Me and my grandfather

Me and my grandfather (A mid20th century surgeon from the point of view of an early 21st-century surgeon)

It is the 104th birth anniversary of my grandfather Dr Narsinha Ramchandra Pathak (Dr NRP). Born in Wai on 30th September in 1915 he went on to become a doctor, social worker, and politician.

On his birthday I wish to focus only on his life as a surgeon.

Most of the material at my hand is

1. The first-hand narration by his brother late Mr B. R. Pathak, friends late Mr Yusufsaheb Sayyed and late Mr R. D. Parakhe.
2. Pathak Hospital Library: there I got a few of his diaries and notes and a lot of books, and also some old patient records of our hospital.
3. The operation theatre of Pathak Hospital
4. Stories heard from my parents, aunts and old staff at our hospital who worked with Dr NRP

Becoming a doctor, a blessing in disguise

At 19 as a first-year science student of the Willingdon College Sangli he had dreamt of following the footsteps of his eldest brother Gangadhar ( Who was a mechanical engineering student and succumbed at an early age to Typhoid at 21) but destiny had some different plans. He was called on by his elder brother Balakrishna who was the personal secretary (later on he went on to become Inspector of Police of Miraj State) to the chief of Miraj Senior Shrimant Raje Sir Ganagadharrao Balasaheb to Mahabaleshwar (Every summer the chief with his entourage would be in Mahabaleshwar). The Rajesaheb ordered him to join the Miraj Medical School which was attached to the Mission Hospital run by the American Presbyterian Church ( Now it’s Wanless Hospital); because the Miraj chief wanted him to join the state-run hospital as a medical officer in future.

There was no question of saying no to the Rajesaheb and he joined the Miraj Medical School. He studied there from 1935 to 1940 and passed the Licentiate exam of the college of physicians and surgeons of Bombay (LCPS). The students from the territory not under direct British rule did not get easy admission to colleges under the British rule, those were ‘colleges’ attached to universities and offered MBBS ‘degree’.

Training of a young surgeon

In 1941 he had completed the internship and did a medical officership for 1 year. A diary from those days is available which reveals a lot about the scope of the internship. The interns of the Mission Hospital got to do a lot of hands-on work in contrast to the present day interns.

The 1941 stint as a medical officer at the Mission Hospital Miraj was the period when he was getting trained as a surgeon. He worked under 2 great surgeons of that time. Dr S. D. Arawattigi and Dr D. P. Gorde.

Dr S. D. Arawattigi was a skilled surgeon who was trained in Mission Hospital Miraj (1928 pass-out batch) and trained extensively by Dr Charles Vail MD FACS DO( in future Dr S. D. Arawattigi would name his private hospital as The Vail Memorial Hospital). Though he was the head of Obstetrics and Gynaecology, he looked after general surgery too. The amount of experience he had as a general surgeon reflects well through this paper on right hemicolectomy that is published in the Indian Medical Gazette in 1944.

Dr D. P. Gorde was trained at the Medical School of Poona (LCPS 1931 pass-out batch). He joined Mission Hospital in 1932 and was made the head of the Otolaryngology and Ophthalmology department in 1936 and in a few years he developed this department working devotedly. He had started his technique of keratoplasty and was a master at ENT operations too especially mastoidectomy. He happened to be the president of the Miraj Municipality in that year. This kept him busy often and gave a lot of opportunities to his young apprentice Dr NRP.

Dr Gorde went on to become the director of the Mission Hospital and his article on the history of the Mission hospital is quite informative.

This one year stint explains 2 things:

The interest of Dr NRP in ENT and ophthalmology and also training in obstetrics and general surgery.

1942: He went to Hukkeri Road ( Now Ghataprabha) and joined the Karnataka Health Institute as a medical officer and worked there for a year and a half. He was trained there by Dr N. S. Hardikar, and Dr G. R. Kokatnur both America trained surgeons who had established that institute. The institute then was a busy sanatorium for tuberculosis and treated all sorts of ailments as such.

In the 1940s the specialization into Medicine/surgery was thing restricted only to the metropolitan cities. In the mofussils and peripheral centre, a single medical man would be an institute in himself. He would be all a physician, surgeon and obstetrician as well. This is quite unimaginable in today’s medical scene in India where the students and patients are too much fixated with the idea of ‘super-speciality.

Ophthalmologist, trained well but sans a degree

In 1943 he went to the Grant Medical College, Bombay. There he got registration for Diploma in Ophthalmology. The work at the JJ Hospital and Grant Medical college made him a trained ophthalmologist now. He pursued the course till the exam and when he was about to appear for the exam he was called at once back to Miraj as he was a bonded candidate and the state of Miraj was in dire need of a medical officer. But his love for ophthalmology and cataract surgery never abated. From 1952 to 1968 every month of May he conducted cataract surgeries free of cost.

Back to Miraj

1945 He joined as the Assistant Medical Officer to the state-run Hospital of Miraj Senior. Dr K. G. Gosavi LCPS was the chief medical officer then. Dr K. G. Gosavi was impressed with him and gave him the liberty to operate independently. A year as the assistant medical officer of the Miraj Senior state taught him a lot in terms of practical knowledge. Soon his reputation as a capable physician and surgeon began to rise. He started his private setup in 1946 and which was named Pathak Hospital.

During 1946-47 he would assist his teachers Dr D. P. Gorde and Dr S. D. Arawattigi again when required. But soon he got too busy with his private practice. 

The busy surgeon who self-learnt and improved

By the late 1950s, his practice had risen a lot and he was a busy practitioner with his own 80 bedded indoor setup and used to carry around 5-7 operations daily. The operations included all variety including urology, general surgery and obstetrics.

In the 1950s he had started his blood bank of sorts. The records in the Pathak Hospital archives show multiple records of blood transfusions during that period. Also, he started developing a pathology collection with jarred and mounted specimens of all varieties. Unfortunately in his later days, due to too much occupation with politics, the upkeep of the specimens was neglected and most of them are lost now.

In the later 1950s and 60s, he travelled all over the world, visited prominent medical centres in all the countries he visited.

One of the high points of his surgical career was when he presented a case of stomach trichobezoar in the plenary session of a Medical Conference in Cairo in 1963. If we go through the details of that paper. It shows that he had adequate anaesthesia equipment to carry out major abdominal surgery. He employed routine laboratory methods and he was very meticulous about record keeping.

The OT equipment he left behind tells us about the range of operations he did

1. Complete cataract operation set, ophthalmoscope ( It was tested by his ophthalmologist granddaughter and found working)

2. Rigid bronchoscope and oesophagoscope

3. An hydraulic OT table purchased in 1950, is still in working condition

4. Hudson’s brace and set of burrs

5. Complete set of dentistry forceps

6. Bone nibblers, elevators, Gigli saw Handles, fracture table

7. Boyle’s apparatus Manufactured in 1958 still functioning

8. Electric sucker manufactured in 1957 still functioning.

9. Thoracotomy set: nobody would purchase unless one does these types of surgeries.

10. Desjardin’s forceps: definitely very specific for CBD stones

11. Adenoid snares

Training the staff

He was always a team man leading from the front. He rotated his employees in all departments so a single individual is capable to do most of the essential things and later on specialise in one, so that even if somebody is absent the work is not stopped.

Behind every successful man….

His mother Mrs Seetabai, always encouraged him. She had personally helped him conduct deliveries before he recruited and trained nurses. His elder brother Mr B. R. Pathak resigned from his job with Police and was a full-time administrator of all his ventures including the hospital, orphanage and also managed his election campaigns. His wife Mrs Vimalbai Pathak used to manage the store and housekeeping of the hospital and was helped by Mrs Indirabai wife of Mr B. R. Pathak. This invaluable family support kept him completely unbridled with other jobs and he could soak in the clinical job all the while during the first two decades of the practice. It was in the latter half of the 1960s that he entered politics formally. After entering politics, he lost a big chunk of his surgical practice and in 1978 when he quit active politics he had to start again from scratch. While busy in politics he had to rely on the surgical services of other surgeons and himself could provide hardly any time for surgery. It was his inspiration that made 4 of his 5 children take up medicine. The eldest daughter worked at a village as a general practitioner for 40 years now is retired, the second daughter is a gynaecologist and is involved in epidemiological research also. Both of them are GMC Miraj alumni and were trained in the same hospital as Dr NRP, the Wanless hospital. He was joined by his son and youngest daughter in 1980 both MS from LTMMC and BJMC respectively.

Impressions of a budding surgeon of his grandfather

I listened to many anecdotes of him as a child from his colleagues and the older staff of our hospital.

Though that OT table and Apparatus are on standby mode now and replaced with motorised adjustable tables and anaesthesia work station. And the big old 15 feet high operation ‘theatre’ with a viewing gallery is now modified to 2 smaller operation ‘rooms’ air-conditioned, now having a false ceiling 10ft high and with air filters, operating on the same table and the same place where my grandfather operated once is always a special feeling for me. The same table is being used by 3 successive generations of surgeons! (The Vail Memorial Hospital Miraj of Dr Arawattigi is the only other hospital where my grandfather, my father and myself have operated.)

Many of the needle holders or artery forceps my parents or I use today were used by Dr NRP once.

I was not fortunate enough to have enough of him, he passed away when I was barely four years old and I have barely a fading memory of him. But somehow I feel his presence through the underscores he made in the books of his library, through pages of his diaries and every time I scrub up for a case in the operating room of Pathak Hospital.

I joined the medical college in 1999 and joined Pathak Hospital in 2014 after 15 years. (After 15 years after joining Medical school Dr NRP had already established his own hospital). I restrict myself to only a particular subset of surgeries. (Dr NRP could do a hysterectomy to cataract everything because he was the only treatment option available for the patient). In the 21st century when you have a specialization, and subspecialization, people doing more and more of a restricted subset and having many people excelling in small subsets has certainly helped the medical field reach new horizons.

In contrast to this, my grandfather was a mid-20th century surgeon who worked at very high volume centres where there was a paucity of trained doctors but got the good fortune of learning with the masters. That exposed him to many cases at a young age and could progress. But it takes a lot of guts and a definitive skillset to progress without a structured programme in so many domains of surgery. One cannot just read and go out and do an operation. One has to be thorough with 

1. The basic surgical skills.
2. He was trained by high volume surgeons at high volume centres with exposure to all domains of surgery hence he could acquire these in a shorter period. 
3. In-depth knowledge about the anatomy of the part being operated and what to do.
4. The library is testimony to this process he underwent. It has multiple editions of Operative surgery text. Most of them are underscored with a red pencil.
5. Knowing the possible complications that can arise and have a plan ready for each of them if they arise. This is not merely possessing knowledge-base but also requires the gifted skill of presence of mind. The use of a myoma screw to deliver a trichobezoar was ingenious.
6. Have the equipment, trained staff to manage the above.
7. Most important: The patient must have faith in you that you can do it successfully and consent ( this cannot be earned overnight)

It says volumes about the quality of training he got at his medical school and self-learning in his own capacity as well.

Conclusion

The take-homes I draw from my grandfather’s career as a surgeon especially the way he trained himself, are,

1. Always be observant. Every small thing you do in daily practice might teach you something
2. Reading keeps oneself updated, and as a clinician, it’s our obligation.
3. The basic qualification is a must but not sufficient, importantly challenging and reinventing oneself keeps us on our toes.
4.  Empathy and patient safety are always important.
5.  Imbibe the extra-academic good qualities of your mentors too.
   1. The missionary zeal he imbibed in the Miraj Medical school helped him to establish Pathak Trust and Anathashram.
   2. The political activism of Dr D. P. Gorde, Dr Hardikar
6.  Work in a cohesive team.