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History of neurosurgery at Christian Medical College, Vellore: A pioneer's tale
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.177625
The Department of Neurological Sciences at Christian Medical College (CMC), Vellore was the first department to start neurosurgical and neurological services in India. Jacob Chandy started the department in 1949 against several odds. He started a formal training program in neurosurgery in 1958, for the first time in India, and went on to qualify several neurosurgeons, who in turn pioneered neurosurgical departments all over India. After 1970, K V Mathai and Jacob Abraham guided the department through some difficult times when there was a severe shortage of personnel and no faculty in the neurology section. Through their commitment and hard work, they continued not only the neurosurgery service but also looked after patients with neurological disorders. Mathew J Chandy, son of Jacob Chandy, joined them in 1980 and introduced micro-neurosurgery and several other neurosurgical techniques. Training of residents in micro-neurosurgery began in the early 1980s. The last quarter of a century has been a period of rapid progress for neurosurgery at CMC. There has been an exponential rise in the number of surgeries, number of residents and number of publications. Research has always been an integral part of the activities of the department and several high impact articles have been published by the faculty and residents. The neurosurgical faculty at CMC has also contributed significantly to organized neurosurgery in India and internationally, with five of them serving as President of the Neurological Society of India, a society which had Jacob Chandy as its founder President. With this heritage, the neurosurgery section at CMC, Vellore is likely to continue to provide high quality ethical neurosurgical care to patients from all over India and overseas. Keywords: India; neurosurgery; pioneer; residency; Vellore
Being a pioneer is both a blessing and a curse. While it enables one to be a leader and set standards, pioneers also have to overcome the skepticism of their colleagues and administrators, demolish myths and have the courage of conviction to stay on the chartered course. Dr. Jacob Chandy had all the traits of a pioneer. He started the Neurology and Neurosurgery services at the Christian Medical College (CMC) Hospital, Vellore in January 1949. Chandy, who was trained in the United States and Canada and had been working there at that time, was invited by the administration of CMC to start the Department of Neurology and Neurosurgery at the hospital when such a department did not exist anywhere in India and for that matter in most of South and West Asia. Chandy entered a challenging milieu in which to establish the new specialty. There was a genuine feeling among several clinicians in the hospital at that time that support for this specialty was wasteful as they believed that there were no patients with brain tumors and hence Chandy would be without work most of the time. This “wasteful” enterprise was especially resented as it took shape in an environment of severe shortage of doctors in basic specialties such as general surgery. Chandy was requested to contribute to the running of the general surgery services while he waited for neurological and neurosurgical patients to start trickling in. However, Chandy wisely refused to do that and insisted that he would only manage patients with neurological and neurosurgical disorders. It is one of the many strategic decisions Chandy took over the next two decades, that helped to establish the specialty not only in CMC, Vellore but also into an academic specialty all over the country. Since its establishment in 1949, neurosurgery at CMC, Vellore has continued to be at the forefront of patient care, research, and teaching. Several neurosurgeons, following in the footsteps of Chandy, have contributed to its continued reputation as a center of excellence in neurosurgery in the country. It should be pointed out that to this day there is no Department of Neurosurgery at CMC, Vellore. Instead, Neurosurgery belongs in a multidisciplinary Department of Neurological Sciences. This is what Chandy established, and this is what his successors have maintained. Thus, CMC, Vellore is one of the few institutions in the world to harbor such a multidisciplinary group in one department. The department has sections of Neurology, Neurosurgery, Neurocritical Care, Neurophysiology, Neurochemistry, Neuropathology, and Neuropsychology. This article will trace the history and accomplishments of the Department of Neurosurgery at CMC, Vellore over the past 65 years.
CMC Hospital, Vellore had humble beginnings as a one-bed clinic in the year 1900. Dr. Ida Sophia Scudder, an American medical missionary started the clinic as a part of her efforts to provide health care for women and children of the northern part of Tamil Nadu or Madras Province as it was then known. Her intention was also to train women as healthcare professionals so that they in turn could serve other women and children. With her focus on medical education, it was not surprising that she started a medical school for women in 1918 that awarded students the Licentiate Medical Practitioner diploma. CMC Hospital grew in fits and starts with periods of doubts about its survival due to lack of staff and finances. With the help of funds generated through overseas (American and British) Christian missions, the hospital was able to not only survive as an institution but also gained a reputation as a center for excellent health care. The main hurdle to its leap into the big league of medical institutions of the country was its 'women only' rule for its patients and students. Although, Madras University had allowed the upgradation of the medical school into a medical college in 1942, Ida Scudder realized that as long as the hospital did not admit male patients and men students, the scope and reach of the college would remain local. Hence, from 1947 she decided to relax the 'women only' rule for the institution. Around the same time, the hospital also embarked on another venture which would change its course and destiny. This venture was related to its transformation from a center that provided excellent services in basic specialties such as pediatrics, general surgery, obstetrics, and general medicine into one that was going to start offering state of the art health care in higher specialties that either did not exist in India or were in the nascent stages of development. The first such higher specialty to be started in CMC was the Department of Cardiothoracic Surgery in 1948. Soon other higher specialty services such as Neurological Sciences, Cardiology, Nephrology, and Urology came to be offered in CMC Hospital. It was in this context that Chandy was contacted by Dr. R G Cochrane, the then Director of CMC, and offered the opportunity to establish the Department of Neurology and Neurosurgery in Vellore. Chandy had trained in Montreal at the famous Montreal Neurological Institute (MNI) under the renowned neurosurgeon, Dr. Wilder Penfield. He was recruited by CMC in the United States and came to CMC with some of the essential equipment needed to start the neurosurgical service. As mentioned above, one of the first tasks Chandy set for himself was to debunk the myth that brain tumors were rare in Indian patients. He scoured the hospital wards for patients with clinical features of raised intracranial pressure (ICP), armed only with an ophthalmoscope. Even carotid angiography had yet to make its appearance in India. He used pneumoencephalography and ventriculography to diagnose brain masses before operating on them. In the forties, many of the neurological disorders were diagnosed as neurosyphilis, degenerative disorders, meningitis, myelitis, etc., The diagnosis of brain tumors, and spinal cord compressions were missed by the general practitioners and physicians. Therefore, Chandy undertook the task of educating the medical community in India. Toward achieving this, he wrote articles in medical journals and addressed many medical and surgical meetings.[1],[2],[3],[4] In CMC itself, he took the liberty of seeing patients admitted to the medical department and maintaining a good relationship with the physicians. Neurosurgical treatment, which carried a significant mortality and morbidity, had to be made acceptable to the people. This became possible through meticulous neurosurgical techniques and good pre- and postoperative care. He was also able to maintain good doctor-patient relationship, a CMC trademark. Medical staffing was a problem. Initially, Chandy had to get help from other departments. Later, Dr. Isaiah, an M.D. in Gynaecology and Obstetrics joined him as Clinical Assistant. In 1950, Dr. Baldev Singh, a senior physician from Amritsar, who had an interest in Neurology, came for a 2 month visit and decided to stay on as a neurologist. The two had a very harmonious relationship. Chandy and Isaiah did the surgical work, and Singh and a junior doctor did the medical work, with Chandy as the Head of the Department. During the 1st year, 404 new patients were seen; 143 patients were admitted, and 131 operations were done. Chandy's efforts at creating awareness about brain disorders amongst his colleagues and the medical fraternity in the surrounding areas bore fruit and soon his practice expanded. A specialized ward for the care of neurological and neurosurgical patients became a felt need. The ward built with the help of a donation from the Irwing Young Foundation in the United States (organized by Dr. Paul Harrison, Chandy's mentor and missionary doctor in Bahrain) was named N ward and was formally declared open by the then Health Minister of India, Rajkumari Amrit Kaur on 20th January 1954. A second ward for women and children and private patients became possible through the generous donation of the grateful family of a patient, the Rajgharias. This ward was constructed over the existing N ward and was formally opened on 7th January 1963 by the then Union Health Minister Dr. Sushila Nayar. The ground floor was named N1 and the first floor was named N2. In 1961, through a grant from the Rockfeller foundation, a well-equipped intensive care area was built adjoining the N1 ward. Later, an intensive care area was established in N2 ward by readjusting the existing space. With the expansion of work, more space became necessary for the offices, electrophysiology, services, library, conference room, and neurochemistry laboratory. All these were housed in the Neurology Block, the cornerstone for which was laid by Penfield on 23rd February 1957 [Figure 1]a. Penfield also attended the annual conference of the Neurological Society of India (NSI) in the same year [Figure 1]b.
In 1949, one operating room (OR) was shared between neurosurgery and cardiothoracic surgery, each using the room for 2 days a week. One day was adjusted between the two departments. Another OR was added to the then existing OR complex in 1955 making a room available exclusively for neurosurgery. When the present OR complex was built, 2 rooms were earmarked for neurosurgery (Room 6 and 7) with an anesthetic room and monitoring-cum-surgeons' room in between. These were occupied in 1973. Isaiah who was a clinical assistant to Chandy for 5 years left the department in 1954. At about the same time, a formal 2-year residency program in neurosurgery was started in Vellore for the first time in India. With the availability of these residents, Chandy got sufficient help in the wards and OR. Drs. R.N. Roy, Gajendra Sinh and R.S. Dharker were the first three neurosurgical residents. With Drs. KV Mathai and Jacob Abraham joining the Department on a permanent basis, continuous help became available, in addition, to the help given by the residents. Over the years, CMC has been among the first in the country to introduce many neurosurgical techniques and instruments [Table 1].
During his time in CMC, Chandy met many eminent personalities in his role as a neurologist and neurosurgeon and in his role as an administrator of CMC [Figure 2]. Chandy retired from CMC in 1970 but went on to be associated with medical education and other health care related ventures in Kerala for several years. He passed away in 2007 at the ripe old age of 97. His cognition was intact until the very end, and he was always available for consultation on any topic of interest. He continued to attend the annual conferences of the NSI for several years after his retirement. The last one he attended was the 51st Annual Conference of NSI held at Cochin in December 2002, when his son, Dr. Mathew J Chandy was the President of NSI.
Chandy's legacy Besides training several neurosurgeons who went on to head neurosurgical departments all over the country [Figure 3], Chandy left behind several processes and protocols that were to distinguish the services of the department and CMC from most other medical institutions in the country. Noteworthy among his contributions to postgraduate medical training and patient care were the residency system of training, introduction of discharge summaries to be given to patients at discharge from the hospital, careful record keeping and follow-up with postcards being sent to discharged patients every year enquiring about their health [Figure 4]. The neurosurgical training program created by him was meant to be comprehensive so that all trainees were well versed in the allied fields of neuroradiology and neuropathology through regular teaching sessions [Figure 5]. His firm belief in research being an integral part of training of a neurosurgeon led him to insist that all trainees produce at least one scientific article in every 6 months of their training period.
As Principal of CMC, he persuaded Dr. Achanta Lakshmipathi, then Vice Chancellor of Madras University, to start formal higher specialty training courses in many specialties besides neurosurgery. These included neurology, cardiothoracic surgery, and cardiology. Thus, Madras University became the trendsetter in being the first University in the country to award these higher degrees. In pursuit of his interest in medical education, he served as the first Editor of the Indian Journal of Medical Education. Chandy was also instrumental in the setting up of the Department of Neurosurgery at the All India Institute of Medical Sciences. Chandy was recognized for his contributions to neurosurgery and medical education in the country by the Government of India and was awarded Padma Bhushan in 1964. He was also presented the Presidential Medal of Honor by the World Federation of Neurosurgical Societies in New Delhi in 1989. A detailed description of Chandy's life and contribution to neurosciences was published soon after his demise.[5]
Two of Chandy's early trainees, KV Mathai and Jacob Abraham took over the mantle of running the department from 1970. They had acquired considerable experience not only in the surgical aspects of the job but also the administrative side of the job of running a department. This was mainly due to the frequent absences of Chandy during the last 5 years or so of his tenure in CMC. Chandy was the Principal of CMC from 1962 till his retirement. In this role, he was closely associated with running of the Medical College in addition to the department. Hence, it is understandable that he handed over most of the departmental activities to his trusted lieutenants. Mathai belonged to the first MBBS batch of men students who joined CMC in 1947. He was spotted by Chandy during his neurology posting in the Department as a third year medical student, as a likely candidate to take up neurosurgery as a career. They developed a personal and professional equation that worked well for the Department and the specialty in CMC. Mathai worked in the Department as a house surgeon for 1-year during 1953–1954. After finishing his M.S. General Surgery training, he worked for 1-year in neuropathology from April 1957 to March 1958. He joined the clinical residency program in April 1958. This was the year M.S. Neurosurgery was started in Madras University and Mathai was the first candidate to register. He completed M.S. Neurosurgery in March 1961. Soon after, he spent 2 months in the Department of Neurophysiology at the All India Institute of Medical Sciences, New Delhi with Dr. Baldev Singh and Dr. B.K. Anand, familiarizing himself with animal experimentation techniques. From September 1961 to June 1963, he was on study leave working on the epidemiological, clinical, and neuropathological aspects of amyotrophic lateral sclerosis and Parkinsonism dementia on the island of Guam and later at the National Institute of Neurological Disorders and Stroke, Bethesda, under Dr. Leonard T. Kurland. Since his return in 1963, he continued with the Department until his retirement in October 1986. Mathai was a meticulous surgeon, a superb and patient teacher, and a brilliant clinician [Figure 6]. Referring to his meticulous hemostasis at every step of the surgery, it is often said that Mathai chased individual red blood cells. The excellent outcome of his surgical patients is a testimony to his surgical technique. He had a large series of patients with meningiomas and arteriovenous malformations, both of which were unfortunately never published. He was meticulous in everything that he did. He would always look dapper in his full sleeve shirt and tie and would be well groomed even when he showed up for an emergency surgery at odd hours of the night. He was the quintessential teacher. He was extremely patient and rarely lost his temper. His dedication and commitment to his students are unparalleled. Until a few years ago, he would be the first to greet all his students on their birthdays and at Christmas and New Year. Mathai retired in October 1986 but continued to help his students in different hospitals in Assam and Kerala.
Abraham worked in the Department as a house surgeon for 1-year during the period 1954–1955. After finishing his training period in general surgery, he worked in neuro-pathology for a year from April 1958 to March 1959. He joined the clinical program in April 1959 and later joined the formal residency program. He passed the M.S. Neurosurgery examination in March 1962. He was the second candidate to qualify from Madras University. Later, he spent 2 years at Dartmouth Medical School with Dr. Ernest Sachs Jr. and a year at Seattle with Dr. Arthur Ward. He also spent time with Dr. Meyers in Houston, Texas working on clinical and experimental problems related to strokes. He was on the faculty until his retirement in May 1991. Abraham was a flamboyant and fast surgeon. His vacuum assisted technique of removing surface meningiomas besides being quick also evoked awe amongst the assistants. Dr. Shankar Gopinath, one of his grateful students, presently working in the United States, documented this technique in a recent article.[6] Abraham also investigated the use of pedicled omental grafts in patients with stroke and spinal cord injury.[7],[8],[9] However what Abraham was mostly known for was his brilliance as a thinking surgeon, besides his wit and sarcasm [Figure 7]. He would go beyond the mundane when looking at any aspect of neurosurgery. His methods of teaching were unique and unorthodox. During ward rounds, he would briefly (sometimes it was just a word) mention something he knew or has recently read about some aspect of neurosciences. This was meant to pique the interest of the student who was then expected to read up more on the mentioned subject. Abraham retired in May 1991 and worked for a short period as a neurosurgeon in a private hospital in Chennai. He later went on to write books on theology and the brain.[10]
For several years in the 1970s, Mathai and Abraham struggled to run the department. To make matters worse, Dr. G M Taori, Professor of Neurology, left the department in 1975 and with that the burden of taking care of neurology patients also fell to them. To their credit, they continued to care for both neurology and neurosurgery patients for several years till Dr. Subhashini Prabhakar joined the department as a neurologist in 1980. Their burden was mitigated to some extent in the early 1980s with the addition of more faculty members. However, the number of faculty in neurosurgery through most of the 1970s and 1980s never crossed 5. Dr. Mathew J. Chandy, [Figure 8] son of Jacob Chandy and a CMC alumnus of the MBBS batch of 1961, joined the Department for training in Neurosurgery in January 1972 after completing his MS (General Surgery) at Stanley Medical College, Madras. He obtained the M. Ch. Neurosurgery degree in April 1974 and worked for 1-year as a Lecturer in the Department. He left the department in 1975 to work in Iran. Later he spent 1-year at the Montreal Neurological Institute. He rejoined the Department in 1980. He continued working in the department until 2001. MJ Chandy introduced several new technologies and techniques to the department. His major contribution was in developing the use of microsurgery. Although the department had acquired a Carl Ziess OPMI 1 microscope as far back as 1972, it was sparingly used till MJ Chandy returned in 1980. He started using the microscope for all the major neurosurgical operations, and soon microsurgery became the norm. Other techniques pioneered by MJ Chandy in the department are transsphenoidal surgery for pituitary tumors, supracerebellar approach for pineal region tumors, radical excision of intramedullary spinal cord tumors, and anterior cervical procedures.[10],[11] He was also meticulous in keeping records with intraoperative photography being his passion. He actively encouraged several medical students of CMC to take up neurosurgery, and some of them joined the faculty of the department. After leaving Vellore, MJ Chandy worked for some years in Kerala and has been working in a private hospital in Dhaka, Bangladesh for the past several years.
Dr. Thomas Joseph [Figure 8] joined the Department in 1976 for training in neurosurgery toward the direct MS Neurosurgery program, which he completed in 1980. He joined the faculty in 1980. Later he spent 2 years on study leave working at Newcastle upon Tyne, Cardiff, and Swansea in the United Kingdom. He continued in the Department and rose to the rank of Professor of Neurosurgery and Head of Unit 2. He left the institution in 1993. Joseph developed surgery for vestibular schwannomas during his tenure in the department. He also introduced intraoperative “brain mapping” which later evolved into intraoperative monitoring (IOM). After leaving Vellore, he settled in Coimbatore. Besides continuing to do neurosurgery, he runs a trust (SAHAI) which cares for physically handicapped individuals and rehabilitates them.
The department has seen rapid growth and progress in the last 25 years with an increase in the number of patients being operated, introduction of several new techniques and technologies and sub-specialization. The faculty numbers have fluctuated widely from being as few as 5 to as many as 12 at any given time. To their credit, the faculty did not let their periodic low numbers significantly affect the quality of care their patients received or the patient numbers. Thus, the number of inpatients and surgeries have consistently grown year on year irrespective of the faculty numbers. The bed strength presently stands at around 100 neurosurgical beds. With three dedicated operation rooms, over 2000 surgeries are done every year. Nearly 800 brain tumors are operated every year in CMC. A major proportion of these patients come from Bengal, Bihar, Jharkhand, and other eastern states. Up to 15–20% of the patients hail from Bangladesh. Dr. Vedantam Rajshekhar, CMC alumnus of the 1975 MBBS batch, joined the direct M. Ch course in 1982. After completing the M. Ch. in 1987 he continued in the Department as a faculty member. He spent time in USA at Dartmouth Medical School, Hanover, New Hampshire from 1989 to 1991. He is currently Professor of Neurosurgery and Head of Unit 2 since 1996. His contributions to patient care include the introduction of several new techniques such as computed tomographic guided stereotactic surgery, radiosurgery, endoscopic surgery, endoscopic pituitary surgery, and uninstrumented corpectomy for cervical spine disorders.[12],[13],[14] He also pioneered transoral surgery for craniovertebral junction anomalies. His major contribution, though, was not directly related to neurosurgical procedures but was in the recognition of the entity of solitary cysticercus granuloma (SCG) in 1989. Through a series of publications, he along with his colleagues in the department went on to elucidate the diagnosis, management and outcome of SCG, the commonest identifiable cause of seizures in Indian patients.[15],[16],[17] In recent years, he has been interested in spinal dysraphism and comprehensive outcome analysis of neurosurgical patients.[18],[19] Protocol based management of neurosurgical patients was his brain child. In 2002, he initiated a periodic and transparent assessment of neurosurgical residents by the entire senior faculty. Dr. Ramachandran Pranatartiharan, [Figure 9] CMC alumnus of 1975 MBBS batch joined the Department for the MCh direct course in 1985. After completing MCh in 1990, he worked in the Department for a year. He worked at the Kasturba Medical College, Manipal for 2 years. He rejoined the faculty in 1993 and rose to become Professor of Neurosurgery and head of Unit 1. His interests were in vascular and skull base surgery, which he developed in the department. He left CMC in 2005 and is presently a neurosurgeon at the Lahey Clinic in Boston, USA. Haran (as he was popularly known) was a much loved teacher, popular not only with neurosurgical residents but also with MD (General Medicine) residents, for whom he used to regularly take evening teaching clinics in neurology. He is a bibliophile and was almost always seen with a book in hand.
Dr. Ari George Chacko, CMC alumnus of 1979–1980 MBBS batch, joined the Department for MCh 5 years course in 1989. He joined the faculty after completing the course in 1994 and has been on the faculty since then rising to the level of Professor of Neurosurgery in 2003. He spent a few months in Germany observing Madjid Samii in 1996 and Vinko Dolenc in Slovenia in 2002. He taught microsurgical techniques related to facial nerve preservation for vestibular schwannomas and extradural middle fossa approaches to the cavernous sinus that he had learned from these masters, to the rest of the faculty. He spent a year and a half at the Department of Neurosurgery at Baylor College of Medicine, Houston, USA in 1999 and 2000 working on cerebral blood flow in traumatic brain injury. He has been Head of Unit 1 since Haran left. He had interest in functioning pituitary adenomas and skull base surgery and pioneered the use of awake craniotomy for eloquent area gliomas and the oblique corpectomy for cervical spondylotic myelopathy.[20],[21],[22] He has actively pursued endoscopic skull base surgery and has put together a multidisciplinary team of surgeons to manage patients with skull base lesions. Since 2010, he runs the epilepsy program in the department in collaboration with Dr. Maya Thomas in Neurology. He is an innovative and skilled surgeon, quick to adopt new techniques. Dr. Roy Thomas Daniel, [Figure 9] who completed MCh 5 years course in the department in 1997 was on the faculty until 2010. He had a special interest in epilepsy surgery and introduced hemispherotomy and other epilepsy surgery techniques.[23] He had training in epilepsy surgery with Dr. Jean Guy Villemure in Lausanne, Switzerland. Daniel also brought in modern spinal instrumentation for complex spinal problems. He left the department in 2010 and is presently Professor of Neurosurgery in Lausanne. Dr. Vivek Bayliss Joseph, completed his 5 years MCh training from the Department in 2001 and has been on the faculty since then. He has a special interest in spinal surgery, and toward that, he did a fellowship with Dr. Michael Fehlings in Toronto in 2005. He is presently Professor of Neurosurgery and Head of the newly created Neurosurgery Unit 3. Dr. Ranjith Kumar Moorthy, CMC alumnus of 1991 MBBS batch, did his 5 years MCh course in the department. After completing the course in 2003, he joined the faculty of the department. He is a Professor with special interest in Pediatric Neurosurgery. Dr. Krishna Prabhu, CMC alumnus of 1989 MBBS batch, did his 5 years MCh course in the department which he completed in 2003. He has been on the faculty since then except for a brief hiatus of 2 years. He is a Professor and has a special interest in spine surgery having completed a 6 month spine fellowship in Korea after which he has introduced scoliosis correction surgery in the department. The neurosurgery faculty and residents in July 2015 are shown in [Figure 10].
Neurocritical care and neurotrauma services A unique feature of the department has been the section of neurocritical care under the leadership of a neurosurgeon, namely, Dr. Mathew Joseph. Dr. MJ Chandy identified M Joseph, then an Assistant Professor of Neurosurgery, to head this section in the late 1990s. M Joseph, CMC alumnus of 1979–1980 MBBS batch, got his MCh after completing the 5 year course in the department in 1993. M Joseph has worked hard to improve the critical care services for neurosurgery and neurology patients. He has substantially expanded the services so that at present, the section has 12 Intensive Care Unit (ICU) beds, 12 high dependency unit beds, and 8 trauma beds. About 5 years ago, he volunteered to take on the care of head injured patients. Protocol based management of head injured patients is practiced with routine intracranial pressure (ICP) monitoring. He devised a cost-effective alternative to the commercially available ICP monitoring kits.[24] About 600–700 patients with head injuries are managed in the unit. The good outcome in several sick patients admitted in the department is largely due to his efforts and those of his team. He is part of the larger, multidisciplinary Critical Care Division in CMC that includes Medical and Surgical ICUs. He is a dedicated teacher, popular both with the MBBS students and the nurses. CMC honored him with the Best Teacher Award last year. Dr. Shalini Nair, a pulmonologist, is an Associate Professor, who helps M Joseph in running the service. Intraoperative monitoring The department was one of the earliest in the country to realize the utility of intraoperative monitoring (IOM). Introduced in 1991, IOM is now an integral component of several neurosurgical procedures such as surgery for vestibular schwannomas, spinal cord tumors, eloquent region brain tumors, brain stem tumors, and spinal dysraphism.[25],[26],[27] Initially, somatosensory evoked potentials were used for spinal surgery but from 2000 onward, motor evoked potentials have become the modality of choice for IOM for spinal cord tumors. Dr. Srinivasa Babu, a neurophysiologist by training has been running this service for over two decades. He has trained several technicians and has frequent visitors from several Asian countries wanting to learn from him. His extensive experience in IOM is an asset to the surgeons and benefits 500 patients annually. Sub-specialization Sub-specialization was initiated in the department in 1992. The three faculty surgeons at that time decided to specialize in a chosen area of neurosurgery. Thomas Joseph chose surgery for vestibular schwannomas, MJ Chandy surgery for pituitary adenomas and Rajshekhar, stereotactic surgery. Over the years, with more faculty surgeons available and others leaving, the areas of specialization have varied. At present, Rajshekhar's area of specialization is spinal dysraphism, Chacko's is functioning pituitary adenomas; Vivek Joseph and Prabhu share craniovertebral junction anomalies and other complex spinal disorders; and, Moorthy is focusing on moyamoya disease and other pediatric disorders. The fact that the number of faculty numbers can vary significantly, either due to faculty members going away on a long leave of absence or leaving the department permanently, means that all faculty members needed to retain some skills to provide the specialized service when the specialized faculty was unavailable. This has forced us to restrict the quantum of work that can be subject to sub-specialization. Nonetheless, it has allowed individual faculty members to claim a small part of the specialty as their own and develop it. Monthly audit meetings One of the strengths of the clinical services has been the running of an uninterrupted monthly audit meeting which is attended by the clinical staff of the entire department including neurologists. All mortalities are discussed dispassionately in this forum, and the lessons learned from the cases are enumerated so that errors resulting in the poor outcome can be avoided in future. This healthy practice was started in 1992 and is an essential part of the training of residents.
A 2 year in-service training program was started in CMC in 1955. At this time, a 2 year training after MS (General Surgery) or FRCS or its equivalent was sufficient, as per regulations, for a faculty position in Neurosurgery in any medical college in the country. In 1958, Madras University started the M.S. Neurosurgery program for the first time in India. CMC was the first institution that was granted recognition for conducting the course. Intake of two candidates each year was approved. The qualification for entrance was MS (General Surgery, Orthopedics or ENT) or its equivalent. In 1962, the department was recognized as the upgraded Department of Neurosurgery by the Government of India. The Government of India and various states started deputing candidates for training in neurosurgery to CMC. Several of these trainees returned after completing their MCh and started the first Neurosurgery departments in many states all over the country. MS (Neurosurgery) was renamed as MCh (Neurosurgery) from the 1965 admission. In 1974, the University made provision for a direct 4 year course after MBBS with a prior 1-year experience in general surgery. The 2 year post MS (General Surgery) program was extended to a 3 year course, and both were renamed as MS (Neurosurgery). The University regulations changed again with the admission batch of 1980. The direct course was made into a 5 year course and was renamed as MCh (Neuro). The number of candidates for MCh training was increased from 2/year to 3/year in 1985 and to 4/year in 2014. Since 1958, CMC has trained over 100 neurosurgeons. The states where neurosurgical trainees from CMC went on to head Neurosurgical departments in Government medical colleges include Tamil Nadu, Kerala, Andhra Pradesh, Odisha, Karnataka, Madhya Pradesh, Rajasthan, Maharashtra, Assam, Bihar, West Bengal, New Delhi, and Uttar Pradesh. Besides these states, candidates from Jammu and Kashmir, Gujarat, Manipur, and Uttaranchal have also trained in CMC. These trainees have helped to spread the legacy of Chandy and the department in different corners of the country. Thus, CMC remains a department with a commitment to train neurosurgeons for all parts of India.
Chandy with his exposure to experimental and clinical research in North America was eager to integrate research into the activities of the new department that he started in Vellore. It is interesting to note that the first year's annual report (1949–1950) had mentioned that a sum of Rs. 150 had been allocated by the Director of CMC for research on the neurological aspects of leprosy. During the first decade of the department's existence, Chandy's research focus was on clinical problems both in neurology and neurosurgery. In the 1960s, two major projects were initiated with the help of PL480 funds through the Social and Rehabilitation service of the U.S. Department of Health, Education, and Welfare and the Indian Council for Medical Research (ICMR). The first was on multidisciplinary aspects of epilepsy (epidemiology, clinical profile, medical and surgical treatment, psychological aspects, job rehabilitation, and public education). This was started in 1964 and was completed in 1971 (Principal Investigator: KV Mathai).[28] The second was again a multidisciplinary study on stroke (epidemiology, clinical profile, medical and surgical treatment, psychosocial aspects and rehabilitation with the principal Investigator being Jacob Abraham). The project was started in 1967 and concluded in 1972.[29],[30] Two ICMR funded studies, one on solitary cysticercal granulomata (SCG), and another, a community-based study on neurocysticercosis (NCC) as a cause of active epilepsy, were performed (Principal Investigator: V. Rajshekhar).[31],[32] Subsequently, several other projects on neurocysticercosis, funded by national and international funding agencies such as Vlaamse Interuniversitaire Raad (VLIR; Flemish Interuniversity Council, Belgian government) and National Institutes of Health (NIH, US government), have been completed. An interesting feature of the projects on epilepsy, stroke and neurocysticercosis, besides being community-based, is that they are not typically considered “neurosurgical” subjects. However, they are important health issues in our country and faculty in neurosurgery were willing to contribute to the knowledge in these allied areas. The research work of Abraham in stroke and Rajshekhar in NCC was recognized by ICMR with the award of one of their highest honors, Basanti Devi Amirchand Award in the years 1984 and 2007, respectively. Other areas of clinical research involving the faculty of the neurosurgery section have included gliomas, pituitary tumors, cervical spondylotic myelopathy, stereotactic surgery, intramedullary spinal cord tumors, and intraoperative monitoring. Many dissertations submitted by the residents to the University as a part of the requirements for MCh course are published. The department has on an average published at least 20 articles every year for the past 20 years or so. The high impact articles from the department are listed in [Table 2].[12],[13],[17],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43] Some of the resident dissertations that led to publications in high impact journals are shown in [Table 3].[34],[38],[39],[44],[45],[46],[47],[48],[49],[50] Residents from the department also frequently bag the Best Paper Awards at the Annual Conference of NSI [Table 4].
Facilities existed for animal experimental work from 1954. The Neuroanatomy/Cerebrovascular Laboratory of the department was established in 1967 by Abraham, who in addition to his clinical commitments, spent a substantial amount of time in developing this laboratory. The laboratory was strengthened with the addition in 1977 of Dr. Deepa Theodore. Theodore obtained her PhD in 1991 working with Abraham. Some of the animal models that have been successfully developed in the Animal Laboratory over the years are for stroke in primates and rats, epilepsy in primates, spinal cord injury model in primates and rats, and cold injury of the brain in rats. Using these models, several studies have been performed.[49],[50],[51],[52],[53]
Neurosurgery at CMC has consistently shown its commitment to organized neurosurgery in the country. Chandy was one of the four founder members of the NSI in 1951. He was also the first President of the society. Besides Chandy (1952), Mathai (1977), Abraham (1983), MJ Chandy (2002), and Rajshekhar (2014) have been Presidents of NSI. MJ Chandy and Rajshekhar served the NSI as Honorary Secretary. Abraham and Rajshekhar have been the conveners for the Continuing Medical Education program of the NSI. An unbroken tradition at NSI conferences is the CMC alumni meet, which has been continued for nearly four decades, driven initially by Mathai, and in recent years by Dr. A K Banerji (alumnus, 1962–1964 and former Head of Neurosurgery at AIIMS, Delhi) [Figure 11].
Rajshekhar was the founder Secretary of the Indian Society for Stereotactic and Functional Neurosurgery (ISSFN), which was founded in 1994. He went to become the President of the same society from 2003 to 2005. He was also the President of the Indian Society of Neuro-oncology (2014–2015). He is presently the Chairman of the World Federation of Neurosurgical Societies Radiosurgery Committee from 2013 to 2017. M Joseph was elected as the Secretary of the Indian Neurotrauma Society from 2014 to 2017.
It is often said that reputations of institutions are cyclical and complete a full cycle of ascent and descent within two generations. CMC has defied conventional wisdom and is still on the path of ascent 115 years after it was established. CMC does not advertise its services, is not posh, is not very easy on the purse either, is crowded and has not always been the first to introduce new technology or techniques. So what is it that attracts patients to the hospital and neurosurgery section for their treatment? Undeniably, it is the anticipation of ethical and compassionate care of the highest quality delivered by a disciplined and dedicated staff (not only the doctors but also the nurses and other support staff), that has engendered trust in patients all over the country and outside. The camaraderie that exists between staff in different departments of the hospital ensures that patient care is not fragmented. Thus, there is the enviable though undesirable situation of patients waiting several days or weeks for beds in a private hospital. Pioneers such as Chandy, Mathai, and Abraham strived to live up to the institution's ideals enshrined in its motto: “Not to be ministered unto, but to minister” and played a major role in the establishment of the unique ethos of the hospital where the patient's interests override all others. There are several other torchbearers who have not only kept the flame burning but also added to its brightness. It is more than likely that the star of CMC and its neurosurgical services will continue to shine bright in the future also. Acknowledgement The early history of the department was recorded by Prof. KV Mathai in the Golden Jubilee Commemorative Volume in 1999, and I have borrowed heavily from that report. I acknowledge the help of my colleagues: Drs. Ari Chacko and Mathew Joseph for critically reviewing the manuscript and providing suggestions to improve it, Dr. Ranjith K Moorthy for getting the information in [Table 3] and [Table 4], and Dr. Srinivasa Babu for his help with the figures. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
[Table 1], [Table 2], [Table 3], [Table 4]
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