Neurosurgery in India.TD Nadkarni, A Goel, SK Pandya
Department of Neurosurgery, King Edward Memorial Hospital and Seth G. S. Medical College, Parel, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 12571403
Source of Support: None, Conflict of Interest: None
Keywords: History of Medicine, 20th Cent., India, Internship and Residency, Neurosurgery, history,
The development of Neurosurgery in India during the past 55 years has almost paralleled the achievements of the country in “55 years of freedom”. There was no trained neurosurgeon nor any department of neurosurgery in India at the time of Independence. A few general surgeons were performing neurosurgery at that time. All heads of surgical, medical and basic sciences department, considered neurosurgery, neurology and its ancillaries - neuroradiology, neuropathology, neurophysiology and neurochemistry irrelevant under the circumstances. It was a continuous struggle to get rid of this controlling yoke.
Over the years, there has been a tremendous change. Neurosurgically treatable diseases are now diagnosed and referred in good time. Many ancillary diagnostic facilities are now available and the patients themselves are aware of the need to seek early neurological consultation. Neurosurgery in India is now at par with the best of such services available in the world. All necessary technological advances as well as qualified personnel are available in the country. Though the centres of excellence are based in the major metropolitan cities of the country, access to these services is easier than before. Assimilation and application of technological advances has been at such a rapid rate that many centres in India are at par with similar ones abroad.
The principal authors of ancient Indian medical text were Sushruta, Charaka, Vagabhata, Bela and Madhava. Ancient Indian medical scientists were uncertain whether Hridaya (heart) or mastishka (brain) was the seat of consciousness. The word mastishka and mastulunga (brain) appears in both the Charaka and Sushruta Samhitas. An account of the central nervous system and its pathology occurs in these texts.
While tracing the development of neurosurgery in ancient India, the following salient references are found. The transplantation of head of an elephant on Ganesha (an Indian Diety), trepanation and removal of intracranial mass by Jivaka (physician to the Lord Buddha) and the neurosurgical accomplishments of Sushruta, the master surgeon, are all documented in the Sushruta Samhita.
Drs. A. P. Bacha, G. V. Deshmukh, R. N. Cooper, A. V. Baliga in Bombay; N. S. Narasimhan, C. V. Vishwanatha Menon and U. Mohan Rao in Madras; Lt. Col. F. J. Anderson and Provat Sanyal in Calcutta, Col. R. Mirajkar and Baldev Singh at Lahore and Balkrishna Rao of Mysore were the pioneers of neurosurgery in India.
Although neurosurgery was being performed with gradually increasing interest by general surgeons in Bombay since 1940, the credit for starting it as an independent speciality goes to Dr. Jacob Chandy of Vellore who after completing his training in Canada and the United States, started a separate department at the Christian Medical College (CMC) and Hospital, Vellore in the second quarter of the year 1949 with 12 beds spread in the various medical and surgical wards.
Dr. B Ramamurthi soon followed at the Government General Hospital in Madras in the fall of the same year. He had to work as a General Surgeon till a separate and independent chair for neurosurgery was created in the year 1950. Dr. S. T. Narasimhan started a private neurosurgical clinic in Madras in the year 1948 and later set up an EEG laboratory at the Government General Hospital, Madras in the year 1950.
Dr. Ram G. Ginde started the first specialised department of neurosurgery in Bombay and the third in the country, at the Seth G. S. Medical College and King Edward Memorial Hospital in April 1951. Initially Dr. Ginde’s patients were housed in a general surgery ward. He carried out all neuroradiological tests himself and performed 2-3 operations every week. More than 80 per cent of the allotted 25 beds were occupied by neurosurgical cases within the first six months. After considerable struggle, a separate and independent department of neurology and neurosurgery was opened in the fall of 1953.
With only three qualified neurosurgeons in the entire country till 1956-57, the workload at all these centres rapidly increased both in quality and in quantity.
Most of the pioneers of Neurosurgery were trained in the west, predominantly in England and the United States. Some of these doctors persevered in their attempts to set up neurosurgical services, however some lost their patience and returned to greener pastures abroad.
In South India
At the CMC and Hospital, Vellore the first neurosurgical department started in April-May 1949 with the appointment of Dr. Jacob Chandy as Associate Professor of Neurosurgery. He became Professor in the year 1954. In the earlier years, he had as his close associate Dr. Baldev Singh, a neurologist. It was here, that the first Residency Training programme was started in 1954. The first recognised University course for M.S and later for M.Ch., was begun in the year 1958. Dr. K. V. Mathai was the first person to have had his entire training in India before qualifing as a neurosurgeon. The first Neurology Training Programme was initiated in the year 1966.
Dr. B. Ramamurthi, in Madras, made a similar headway at the Madras Medical College and Governmenat General Hospital. The Institute of Neurology was later established here in 1965. The other centres of note were Stanley Medical College, Madras which was started in 1962 under Dr. P. Narendran and one at Madurai in 1963 under Dr. M. Natrajan. The late Govinda Swami established the All India Institute of Mental Health at Bangalore in early 1950s. Dr. R. N. Verma started a formal neurosurgical department in the mental hospital in the year 1959. This was later to form the National Institute of Mental Health and Neurosciences. In Kerala, the first neurosurgical unit was started at Trivandrum in the year 1966 with Dr. Bahuleyan and Dr. Sambasivan and another one at Calicut with Dr. Rajan in 1969.
In West India
Regular neurosurgery was started in Mumbai in January 1951 at the Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital. However it was not until October 1957 that the Department of Neurology and Neurosurgery was at last opened after a considerable struggle by Drs. Homi M. Dastur and Anil D. Desai with a separate ward of 40 beds and an independent operation theatre. Dr. U. S. Vengsarkar and later Drs. Sunil K Pandya, Ranjit D. Nagpal and Anil P. Karapurkar worked in the unit.
At the Grant Medical College and the Sir Jamsetjee Jejeebhoy Group of Hospitals, one of the three oldest medical colleges in the country, a separate neurosurgery unit was started in 1959. Shantilal J. Mehta, Professor of Surgery encouraged Gajendra Sinh, to train in neurosurgery at Vellore, and then head this department. Dr. S. N. Bhagwati, Dr. V. S. Dave and Dr. R. G. Ginde later joined him.
At Topiwala National Medical College, Dr. S. Patrao a senior honorary general surgeon had started operating occasionally for lumbar discs and spinal cord tumors and tics in the early fifties. Dr. V.G. Daftary later joined him. In 1971 a formal department of neurosurgery was established. Dr. B. J. Damany and Dr. P. S. Ramani set up the department of neurosuregry in Lokmanya Tilak Medical College and Hospital, Sion in 1975.
Neurosurgical work for private patients in Mumbai was started at the Bacha Memorial Nursing Home and Parsee General Hospital in 1951, thereafter at the Breach Candy and the Bombay Hospitals in 1954.
In Poona, Dr. R. D. Variava was practicing neurosurgery since 1966. Dr. S. D. Dighe followed him soon therafter. Col. Virendra Mohan at the Armed Forces Medical College, Dr. Azariah in Miraj, Dr. N.A. Siddiqui at Nagpur were the pioneers of neurosurgery in these cities.
In Ahmedabad, the services were started under Dr. P. R.Thakore at the Civil Hospital. The first Department of Neurosurgery was however opened at the Sheth Vadilal Sarabhai Hospital in 1963 by Dr. B. J. Damany.
In North India
Neurology and Neurosurgery started in 1956 with the arrival of Dr. Baldev Singh from Vellore, at the Tirath Ram Shah Charitable Hospital. Dr.Victor M.Rao started regular neurosurgical work in the year 1958-59. In 1962-63, a second neurosurgical unit came into being at the G B Pant Hospital, Delhi with Dr. Arjun Sehgal as neurosurgeon.
The All India Institute of Medical Sciences was founded in 1946-47. The regular departments of neurology and neurosurgery came into existence only in March 1965 with the appointment of Dr. Baldev Singh as Professor of Neurology and Dr. P. N. Tandon as Professor of Neurosurgery. Drs. Brahm Prakash, Ajit Banerji and Ravi Bhatia later joined him.
Another neurosurgery unit came into existence at the Safdarjung Hospital, New Delhi in the year 1967 under Dr. H. S. Ahluwalia. A unit in the Military Hospital in New Delhi with Major R. S. Rana at the helm followed this.
Other centres in the northern region were as follows: at Lucknow Military Hospital under Lt. Col. A C Ray in 1958, the Post Graduate Institute of Medicine and Research, Chandigarh Dr. D. R. Gulati in 1962, Christian Medical College and Hospital, Ludhiana under Dr. Namboodripad, Dr. M. G. Sarin at SMS Hospital, Jaipur in 1961-62, and Banaras Hindu University in 1963 under Dr. S. K. Mukherjee.
In East India
In 1955, Herbert Krause of Vienna came to Calcutta at the invitation of B.C. Roy, the Chief Minister of the Government of West Bengal and set up neurosurgery at the S.S.K.M. Hospital. Dr. R. N. Chatterjee and Dr. Asoke Bagchi trained under him.
A centre was started at Ranchi, Bihar under Dr. R. Prasad and Dr. Jaiswal and at Bhubaneshwar, Orissa by Dr. Sanathan Rath.
In Central India
The first neurosurgical unit in this region was started at the King George Hospital at Vizag (now Visakhapatnam) in 1956 by Dr. S. Balaparmeshwara Rao. Dr. B. Dayanand Rao started a unit at the Osmania Medical College and Hospital at Hyderabad in 1957. Units were also started at Kurnool under Dr. K. V. Chalapathy Rao in 1964 and at Guntur Medical College with Dr. M. V. Subramaniam.
In 1950, four full-time neuroscientists met in the city of Madras. Two neurosurgeons - Drs B. Ramamurthi and Mathew Chandy, one neurologist Dr. Baldev Singh and one clinical neurophysiologist Dr. S. T. Narasimhan. As a result of this meeting, the Neurological Society of India was inaugurated in the year 1951 at Hyderabad along with the annual meeting of the Association of Physicians of India. The four charter principles of the Society were as follows:
1.All branches of the neurological sciences shall keep together as a united body as long as possible for their own development, which have close linkage and so shall be supporting each other.
2.Full members of the Society shall be only full time career worker in any of the neurological science discipline.
3.The Society shall always strive for excellence in their disciplines;
4. Competence shall be the hallmark of the clinical sections of the neurological sciences.
Neurology India is the scientific publication of the Neurological Society of India started in 1953.
Pioneering work has been done by Indian neurosurgeons in the following fields: craniovertebral anomalies, encephalocoeles, tuberculous meningitis, tuberculomas, anti-tuberculous therapy for intracranial tuberculous disease, parasitic infections, stereotactic surgery and fluorosis. Many research activities have been conducted in the above fields.
The first neurosurgical training centre in India was at the Christian Medical College, Vellore. The Madras Medical College followed soon after. Since then, training centres in Neurosurgery have been set up in most other states. Many have obtained the coveted postgraduate qualification in Neurosurgery and have spread out to render excellent service to the pubic in various parts of India.
The Vice Chancellor of the Madras University Padmavibhushan Sir Lakshmanaswami Mudaliar was a very dynamic, progressive medical educator. He championed the concept of postgraduate degrees in the higher specialities in medicine and the concept of residency programmes in training. It is noteworthy that to maintain high standards, the University of Madras enacted a regulation insisting that each candidate appearing for the examination leading to M.Ch., in Neurosurgery performs an actual operation under the responsibility and supervision of the Professor of Neurosurgery at the Institution. This pattern had since been adopted at all other neurosurgery centres in the country.
Neurosurgery residency programmes are available for three years after postgraduation in General surgery (M.S.) or a direct five years course after medical graduation (M.B.,B.S.). The Diplomat of National Board (D.N.B.) is awarded by the National Board of Examination, New Delhi. Students work in recognised departments under the guidance of recognised teachers.
During the last 30 years the number of neurosurgery centres has increased from the original three centres at Vellore, Madras and Mumbai to many units distributed in different parts of the country. Many of these units are adequately equipped to enable basic neuroradiological investigations and to cope with varieties of neurological and neurosurgical problems. They are adequately staffed with medical and paramedical personnel to ensure timely and efficient treatment to be given to serious and emergency cases at short notice and to provide proper aftercare and follow-up. There is proper record keeping, satisfactory secretarial assistance, a good reference library with sufficient books and periodicals. There is a continuous well-organised in-service graduate training programme for candidates who are selected after proper screening. This covers the theoretical aspects in the main and allied subjects and ensures a very satisfactory practical approach to clinical neurology and familiarity with bedside, diagnostic and operative procedures. There are regular ward rounds, seminars, group discussions and actual performance of technical and diagnostic procedures including different types of operations under the supervision and guidance of the senior members of the staff. A dissertation based on a more detailed study in one of the aspects of the speciality is compulsory.
Today we have at least 15 centres of excellence where skull base surgery, vascular surgery, neuroendoscopy, radiosurgery, interventional neuroradiology, complex spinal instrumentation, deep brain stimulation and every conceivable type of neurosurgical procedure is carried out. We have also a National Brain Research Center in New Delhi. We offer teleconsultation in neurosurgery to remote villages through satellites orbiting in outer space, which the Department of Space, Government of India has indigenously made and launched. There are only seven countries in the world, which have this capability. At present, there are 800 neurosurgeons, 110 neurosurgical trainees in 55 residency programmes (5 National Institutes, 4 Deemed Universities, 25 Medical Colleges, 21 corporate, private and trust Hospitals) in India. 90 of 160 medical colleges have neurosurgical departments. 45 out of 275 corporate hospitals have neurosurgical units and about 125 small to medium nursing homes have facilities for basic neurosurgery. This is no doubt insufficient for one sixth of the humanity living in India. Many Government Hospitals in India provide the most complex neurosurgical services free of cost.
Besides general neurosuregry, various sub-specialities have developed as per international standards. These include, paediatric neurosurgery, stereotactic surgery, functional neurosurgery, epilepsy surgery, skull base surgery, interventional neuroradiology, and spine surgery.
It is gratifying to note that from a humble beginning at Vellore, Madras, and Bombay between 1949 and 1954, the country has now a multitude of neurosurgical services. Yet the total number of neurosurgeons outside major cities is inadequate even to provide uniform minimum basic neurosurgical facilities. It is expected that this shortfall will soon be overcome.