emergence of neurosurgery in india

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Journal of the neurological Sciences 71 Elsevier Publishing Company, Amsterdam - Printed in The Netherlands Emergence of Neurosurgery in India H. GASS* Department of Neurosurgery, Wayne State University School of Medicine, Detroit 2, Mich. (U.S.A.) (Received 23 June, 1966) In the developed countries of the West, the growth of neurosurgical services kept pace with the maturation of the specialty of neurological surgery according to the frame- work of health service provided by the country concerned. Many underdeveloped countries have not yet faced or are just beginning to face the problem of the distribu- tion of neurosurgical services to their people. In this regard the experience in India since achieving its independence in 1947 is pertinent. Neurosurgery has taken root in that country only in the last seventeen years and is now emerging as an acknowledged specialty. As in all underdeveloped countries quite naturally the greatest medical effort has been expended in the direction of major quantitative needs, namely toward the control and treatment of epidemiological disease and to the distribution of medical services to the rural areas which in India contain 80 % of its population. Facts show, however, that neurosurgery and other higher specialties may develop simultaneously with these more demanding epidemiological services. To neglect deserved attention to these narrow needs is to be wasteful with already scarce facilities. The record of development of neurosurgery in India offers a unique opportinity to learn from histori- cal experience how neurosurgery has fared under these circumstances. Its development there has been largely spontaneous. At the beginning of 1949 India's 450,000,000 people did not have available the service of a single fully trained neurosurgeon. Prior to this the only neurosurgical activity that existed in the country were sporadic efforts occasionally made by a bold general surgeon here and there, especially in Bombay, Calcutta and Madras, for trauma to the spine or head or for a spinal cord tumor or even a brain tumor, but these operations were done without prior formal training in the specialty and ended often disastrously or ineffectively. A single exception was the effort by Dr. Baldev Singh who attempted in 1939 to do neurosurgery in the Punjab but had to give it up after 6 months because of a heart attack. None of the neurosurgery performed by eminent visiting neurosurgeons during the second World War left any effect on * Clinical Associate Professor of Neurological Surgery, Wayne State University School of Medicine. The information contained in this report was obtained by the author while serving in the Visiting Neurosurgeon Program to the Christian Medical College Hospital, Vellore, South India, in December 1963 and January 1964which was sponsored by the Congress of Neurological Surgeons and the office of Vocational Rehabilitation of the Department of Health, Education and Welfare, and subsequent correspondence. J. neurol. Sci. (1967) 5:71-78

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Page 1: Emergence of neurosurgery in India

Journal of the neurological Sciences 71 Elsevier Publishing Company, Amsterdam - Printed in The Netherlands

Emergence of Neurosurgery in India

H. GASS*

Department of Neurosurgery, Wayne State University School of Medicine, Detroit 2, Mich. (U.S.A.)

(Received 23 June, 1966)

In the developed countries of the West, the growth of neurosurgical services kept pace with the maturation of the specialty of neurological surgery according to the frame- work of health service provided by the country concerned. Many underdeveloped countries have not yet faced or are just beginning to face the problem of the distribu- tion of neurosurgical services to their people. In this regard the experience in India since achieving its independence in 1947 is pertinent. Neurosurgery has taken root in that country only in the last seventeen years and is now emerging as an acknowledged specialty. As in all underdeveloped countries quite naturally the greatest medical effort has been expended in the direction of major quantitative needs, namely toward the control and treatment of epidemiological disease and to the distribution of medical services to the rural areas which in India contain 80 % of its population. Facts show, however, that neurosurgery and other higher specialties may develop simultaneously with these more demanding epidemiological services. To neglect deserved attention to these narrow needs is to be wasteful with already scarce facilities. The record of development of neurosurgery in India offers a unique opportinity to learn from histori- cal experience how neurosurgery has fared under these circumstances. Its development there has been largely spontaneous.

At the beginning of 1949 India's 450,000,000 people did not have available the service of a single fully trained neurosurgeon. Prior to this the only neurosurgical activity that existed in the country were sporadic efforts occasionally made by a bold general surgeon here and there, especially in Bombay, Calcutta and Madras, for trauma to the spine or head or for a spinal cord tumor or even a brain tumor, but these operations were done without prior formal training in the specialty and ended often disastrously or ineffectively. A single exception was the effort by Dr. Baldev Singh who attempted in 1939 to do neurosurgery in the Punjab but had to give it up after 6 months because of a heart attack. None of the neurosurgery performed by eminent visiting neurosurgeons during the second World War left any effect on

* Clinical Associate Professor of Neurological Surgery, Wayne State University School of Medicine. The information contained in this report was obtained by the author while serving in the Visiting Neurosurgeon Program to the Christian Medical College Hospital, Vellore, South India, in December 1963 and January 1964 which was sponsored by the Congress of Neurological Surgeons and the office of Vocational Rehabilitation of the Department of Health, Education and Welfare, and subsequent correspondence.

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civilian medical practice after the war was over. Likewise, ancient and medieval Indian cranial surgery left no mark except an historical one. In 1947 a neurosurgical effort was made in Madras by the late Dr. Narasimhan on the basis of experience gained in New York. He started a neurological institute, brought the first electroen- cephalograph to India and by the end of 1947 was performing many brain operations including a large number of prefrontal lobotomies, but some brain and spinal cord tumors and tic surgery also.

The actual beginning of modern neurosurgery in India which blossomed and en- dured can be dated to the spring of 1949 when Dr. Jacob Chandy arrived at the Christian Medical College in Vellore, South India to institute the first neurosurgical service. In recognition of his contribution to India, not only in neurosurgery but in medical education as well, the title of 'Padma Bhushan', - - an honorary title equiva- lent to knighthood in England, was recently bestowed upon him by the Indian Government. Although during the next few years neurosurgical seeds were sown in- dependently in Madras and Bombay, and a little later in Calcutta, the credit for the initiation of this specialty in India belongs first to Dr. Chandy. Not only was his the first service established in India, but about one-third of the forty or so neurosurgeons presently in that country had all or nearly all of their specialty training in his unit. A year or so later, in 1950, Dr. Ramamurthi started a neurosurgical service in Madras and Dr. Ginde did likewise in Bombay in 1951. Dr. Chatterjee and Dr. Bagchi began in Calcutta in 1955. These were the early milestones. The significant feature about these separate early neurosurgical loci is that they do not represent a response to any overall governmental or professional planning and their existence today is largely a reflection of the initiative, courage and perserverance of the personalities involved.

The strongest strut of neurosurgery in India, the service at the Christian Medical College in Vellore, is the result of the combination of two circumstances, the dedicated personality of Dr. Jacob Chandy and the existence of the medically sophisticated institution in Vellore. The development of this institution is an epic itself, already widely told, and represents the result of the heroic devotion of Dr. Ida Scudder, who built this institution almost single-handedly from a small mission dispensary to an elaborate hospital and school, which subsequently became one of the medical colleges of the University of Madras. Over the years it became the focal recipient for a maximum world-wide missionary effort, supported throughout all this time by the combined energy of the missionary services of over forty Christian Church denomina- tions. It was this contact with the West which made it more ready and able to accept neurosurgical as well as other specialty services in advance of other institutions in India. Today it enjoys a reputation of being one of the outstanding medical institu- tions in India and in the East both for service and training, post-graduate as well as graduate. In 1948 representatives of the institution, hearing that an Indian, Dr. Chandy, was being trained in neurosurgery in the West, approached him to come to Vellore to initiate a neurosurgical service there, the first in India. At that time the institution lacked many of the material assets which have accrued to it in subsequent years and which have enabled the blossoming of neurosurgery there. The high cost of developing a neurosurgical service could be borne here in an institution supported by foreign funds; this would have been almost impossible elsewhere in India in such a

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short time. When Dr. Chandy was first invited to come to the Christian Medical College Hospital, however, no such funds were available. The invitation was offered largely with the faith that somehow support would be forthcoming.

Dr. Chandy was inspired towards neurosurgery by his association over a 4-year period while working at a mission hospital in Bahrein on the Persian Gulf with Dr. Paul Harrison who had been in that region for many years. During the latter's training at Johns Hopkins University he had spent several months on Dr. Harvey Cushing's service. In 1944 Dr. Chandy began preliminary training at the Graduate School of Medicine at the University of Pennsylvania, following which he was accept- ed at the Montreal Neurological Institute for training in neurology and neurosurgery. He remained there until January 1948, when he left with Dr. Rasmussen to be his senior resident in Chicago. These were years of personal privation and ceaseless work and study. It was while he was still in Montreal that he was approached by representatives of the Vellore Institution to return there. Because they were unable to provide the necessary funds for equipment, the potential at Vellore did not seem promising. At a subsequent date, however, while Dr. Chandy was still in Chicago, Dr. Harrison, to whom Dr. Chandy had communicated his dilemma, came to Chicago to present Dr. Chandy with two checks totalling $13,000 to be used for neurosurgical equipment in Vellore, which he had raised on his own from trusts and foundations. With this financial support he cabled the officials in Vellore that he was

coming. His arrival at Christian Medical College Hospital at Vellore on April 14, 1949 to

start work was not met with enthusiasm. Some conflict regarding the need for neuro- surgery at the hospital had developed. The chief of medicine had said that he saw little need for neurosurgery, since in 30 years he had only seen three brain tumors. The hospital director had changed, and the only space available to Dr. Chandy for an office was a chair in the director's office. The difficulties that he encountered at this point in finding available beds, operating time and assistance, indoctrinating physi- cians with frequent publications and lectures in elementary neurosurgical concepts and diagnosis, being omnipresent at all grand rounds, organizing a neurosurgical clinic, participating in medical student teaching, improvising in the X-ray department, in the operating room, in the wards and in the laboratory were problems and hardships, many of which were shared similarly by Dr. Ramamurthi in Madras, Dr. Ginde in Bombay and neurosurgeons in other centers where the specialty has taken root. During the years Dr. Chandy has assumed an increasing role in medical school teach- ing, and presently is the Dean of the school. Within about 6 months of his arrival at Vellore, patients were coming there specifically to see him. One of the most difficult problems in the beginning was resisting pleas for him to do general surgery also, especially emergency work, since he had had some general surgical background. This has been a problem to other neurosurgeons who have since come into posts in Indian hospitals where neurosurgery has not been specifically established.

By 1955, Dr. Chandy initiated his first formal neurosurgical training when he assumed the responsibility of training Dr. R. N. Roy from Calcutta. The latter spent 2 years with him and since then a neurosurgical training program has been contin- uously functioning. In 1957, Dr. Wilder Penfield dedicated the present unit which

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houses upwards of seventy beds. It is an integrated unit combining both neurology and neurosurgery. Training is provided in both disciplines. As of the end of 1966, fifteen neurosurgeons had trained on his service, almost all of them for a minimum of 2 years.

The next two neurosurgeons in India, after Dr. Chandy, developed in response to a stimulus issued by the national government. Not long after India achieved independ- ence its government issued an announcement indicating a desire to develop neuro- surgery in India and called for applicants to be sent abroad for training. Among the few physicians who responded were Dr. R. Ginde of Bombay and Dr. B. Ramamurthi of Madras. Dr. Ginde who was older was selected for the one fellowship available that year. He was sent to Montreal to be trained at the Neurological Institute. How- ever, after Dr. Ramamurthi returned to Madras following the interview for this position, the State of Madras made available funds with which to finance Dr. Rama- murthi's training in the United Kingdom. He completed his training sooner than Dr. Ginde and actually returned to set up practice in Madras in September 1950, whereas Dr. Ginde returned to initiate neurosurgical practice at the KEM Hospital in Bombay in 1951.

Dr. Ramamurthi 's neurosurgical training in England consisted of 20 very busy clinical months on Mr. Rowbotham's service at Newcastle' upon Tyne. Following this he spent 9 months at the Montreal Neurological Institute studying neuropathology and electroencephalography and then 3 or 4 months visiting various clinics in the United States. Upon his return to Madras a neurosurgical post was not available and he continued in his previous post as general surgeon utilizing his general surgery ward for neurosurgical patients. Within about 4 months he was given a post in the govern- ment hospital as neurosurgeon and a faculty position in the medical school. Since then the department has grown, so that now there are officially sixty-seven beds allotted to it, although the unit usually has ninety patients, the overflow often residing on mats on the floor. The staff also has expanded to include beside himself as professor of neuro- surgery, an associate professor each in neurology and neurosurgery, two neurosur- geons with honorary posts, and two staff neurologists. A neuro-radiologist trained by Dr. Bull at Queen Square has joined the department, and neuro-pathology and neuro- chemistry sections are shortly to be added. It is proposed to shift this entire department of neurology and neurosurgery with its ancillaries to a post-graduate institute under the auspices of the University of Madras, to be located a few miles outside of the city. The Madras government has been very cooperative in providing him with what he needs in the way of costly equipment such as electroencephalographic and other expensive instrumentation. The Colombo Plan scheme has been the mainstay in arranging for training abroad for the various specialists who have joined the department. Some aid has also been given by the Rockefeller Foundation.

In order to avoid being overwhelmed with work, he has favored the allocation of head injury work to the general surgeons, with assistance by the neurosurgical department when needed. By the end of 1966 it has been planned to concentrate all head injury cases in the city (2.5 million population) in one area under the control of the neurosurgeons. The University of Madras has nine medical college hospitals associated with it, of which eight are run by the state, the Christian Medical College Hospital at Vellore being a private institution. A regular neurosurgical training pro-

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gram has been started by Dr. Ramamurthi which will qualify for the examination for the degree of Master of Neurosurgery given by the Madras University. Thus far seven men have completed or are in the process of being trained in that program.

Dr. Ginde had received his general surgical training and had held a general surgical post at the KEM Hospital in Bombay prior to his formal training in neurosurgery. Duriag that time, between the years of 1940 and 1949 with the guidance and support of his chief, the late Dr. R. M. Cooper, a pioneering surgeon, Dr. Ginde had begun to perform laminectomies, tic surgery etc. without formal training, based on personal cadaver practice. Among the neurosurgeons, therefore, his efforts in this field were the first in India. After nearly 3 years of training at the Montreal Neurological Insti- tute, during which period he also visited various neurosurgical centers in the United States, he returned to initiate neurosurgery at the KEM Hospital in Bombay. A few years thereafter, due to increasing difficulties, he had to give up his municipal hospital appointment and was involved largely in private practice at the Breach Candy European Hospital, and the Bombay Hospital. At the latter institution, he built up an active department of neurosurgery with twenty public beds and twelve to fifteen private patients with a separate ward, radiological, electroencephalographic and neuropathological departments, and ran a separate theatre service. Recently, he has been appointed to the staff of the government-run J. J. group of hospitals, where a neurological and neurosurgical center is developing. There are two neurosurgical units there, each with thirty beds, one headed by himself, and the other by Dr. Singh, a Chandy-trained neurosurgeon. There is also a unit of thirty beds in neurol- ogy, headed by British-trained Dr. Wadia. Dr. Ginde has so far trained partially four neurosurgeons who subsequently completed their training in neurosurgical centers

abroad. Neurosurgery as a specialty started in Calcutta in 1955 when Professor Herbert

Kraus of Vienna came there for that purpose. This invitation was instigated by Dr. B. C. Roy, the Chief Minister of Bengal, who had been visiting Vienna. He met there Dr. Bagchi who was under training with Professor Kraus and which led to his con- tact with him. During the year Professor Kraus spent in Calcutta, Dr. R. N. Chatterjee trained with him and subsequently spent an additional 6 months with him in Vienna. In the meantime, Dr. Bagchi also returned to Calcutta and started working with Dr. R. N. Chatterjee at the SSKM Hospital. The invitation to Professor Herbert Kraus to come to Calcutta was issued and supported by the State Government of Bengal.

From these starting points in Vellore, Madras, Bombay and Calcutta, neuro- surgery has now spread to several other cities in India which include Jaipur, Gwalior, Visakhapatnam, Bangalore, Lucknow, Chandigarh, Madurai, Poona, New Delhi, Hyderabad, Ludhiana, and Ranchi. Of the approximately forty neurosurgeons presently in practice in India about half of them received their training in that country. There are several additional men currently in training abroad in the United Kingdom, in Germany, in Scandinavian countries, in Canada and in the United States.

Inevitable by-products of a professional discipline are professional associations of persons with a kindred interest and publications in the special field of interest. Both of these developed soon after the appearance of neurological specialists in India. In 1953 at the instigation of Dr. Chandy and Dr. Baldev Singh, and together with Doe-

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tors Ramamurthi and Narasimhan, the Indian Neurological Society was created. Dr. Ginde and Dr. T. K. Ghosh of Calcutta joined soon afterwards. The early meetings were held in conjunction with the annual meeting of a national Indian medi- cal society, but since 1964 the Neurological Society of India holds its meeting annually, separate from other societies in a different city in India. The total membership of the society has now exceeded one hundred members whose full-time interest concerns neurology or any of its allied disciplines, and its membership is not limited solely to physicians. The journal of this Society, called Neurology, began a year after the formation of the Society and appears in publication quarterly. It is currently in its fifteenth volume.

One of the problems presently facing Indian neurosurgery is the standardization of training of neurosurgeons as well as their certification. The authority for adequacy of neurosurgical training has rested with the Indian Medical Council. This body, although consisting essentially of elected members from the medical profession, has statutory power from the government to control many aspects of medical life in India including medical education. The Indian Medical Council has recognized neurosur- gery as a separate entity in the field of higher specialties, and has indicated that in order to gain recognition as such, a specialist surgeon must have had at least 2 years of training in this special field after having his M.S. in general surgery. Similarly, in order to achieve recognition as a specialist in neurology he must have had 2 years of training in the special field of neurology after having earned his M.D. degree in medicine. These qualifications have been the controlling factor in the training of the forty or so neurosurgeons presently in India. The general surgical background repre- sented by the M.S. degree in surgery earned at an Indian University may also be ful- filled by the award of the Fellowship certification of the Royal College of Surgeons or by the diploma award of the American Board of General Surgery. Recently Fellow- ship in the American College of Surgeons has also been accepted as indicating ade- quate general surgical training. The first effort to standardize neurosurgical training in India itself, has been the M.S. degree in neurosurgery offered by the University of Madras. This is at present the only higher specialty degree in neurosurgery offered in India. The first such degree was issued in 1961 to Dr. Mathai presently on the staff at Christian Medical College in Vellore. The issuance of this degree has been sanctioned by the Indian Medical Council. The degree has been issued as of March, 1966 to eleven neurosurgeons trained in India either at the University of Madras Medical College or Christian Medical College at Vellore, both institutions being part of the University of Madras. The candidate first must pass a written examination in neurosurgery. Then at the end of his training period he is examined by two examiners who visit his place of training and see him actually at work. As other neurosurgi- cal centers develop it is likely that similar higher specialty degrees in neurosurgery will be awarded by other universities.

The question of national certification in neurosurgery as well as other fields of specialization is now being faced for the first time. At the end of 1963 the Minister of Health in India, recognizing this need, approached the newly formed Indian Academy of Medical Sciences to undertake investigation and establishment of certifying bodies for various specialty degrees. This organization, without statutory governmental

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power but developed with the support of the Prime Minister and Minister of Health, consists of about 120 members who represent the highest selection of Indian medical talent concerned with academic achievement and professional attainment. Un- doubtedly, in the near future, a system of certification in various higher specialties, including neurosurgery, will be forthcoming from the efforts of this group.

In a new government with a strong socialistic trend the deficiency of effort that has been expended towards the guided controlled growth of higher medical specialties is noteworthy. Virtually no organization has been planned in the hierarchy of medical service on a nation-wide basis to make provision, for example, for neurosurgery as a specialty. One of the unfortunate consequences in neurosurgery has been the lack of provision of suitable facilities and equipment in institutions throughout India so that an incoming neurosurgeon may be able to undertake adequate practice. This has led to properly trained neurosurgeons arriving at such institutions without allotted beds, assistance, instruments, operating room time and personnel, X-ray and laboratory facilities, to enable them to practice their specialty. Consequently, they have been forced too often into compromising their own standards by inadequate studies and performance, referral of patients away from them to other areas, or simply inability to practice the skills which they have mastered, allowing them to become rusted by inactivity. This lack of planning has meant that posts have not been available at government hospitals or university departments earmarked for neurosurgeons, despite the fact that their services are desperately required. They may have been forced in the beginning to assume posts as general surgeons gradually establishing themselves exclusively in neurosurgical practice insofar as they are able. Ultimately, both universities and government hospitals after a period of time and observation of the newcomer have tended to assign specific neurosurgical posts at the hospital or chairs at the university in neurosurgery. In the absence even of an available general surgical post, a newcomer trained in neurosurgery could be forced into a government pool of physicians being assigned to wherever an opening might be in order to gain sustenance for living, hopeful that a post would open that would enable him to practice his specialty in the near future. Of the 100 or so medical college hospitals presently in existence in India, only about eighteen of them have neurosurgical coverage. A number of Indians being trained abroad and wishing to return to India are discouraged from doing so because of the lack of the availability of existing posts in neurosurgery. The enormous pressures on other aspects of Indian development have kept the Indian government from creating such posts only to leave them vacant awaiting surgeons to fill them. It is hoped that Indians who have been trained abroad will return to their respective states and give the government an opportunity to create such neurosurgical units for them.

Future development of neurosurgical centers will probably occur in conjunction with the growth of a number of post-graduate institutes. Several of these are in the development and planning stage and promise to provide comprehensive coverage of all the specialties for training and research. Such institutes as the All-India Institute in Delhi and the post-graduate institutes at Lucknow and Chandigarh are institutions of this type. Not only do monetary restrictions impede their development but, in particular, the lack of trained personnel in the basic sciences is a major bottleneck to

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their fruition. As these institutions develop into maturity each specialty in its own way will undoubtedly provide a training center at these institutions for other men in that field.

Most of the practice in neurosurgery in India has to be either in government hospitals, medical college hospitals, or mission hospitals. There are a number of small private hospitals in large cities. Most of these are small institutions of fifty to one hundred beds in size and are not able to afford the equipment and installations necessary to sustain a private neurosurgical practice. Nevertheless, many neurosur- geons do supplement their full time government and university employment with after-hours work in these private institutions, but at least in the foreseeable future the volume of neurosurgery done in this capacity of private practice is bound to be a small fraction of the total. Material shortages of such things as X-ray film, contrast material, surgical instruments, and electronic equipment are restrictive influences on all forms of medicine as well as neurosurgery. The importation of foreign equipment even gratuitously provided is rigidly controlled. Efforts are being made to enlarge the domestic production of surgical instruments and other hospital necessities.

ACKNOWLEDGEMENTS

The author wishes to express his gratitude to Dr. J. CHANDY, Dr. B. RAMAMURTHI,

Dr. R. GINDE and Dr. A. BAGCHI, from whom he collected the information, gra- ciously provided, that appears in this paper. He wishes also to thank Dr. R. TYRER, JR.,

who together with Mr. J. LAROCCA at the Office of Vocational Rehabilitation, Department of Health, Education and Welfare, conceived and arranged the Visiting Neurosurgeon Program to Vellore.

SUMMARY

An historical review of the inception and development of modern neurosurgery in India is presented. Brief, personal accounts of pioneering efforts made in Vellore, Madras, Bombay and Calcutta are presented along with highlights of the initiation and growth of domestic neurosurgical training, establishment of a neurological society and journal and the issues of standardization of training and certification. Problems that hamper expansion of neurosurgical service due to inadequate national or state planning for the specialty are mentioned.

J. neurol. Sci. (1967) 5:71-78