Prof. B. Ramamurthi: Contributions to Indian neurosurgery (A personal tribute)
It is a privilege to have been asked to contribute to the commemorative volume of Neurology India being published to honor the memory of Prof. B. Ramamurthi who was its Founder Editor. So soon after his passing away, it won't be easy for me to not be emotional since I have been so close to him for nearly four decades. Before I write about his contributions to neurosurgery I take the liberty to record a few personal anecdotes which reflect his outstanding qualities.
Soon after I returned to India in 1961 after completing my neurosurgical training at Oslo and Montreal and joined my Alma Mater - the King George's Medical College, Lucknow as a CSIR Pool Officer, I was very pleasantly surprised to receive a letter - the first ever - from Dr. B. Ramamurthy (BRM), welcoming me to the neurosurgical fraternity of India, referring to the difficulties a new comer was likely to face and offering to provide all help whenever needed. I was really touched by this gracious act, coming from someone I had never met, who was already an acknowledged leader in the field. I had of course heard about him from my mentor Prof. Kristiansen who had known him personally and was greatly impressed by his intellectual and professional attainments. This letter was the beginning of a lifelong personal bond which soon extended to our families.
I first met him personally during the meeting of the Neurological Society at Calcutta (Kolkata) in January 1962. I was overwhelmed by the genuine warmth of his friendship, and his graciousness in making a beginner like me feel accepted as a fellow traveler in the march to promote neurosurgery in India. Looking back at these events I have often wondered how many of us have extended such a warm welcome to our younger colleagues.
A couple of years later, after I had moved to AIIMS, New Delhi, we decided to organize a seminar on neuroradiology, primarily for postgraduates and young faculty members. BRM happened to be in Delhi for some other meeting. He spent most of his time attending the seminar just like any other student. At the end he paid to get a set of the teaching slides prepared for the occasion of the seminar. Imagine what a boost it was for our ego when he later told us that he used these slides for teaching. It also reflected his thirst to learn from whatever source and this remained his trait till the very end.
In 1965 I first experienced the warm hospitality of Mrs. Ramamurthy at their home. On my way to the Neurology Society Annual Conference at Vellore, on his invitation, I had decided to stay at Madras, to visit his already well-known department at a time when we were still struggling to establish one at AIIMS. The personal attention I received from both of them - at home and in the hospital is still fresh in my memory. Over and above I felt even more proud to be driven with him in his car to Vellore.
The bond of our friendship progressively increased. For several years, when he visited Delhi he stayed with us at home and at Madras an affectionate welcome always awaited me at his home. While working together on the Textbook of Neurosurgery our interaction became more and more frequent. During the final stages of its preparation I spent a week at their home, when we worked from early morning to late at night with only brief interludes necessitated by only the most unavoidable demands of his official responsibilities. Notwithstanding a retinue of house help, both of them would personally look after every aspect of my comfort. My wife and I had a memorable holiday with them at their Kodaikanal residence.
Let me narrate a couple of instances providing a window to his professional and scientific working. In a report published by the Institute of Neurology, Madras, I discovered some discrepancies in the data. I mentioned these to him while we were flying together to Madras. Unlike many others who would have liked to dismiss these as of little consequence, he took me straight to the Institute when we arrived at Madras. To my surprise the first thing he did was to call for all the admission discharge registers meticulously maintained in his office and I was requested to review these to discover the source of the anomalies pointed out by me. I could find the underlying flaw in the recording system responsible for the conflicting data. Steps were immediately instituted to remedy the same.
During one of my visits to Madras, I found him somewhat anxious. I discovered that he was worried about an adolescent son of a doctor colleague who was admitted with progressive paraparesis. His neurology colleagues had suspected an intramedullary tumor. He asked me to examine the patient and discuss with his colleagues. According to my assessment it was unlikely to be an intramedullary tumor. Even after a myelogram (this was before the CT/MRI era) the neurologist in charge insisted on his diagnosis. The next day, following laminectomy when no tumor was seen and the spinal cord appeared somewhat broadened, I suggested looking anterior to the cord. BRM then requested me to join him at surgery. A developmental cyst anterior to the cord was easily excised. He did not hesitate to inform the mother of the patient about the help he received from me. Of course the neurologist concerned had to treat the whole team to ice cream that night.
We were very keen to host the Ninth World Congress of Neurosurgery in India. This was virtually agreed to by the World Federation. At the last moment an unexpected hitch was created. In the past, on several occasions, the President of the Federation and of the Congress had been the same person from the host country. Therefore, the Neurology Society had proposed Dr. Ramamurthy to be the President of both. However, the then office bearers of the Federation insisted that if he wished to be the President of the Federation, the Congress President (and hence the Congress) could not be from India. He came to Delhi, discussed his dilemma with me, but without any hesitation he offered to withdraw from the Presidentship of the Federation so that the World Congress could be held in India. And what glory it brought to the country. This single event, more than anything brought Indian Neurosurgery to the global attention even though it meant him being deprived of a well-deserved honor of becoming the President of the World Federation.
As one of the founding fathers of neurosurgery in India, BRM's contributions to Neurosurgery, extending over half a century touched upon every sphere of it. He published profusely from the very early days of his career. Some of his earliest papers in the 1950s like those on spinal extradural granuloma, brain abscess, ventriculographic diagnosis of cysticercosis, pituitary apoplexy (even as case report) reflected his capacity for keen observations and systematically documenting the same. By 1957, he had already accumulated a remarkable experience with brain tuberculomas, a series of over 200 cases was presented by him at the joint International Congress of Neurology and the World Congress of Neurosurgery at Brussels. The impression it made on the participants was narrated to me by Prof. Kristiansen on his return to Oslo, (where I had just started my neurosurgical training) after the Congress. His numerous publications on the subject over the years touch upon every aspect of CNS tuberculosis - from diagnosis to pathogenesis and therapy. Some of the earliest descriptions of lesions like the intramedullary spinal tuberculomas, optochiasmal arachnoiditis, tubercular spinal arachnoditis, were provided by him.
Head injuries were no doubt a subject of great interest to all neurosurgeons. He recognized the need for creating a specialized separate head injury unit to provide standardized care not possible in a busy, overcrowded, understaffed general ward of a government hospital. This was the first of its kind in India. His scientific publications dealt with the prevention of head injury, strategies to reduce mortality, management of intracranial hematomas, growing skull fractures and posttraumatic psychological effects. He was invited to write a chapter on Acute Subdural Hematoma for the Handbook of Clinical Neurology edited by PJ Vinken and GM Bruyn.
The rarity of intracranial aneurysm in his large collection of clinical material prompted him to publish this observation in the Journal of Neurosurgery. Yet he had an open mind on the subject. Accumulating experience from other parts of the country, especially Delhi and Trivandrum, prompted him to participate in a multicentric study under the aegis of the Indian Council of Medical Research (ICMR) between 1970-75. Arteriovenous malformations, strokes in the young and cerebrovascular complications in pregnancy were subjects of a number of publications.
Under the auspices of the ICMR, supported by PL480 funds, a multicentric extensive study was carried out on epilepsy, BRM being one of the principal investigators. In addition, a number of papers were published on the surgical treatment of epilepsy including stereotactic amygdalotomy and section of the corpus callosum.
He was one of the pioneers to establish and promote stereotactic surgery in India. Along with his colleagues he succeeded in making the Madras Institute of Neurology an international leader in the field. Besides using it for patients with movement disorders, its scope was extended to use it for the management of epilepsy, pain relief, cerebral palsy and drug addiction and some psychiatric disorders. As was so characteristic of him, the unique opportunity was exploited to explore neurophysiological functions of the amygdala, hypothalamus and other deeper brain regions. Few centers in the world could have matched the vast experience thus accumulated over more than two decades.
As mentioned earlier, no aspect of neurological and neurosurgical disorders remained unexplored. Every opportunity was exploited to advance the frontiers of knowledge and sharpen the technique of surgery. Thus his publications included various facets of diagnosis and treatment of a variety of tumors - especially pituitary adenomas and acoustic neurinoma, slow-growing gliomas or craniopharyngiomas. New clinical signs were described. Aphasia and bilingualism were studied, as was use of bio feedback technique and yoga for disorders of the higher nervous system.
Similarly, as new diagnostic procedures or surgical techniques were introduced anywhere he would see to it that he and his institution would not lag behind. Difficulties in importing were overcome by encouraging indigenous production. All attempts were made to acquire the technology and expertise and utilize it for the dual purpose of improving patient care, advance new knowledge and promote its spread in the country. When many much younger to him were reluctant to introduce microsurgical techniques, he, already past sixty, adopted it with enthusiasm.
Notwithstanding his extremely busy professional life, all avenues to promote neuroscience education and research were eagerly explored. While on the one hand he went to address the smallest branches of the Indian Medical Association in remote areas, he was an eagerly sought after person to advise the highest policy-making bodies like the ICMR, DST, DBT, Health Ministry. He was a member of the national committee constituted to select a site for a neurosciences center, later established at AIIMS. Likewise, he played a critical role in the creation of the National Brain Research Center at Manesar. He was a member of the ICMR review committee and AIIMS Committee to formulate plans for its future growth. As President of the National Academy of Medical Sciences and later of the National Board of Examination he initiated several novel programs having a direct impact on medical education in general. Being a co-editor I am well aware of the untiring efforts he made in bringing out the first edition of the Textbook of Neurosurgery at a time when he had innumerable professional, academic and administrative responsibilities. The Textbook of Operative Neurosurgery which is already in press received his full attention at a time when he was virtually confined to bed.
I must confess that I always marveled at his unfathomable energy, a total commitment to causes dear to his heart, and a complete disregard for his personal comforts in pursuit of his goals. And yet he could find time for his family and friends, for a game of bridge or golf, a music concert or a dance performance. It is no surprise that he became a legend in his lifetime. I write this with a fond hope that this will serve as a beacon for the younger generation.
His contributions will no doubt serve as monuments to make him immortal. May I end this tribute to a great son of India by quoting from his own autobiography:
“I have erected a monument more lasting than bronze
And taller than the regal peak of pyramids
I shall never completely die”
Epilogue from Horace's third book of Odes : (Horace : Roman Poet 23BC)