by Joan Arakkal
One day, a thirteen-year-old boy climbed onto the steps of the moving bus, lost his grip and fell onto the road. Hearing the shrieks of people inside and outside the bus, the driver applied his brakes – but only after the back wheel had grazed the boy’s abdomen. An auto-rickshaw was hailed and the boy was rushed to hospital. He was taken to the operating theatre, where part of his damaged bowel was removed along with a large part of his crushed abdominal wall. Caring for the boy on the surgical ward was heartbreaking. His gut was exposed and the antibiotics did little to control the florid infection that had set in. All the masks could not ward off the foul smell. Hiding my revulsion as I dressed the wound each morning, I attempted a cheerful conversation with the lad.
Looking up from the dressing one day, I saw the bus conductor waiting to see the boy. He did not tarry long, as the powerful stench overtook him. Bidding goodbye to the boy and his parents, the bus conductor left, acknowledging me along the way.
I settled into a seat on the Number 11 bus the next morning and the conductor came towards me. I saw respect and sympathy mingled in his look as he ripped off a familiar ticket. ‘I feel sorry for you, doctor,’ he said. ‘I don’t know how you do what you do. I would not do that for 1000 rupees.’
Our internship was coming to an end. We had made the journey through the thrills of curing the sick, felt the heartbreak of losing patients, cursed the thoughtless nurses whose requests for mundane prescriptions had broken into our well-earned sleep. We had run around collecting investigations in preparation for ward rounds, been chastised for discharging patients too quickly and praised for organising operating lists – all while trying to make plans for our future as proper doctors. Though we were thrilled at the prospect, we also feared the responsibilities and expectations that would come with appending ‘Dr’ to our names.
I loved the hospital library. It was where I unwound and relaxed. One day I chanced upon a paperback edition of Ten Fingers for God. The book was about a British surgeon, Paul Brand, who pioneered the reconstructive surgery of hands mutilated by leprosy. Like a potter, he moulded deformed hands to allow them to grasp and hold. His patients had been assailed by an infection for which they were not responsible. Not only were they disfigured, they were also cast out of mainstream society. As the bacteria took hold of their bodies, they lost their livelihoods, their families and their humanity. ‘Hansen’s disease’, as we were taught to refer to leprosy, was still prevalent and, despite being treatable, it continued to be stigmatised.
Contrary to widely held notions, leprosy does not spread easily, but the disfigurement it causes made people fear it. Even close family members shunned the afflicted. Patients who had not received timely medical treatment were left with distinctive physical deformities. The leprosy bacteria destroys the nerve endings that normally allow the perception of touch and temperature. Patients did not have the protective instinct to draw away from harmful stimuli. Their wounds went unnoticed and uncared for, until their hands and feet appeared eaten and shrivelled, and their stumpy fingers discharged pus. The bacteria also attacked the tissues in their face. Nodules appeared on cheeks and foreheads. Noses collapsed. With their deformed ears and opaque eyes, the patients could well have been wearing masks. Their faces were described as ‘leonine’, a metaphor that stripped away their human dignity. Fear and revulsion caused people to step away as they stretched out their swollen, claw-shaped hands to seek alms.
The magic that Paul Brand worked with his innovative surgical techniques restored dignity to his patients. His work was fascinating. It sounded challenging and life-changing.
I started dreaming about making a vocation out of fixing hands. I imagined the thrill Paul Brand must have felt every time his patients returned to earning a livelihood, thanks to his skilful restoration. The idea grew and took shape until I couldn’t ignore it. I was further enthused by my first medical pilgrimage to Karigiri Hospital, where Brand had worked decades earlier. Located near the Christian medical college in Vellore, the hospital – now called the Schieffelin Leprosy Research and Training Centre – was involved in all aspects of care of the disease while also undertaking research into Hansen’s disease.
I was humbled by the gratitude of the patients treated there. Being touched and cared for, when previously they had been feared by society, they found hope as their deformities were corrected and function was restored to their hands. In the workshops where men crafted wood and women wove baskets, their loud and boisterous laughter could be heard above the awful silence of the society that had shunned them.
My fellow interns were also exploring avenues to convert their professional qualifications into a vocation. Some planned to study in the West and make their futures there. Several of my colleagues sat licensing exams in the US and UK. They were not alone. In the decades after India became independent, there was a mass exodus of talent. Skill and excellence can only bloom when they are nourished with resources and, in the impoverished country, talent stagnated and progress was slow. The English poet Thomas Gray wrote, ‘Full many a flower is born to blush unseen, And waste its sweetness on the desert air.’ Many professionals were lured from the ‘desert air’ to wealthier nations where their burgeoning talent could be supported.
It was the early eighties and televisions had only just begun filtering into the homes of middle-class families. The 1984 Los Angeles Olympics gave many of them the opportunity of watching live what they had hitherto only seen as blurred images on a newspaper the following day.
Most of what I knew about the West was gleaned from the books I read and the enchanting suitcases opened by relatives returning from Australia and the US. I looked at the Toblerones, the ‘foreign’ tape recorders, the refillable pencils, the shampoos in attractive containers and the synthetic dress materials with awe. Yet, for me, India, with all its frustration and perceived lack of opportunity, was home. It was where I thrived. Leaving my homeland after I had used her taxpayers’ money to obtain a medical qualification held no appeal for me.
As a middle-school student, I had once sat on a school stage, wearing a white cotton sari and clumsily spinning a wheel, while a bespectacled boy who represented the young Gandhi sat beside me. My teachers were staunch Gandhians. They instilled in me a sense of national and cultural identity. Serving our countrymen was seen as our duty. Leaving this wondrous land was out of the question. Why cross the oceans when all I wanted was here? But was it?
HAPPY FEET
My days as an intern came to an end. Six-and-a-half years after entering medical school, I was a doctor with a dream of being a hand surgeon. India’s emergency days, which had facilitated my entry into medical school, were now behind us. The country had moved on, amidst upheavals and strife. The rigid taxonomy of the caste system was no longer the preserve of the British. In the interest of continuity, a free India had chosen to embrace many of the institutions and practices that had been imposed on it during colonial rule.
Sixteen seats at the hospital in Coimbatore were set aside for aspiring surgical trainees. Fifteen of these were categorised for the ‘backward’ community. Just one place was set aside for a student who could not slot into a backward status. The Brahmins, some sects of Christians, and Muslims of a particular type jostled for the prized ‘forward’ seat. Having received both a gold medal and a certificate for being the ‘best outgoing student in surgery’ and another medal for having the highest score in surgery, I was lulled into believing that I had an easy pass to the open postgraduate trainee’s chair. I was wrong.
The corruption that had briefly stepped aside to allow me entry into medical school was back, as were the rapacious officials who had the power to decide who would be a future surgeon and who would not. Money spoke louder than any medal or certificate.
I sat across from the interview panel for selection into surgical training and the head of surgery asked me why I wanted to be a surgeon. He referred to my ‘petite’ frame, seemingly a negative trait for the pursuit of a surgical career. He was
not a large man himself, but his chronic-smoker’s thin build was apparently acceptable for a male surgeon. He continued, in a posh British accent acquired during years of training in England, ‘But what will our boys do if women enter surgery?’ I wondered. Work harder to qualify for the position? Do a better job? Collaborate professionally for the benefit of their patients? But he was not looking for a reply. I realised he was using gender as a ploy to cover up corruption. I could have been a muscular, six-foot-tall man and the outcome would have been the same. I was unaware of the fraudulence involved in the selection process.
A friend had already tried to tell me that the position had been spoken for. A young male doctor was a good catch in the marriage market. A timber merchant who had toiled hard came into money, his daughter was a doctor of marriageable age and he was looking for a son-in-law. He wanted one who was educated, preferably a doctor. It would be even better if he were a surgeon, or at least a potential surgeon. The astute businessman went about the task of securing his daughter’s future. A suitable candidate was identified, and with some political clout, enough money and an amoral surgeon on the interview panel, a groom was born. Much to my dismay, the future surgeon and son-in-law to the iron merchant was to sit in the seat that I had hoped to occupy.
With the door to surgical training closed to me, I had to look elsewhere. I entered the large anatomy hall of St John’s Medical College in Bangalore as a tutor. I enjoyed teaching and I relived my days with Caddy as I guided students through their first dissections. Revisiting those lifeless tissues, seven years after entering medical school, gave me the opportunity to view them in a clinical context. This unexpected opportunity helped my anticipated surgical career. What better way to learn something than to teach it?
I studied the human body again, alongside my students. Unlike them, I now understood the importance of knowing the details of structures and their relationship to each other. Anatomical landmarks took on added significance as I imagined making incisions that avoided nerves and blood vessels. Langer’s lines of skin tension took on a new importance, as I considered how to avoid ugly scars when I finally operated on patients. Surface anatomy was now as important to me as the structures that lay beneath the skin.
The year and a half that I spent teaching in Bangalore was an indulgent time. The salary was a princely sum compared to the paltry intern stipend. Abe was also a third-year medical student at St John’s at this time. Spending money that never seemed to run out, we enjoyed the culinary delights of Bangalore. With our friends, we dined on continental cuisine at Caesars, ate Chinese at the Rice Bowl, enjoyed the rotisserie chicken basted with spicy lemon on Mahatma Gandhi Road and ate late-night parathas from roadside dhabas. On Abe’s twenty-first birthday, we even treated ourselves to our first-ever fish and chips at the posh Windsor Manor.
I also had the honour of meeting and forging a lifelong friendship with the Appu family. Mr Appu was the director of the Lal Bahadur Shastri National Academy of Administration which is situated in the picturesque town of Mussoorie at the foot of the Himalayas. A few years earlier, he made headlines when he resigned from his position on a matter of principle. During a Himalayan trek, a male probationer from his academy sexually harassed two female trainees and threatened them with a gun. Mr Appu recommended that the trainee be discharged, but political clout saw the student worming his way back into the institution. Mr Appu resigned in protest and brought the matter to the attention of the Prime Minister, Indira Gandhi. The scandal rocked parliament, Mr Appu’s decision was upheld and the student was discharged. His integrity and the boldness of his move was big news and was discussed over dining tables across the nation, including ours.
In his first year at medical school, my brother was out on a stroll in the suburbs of Koramangala. Imagine his surprise when he saw Mr Appu, the object of his hero worship, standing at the gate of the house where he now lived. When I arrived at St John’s a few years later, I had the privilege of being included in the friendship between the Appu family and my brother. Mrs Appu was a true Gandhian. Any self-respecting Kerala woman has a sizeable collection of gold jewellery but as a young woman, Mrs Appu gave her gold to the independence movement. When I met her in her later years, her neck remained bare, reminding me of the sacrifices made by her generation. She was also a splendid cook. Abe and I still fondly remember her specialities: ginger chicken cooked in wine, and lemon soufflé. Mr Appu, the man with the unshakeable moral core who taught us enduring lessons about the value of dissent, continued to be a strong presence in our lives until he passed away in his eighty-third year.
My dream of becoming a hand surgeon gained strength during my time at Bangalore and the prospect of entering surgical training became more likely.
Around 1985, universities replaced applications and interviews for selection into postgraduate training with written examinations. Impersonal answer sheets did not reveal details of the applicant, thereby minimising the chances of favouritism and corruption in the process. Two years after joining St John’s, I entered orthopaedic training at Calicut University in Kerala. The 2000-bed tertiary hospital serviced the population of northern Kerala. Patients with broken bones, maimed extremities and legions of birth defects found their way to the emergency department or outpatient clinics of Calicut Medical College. This is where my life in orthopaedics, which would eventually lead to hand surgery, began. For me, orthopaedics was a means to an end.
When new acquaintances asked what my medical speciality was, my reply raised eyebrows. ‘Orthopaedics?’ The responses carried a common thread of incredulity. A woman practising orthopaedics was a novelty. Looking at my small frame, they said, ‘But you don’t look the part. We thought orthopaedic surgeons had to be big.’
I honed my response to this question. ‘Good techniques come in small packages! Modern orthopaedics is not all about brute strength.’ If they were unconvinced, I added that life-threatening emergencies in orthopaedics were few, and being able to work civilised hours was not without its appeal.
There are 206 bones in the adult human body. A few are big, but most are small. More than half reside delicately in the hands and feet: fifty-four in the hand and fifty-two in the feet.
There was a time when brute force would have served well in the treatment of bones. Without sedatives and the muscle-relaxing effects of anaesthesia, patients had to be held down forcibly. Alcohol did not numb the pain of a bone crushed under a boulder or splintered by the sabre teeth of a tiger. The walls of the Royal Colleges were decorated with gory medieval paintings in which anguished patients were held down by cloaked men in tunics, barber surgeons brandished saws over limbs and patients had their feet cut off after being given a sponge soaked in hemlock. I was pleased to have entered an orthopaedic world that had left these antiquated techniques behind.
The diminutive Dr Vishwanathan was Unit Three’s popular head. His gentle demeanour and manners were unlike the other assured and sometimes brash orthopaedic surgeons in the department. Yet going on early-morning ward rounds with Dr Vishwanathan was challenging. We called him Speedy Gonzales. His short figure sped through the corridors and his retinue struggled to keep pace as he avoided the lifts and raced up the stairs to the orthopaedic wards. His club foot propelled him faster than our feet could carry us.
It was not difficult to guess why he had developed a special interest in the treatment of club foot. While we knew little about the background of his congenital condition or why it appeared to have been left untreated, we understood the empathy he had for the children who were referred to him. Dispelling superstitious notions and reassuring mothers that their child’s club foot had nothing to do with them watching the eclipse or stepping on a grave, Dr Vishwanathan manipulated and stretched the little feet, week after week, to get them to look and function normally. We watched and learnt as he applied a moistened, narrow, plaster of Paris roll over a deformed foot using the Ponseti method. As he gently pushed the ankle and turned the foot outward, he warned us about the pot
ential dangers of overzealous manipulations. Every week, the mothers and their babies travelled long distances to have their plasters changed and fresh ones applied, correcting the foot ever so slightly at each visit.
When I entered the plaster room in my first week of joining the department, I was given a long, white, coarse cotton gown to wear over my dress. The wisdom of that became obvious as I stepped into the world of plastering. The new trainees were given rolls of white gauze and a bag of gypsum powder. We powdered the long reels, rolled them and manipulated them into position over broken bones. It was important to soak the roll in the tepid water for exactly the right amount of time. Too long and we were left with a squishy mess that congealed into a gluggy slippery lump as we tried to unroll it over the limb.
Mr Nair was the plaster technician. He was always immaculately dressed in white trousers and a white shirt. I often wondered if the white hair on his arms, eyebrows and head – a colour that contradicted his youthful persona – was a result of years of gypsum exposure. Initially, Mr Nair’s attitude towards me was dismissive. In all his years at the hospital, no female orthopaedic trainee had entered his domain. He wagered a private bet with some of the other trainees: he was certain I would not last the length of the training. As the months rolled on, it became clear to him that not only was I there to stay, but I relished the process of straightening bones, using techniques of functional bracing that made surgery unnecessary and splinting them in plaster of Paris casts. Eventually, his morning greetings became warmer.