients treated in his unit. (Dr. Rao's account of a faux pas during this study and how he got out it unscathed is of interest.) The study also brought home to him the value of carefully maintained meticulous medical records.
Dr. Rao first met Dr. Prakash Tandon whilst the latter was working with Dr. Kristiansen in Oslo.
He describes the operation by Dr. Wylie McKissock to remove a meningioma. On opening the dura, he failed to find the tumour. A look at the angiogram showed that he was operating on the wrong side. Dr. McKissock asked an assistant to close the wound and prepare the correct side and went on to remove the tumour with impressive ease. ‘I wondered how such blunders could occur not only in lesser centres but also in National Hospitals.’
‘When I went to the Infirmary in Edinburgh, I met an old person, not very smartly dressed and mistaking him to be some unimportant person, I asked if he could direct me to Professor Dott's office. The old gentleman smiled and said to my utter confusion and embarrassment. “I am Dott. I see you are Dr. Rao from my friend Dr. Rowbotham. I am expecting you.” Great men are never proud but humble and Dr. Dott was easily the most humble of the all-time great neurosurgeons… He kindly invited me to dinner in his house…'
As with Dr. Ramamurthi, Dr. Rao also describes his performance of prefrontal leucotomies in various mental hospitals around Newcastle and later after his return to India.
Dr. Rao found that whilst Mr. Rowbotham appreciated his successful operations, there was never a harsh word of disapproval on the few occasions when he went wrong. ‘When I confessed to Mr. Rowbotham that I had accidentally plunged the skull perforator into the brain, he remarked, ‘Well, it happened to me twice but it must be only once for you. There is nothing to be ashamed of.’
In this chapter, he also describes the teething troubles that he experienced in setting up a department of neurosurgery at the Osmania General Hospital in Hyderabad in what was now in the state of Telangana. The manner in which he obtained a single ward in which all his patients were housed is an object lesson for all young neurosurgeons (Pages 119-120). The sage advice offered by Mr. Rowbotham benefited him as he started neurosurgery, as it will benefit all neophytes (Page 121). As a consequence, he provided the first 24-hour head injury service in the country in 1957.
When he returned to Hyderabad in 1961 after attending the 2nd International Conference of Neurosurgeons in Washington, he found to his horror that his carefully set up exclusive neurosurgery operation theatre was allotted to ENT surgeons for two days each week. ‘My father used to tell me that the oral cavity is the most filthy body cavity both micro-biologically and metaphorically.’ The struggle to restore absolute sterility in his theatre merits study (pages 122-123). Shortages in all items needed for the care of patients are exemplified in the anecdote on page 125. ‘When I asked the compounder to dispense a mixture, he told me that except for one item, all the items in the prescription were not in stock. When I asked him what the single available item was, he replied, “Aqua, sir.” ‘ At the same time there were repeated instructions from the government that patients were not to be asked to purchase any items from the market! This chapter also illustrates well the pig-headed obstinacy and thoughtlessness that so often characterizes medical bureaucrats.
Under ‘Team Building’, Dr. Rao teaches us important lessons on how each of us can help deserving junior colleagues to blossom. He persuaded the Director to depute Dr. V. Prabhakar, a brilliant young pathologist to spend a year with Dr. Darab K. Dastur in Bombay. When Dr. H. M. Zimmerman visited Hyderabad, he was so impressed by Dr. Prabhakar that he offered him a position in his own department in Yale University! Another example was Dr. D. Raja Reddy. ‘No one whom I trained ever gave me as much happiness and pride as Dr. Raja Reddy.’
The formation and the early years of the Neurological Society of India are also dealt with in this chapter. The anecdote regarding his presidential address to the Society at Calcutta in 1968 is amusing (page 134).
In 1969, Dr. Rao, along with Dr. Raghava Reddy (neurophysician) and Dr. Kakarla Subba Rao (radiologist) visited Dr. Lassman at Newcastle General Hospital. Dr. Rao writes that this is where he first learnt of the ‘new syndrome of lumbar stenosis'. On his return, Dr. Rao organized the annual conference of the Neurological Society of India in Hyderabad. He presented his experience of 8 patients operated upon by him and had it published in the Indian Journal of Radiology.
He was promoted to the post of Principal of the Osmania Medical College and later appointed Deputy Director of Medical Services. At Dr. Ramamurthi's behest, he was also appointed Postgraduate Professor of Neurosurgery. In 1971, he handed over charge of the department to Dr. K. V. Chalapathi Rao. Drs. Dinakar and Balaparameshwara Rao succeeded Dr. Chalapathi Rao.
In my opening paragraph, I wrote of his courage. Nothing illustrates it better than the manner in which he kept the college open and functioning during the violence of the Telengana agitation. You can read about it in Chapter 9.
The experience with the cabinet minister who met with an accident in Chandigarh, and when Dr. Chandy from Vellore and Dr. Rasmussen from Montreal also helped Dr. Gulati and Dr. Rao in his care, is of interest, as is the observation made by an astute critic of the ‘Very Important Person (VIP)” who went to Britain to get his cataract removed (pages 139-140).
Likewise, his experience with another minister (described on pages 141-142) will boost your admiration for him. He ends this description of events thus: ‘The minister did not have even the courtesy of thanking me but the father (a civil assistant surgeon) of the patient and father-in-law … became good friends…' He offers advice which will remain relevant to the Indian scene: ‘The moral is that conscientious specialists working solely in government hospitals should not aspire to any publicity or deal with VIPs. They must be content with the silent but heart-felt gratitude of the poor patients whose treatment they undertake as part of their duty. The poor will never forget him and his services. On the other hand, the rich will never remember him with gratitude. They even think that they are doing him a service by accepting him as a surgeon.’ Typically, he ends with a quotation of the last two lines of the following stanza:
Far from the madding crowd's ignoble strife,
Their sober wishes never learn'd to stray;
Along the cool sequester'd vale of life
They kept the noiseless tenor of their way.
Although he did not disclose the source, you will, of course, have recognized that this is from Thomas Gray's Elegy written in a country churchyard.
You will chuckle at his interpretations of notations by bureaucrats. ‘Please speak' means ‘I am too lazy to go through the file. Come and explain.’ ‘Put up the connected files' means ‘Don't worry me with this file any more.’ ‘Needs further probe' means ‘You have not delayed this file as long as you should.’ He also explained that he learnt as Director of Medical and Health Services, Government of Andhra Pradesh, that ‘whenever one felt the need for diversion for oneself or one's wife, one could go on an inspection tour at the expense of the tax-payer. Such tours, as a rule, reveal no more information than what one knew already.’ He quotes with approval Mr. K. P. S. Menon's experience with a senior English Indian Civil Services officer, who told him, ‘The Accountant-General is debarred by virtue of his office from exercising his common sense.’
His experience as ‘Auto-doctor' (pages 150-154) describing how he got engineers under his charge to repair faults in the 1300 vehicles they had at minimal cost even as he boosted their morale, is eye-opening.
As he ruminated, he listed some of his achievements. I shall quote merely three of them. He set up the first neurosurgery postgraduate centre in the state in 1968. As early as 1957, he had set up the first 24-hour neurosurgical head injury in the country. His department contributed three Presidents to the Neurological Society of India.
At the end of his preface, Dr. Rao summed up, ‘I have lived a life full of action and happiness. I have always tried to be truthful to myself and useful to others. I have no regrets… I do not claim not to have burnt my fingers, but I carry no ugly scars.’
As Professor I. V. Chalapati Rao wrote in his preface, the book is a source of inspiration for each of us as it upholds the vanishing values of life.