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|NI FEATURE: CITADELS SCULPTING FUTURE - REVIEW ARTICLE
|Year : 2015 | Volume
| Issue : 1 | Page : 91-95
History of Neurosurgery at National Institute of Mental Health and Neurosciences: An epitome of steady growth
Dhananjaya Ishwar Bhat, Indira B Devi
Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
|Date of Web Publication||4-Mar-2015|
Dr. Dhananjaya Ishwar Bhat
Additional Professor of Neurosurgery, Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhat DI, Devi IB. History of Neurosurgery at National Institute of Mental Health and Neurosciences: An epitome of steady growth. Neurol India 2015;63:91-5
The National Institute of Mental Health and Neurosciences (NIMHANS) is a multidisciplinary institute aiming to provide service, training, and research in the fields of mental health and neurosciences. The Department of Neurosurgery is nestled in a humble building, the Neurocenter and its adjacent Casualty and Neurosciences faculty block, within the sprawling 132 acres of NIMHANS campus. The Department of Neurosurgery was started in 1958 under the leadership of Dr. RM Varma, and the growth and development of the Neurosurgery department are intricately woven with that of the institute.
| » Genesis of Mental Hospital|| |
In 1848, due to the insistence and persistence of Dr. Charles Irving Smith, surgeon in the Mysore Commission, the Lunatic Asylum was established in Bangalore to treat persons with mental illness. Later in 1926, by the orders of the Maharaja of Mysore, His Highness Sri Krishnaraja Wodeyar, the Lunatic Asylum was renamed as the Mysore Government Mental Hospital (MGMH). In 1937, the mental hospital was shifted to its newly constructed building at the current location following grants from the Maharaja of Mysore and Dewan Sir Mirza Ismail [Figure 1].
In 1954, following recommendations by the Bhore Committee Report, the All India Institute of Mental Health (AIIMH) was established close to MGMH in order to treat and train manpower in the area of mental health. The building of AIIMH, currently houses the administrative sections and many basic science departments of NIMHANS. It was Dr. MV Govindaswamy, the doyen of psychiatry, who became the founder director of AIIMH [Figure 2]. Neurosurgery spawned during that time. A great visionary and leader Dr. Govindaswamy, though a psychiatrist, paved way for the modern neurosurgery in this institute. He was instrumental in starting psychosurgery at the AIIMH. The Portuguese neurologist António Egas Moniz working with neurosurgeon Pedro Almeida Lima, started psychosurgery for calming down extremely aggressive and uncontrollable mentally ill patients during 1933-1935 by performing frontal leukotomies (severing the neural tracts in the frontal lobe). In the West, while leukotomies were still being popularized by Walter Freeman and the neurosurgeon James W Watts, Dr. Govindaswamy went to Delhi, learnt the technique from Dr. Balakrishna Rao, a general surgeon and performed leukotomies at the MGMH in 1942. Dr. Govindaswamy went on to become the first psychiatrist to conduct psychosurgery inIndia [Figure 3]. Along with Dr. Balakrishna Rao, he published their experience in Lancet, 1944 under the title "Bilateral Prefrontal Leucotomy in Indian Patients". Dr. Govindaswamy was a dynamic person and to his credit goes the framing of the more humane Mysore Lunacy Act, the starting of insulin coma therapy. and the electroconvulsive therapy for persons with severe mental illness in MGMH. ,
|Figure 2: The Pioneers of National Institute of Mental Health and Neurosciences (NIMHANS), Neurosurgery; Dr MV Govindaswamy, Dr RM Varma, and Dr GN Narayana Reddy|
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| » Department of Neurosurgery is Formed|| |
Within a few years of starting AIIMH, Dr. Govindaswamy, realizing the inseparability of mind and the brain and hence between behavioral and neurological sciences, started the Departments of Neurology and Neurosurgery. In 1958, Dr. Raja Martanda Varma joined the AIIMH as its first neurosurgeon and started the Department of Neurosurgery. He later went to become the director of AIIMH in 1969. He had undergone neurosurgical training at Bristol, UK. His first assistant was Dr. GN Narayana Reddy [Figure 2]. Dr. Reddy had completed Diploma in Psychiatric Medicine (DPM) and was encouraged by Dr. Varma to undergo neurosurgical training. After his successful training at Edinburgh, UK, Dr. Reddy joined the neurosurgery department in 1966. Till he returned, Dr. Varma single handedly ran the department and his hard work and dedication brought him a lot of accolades from one and all. It was due to the combined efforts of these two neurosurgeons that neurosurgery escalated to new heights [Figure 4]. They worked in extremely difficult conditions and as the saying goes "when the going gets tough, the tough get going", both struggled against all odds to develop neurosurgery. Both neurological and neurosurgical patients were admitted in the same ward within the Mental Hospital Complex. The operating theater was a wing of the ward with some modifications. There was no anesthetist as a faculty. Hence, both of them had to go to Victoria Hospital (Government General Hospital) to request the anesthetist personally to help them with their cases. Dr. Ramachandra, the senior anesthetist in Victoria Hospital was a sincere, hard working person with an interest in neurosurgical procedures. After finishing his regular work in Victoria Hospital, he used to come in the evening hours to AIIMH to help in the neurosurgical procedures. Thus, most of the operations were done late in the evenings. The first neurosurgical procedure, apart from leukotomies, was performed on a patient with chronic subdural hematoma on 7/1/1958; and, on 29/12/1958, the first vestibular schwannoma was operated. Fifteen surgeries were done in 1958, and it increased to 117 and 132 in the following 2 years. In 1962, the first full-time anesthetist, Dr. S Malathi, was appointed. ,
|Figure 4: Dr RM Varma along with the President of India Sri VV Giri. Dr GN Narayana Reddy is seen behind them|
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Dr. RM Varma is credited to have started a unique percutaneous chemothalamotomy for patients with Parkinsonism More Details tremors and movement disorders. He realized the constraints of working with limited resources with a heavy case load and devised this excellent technique. Patients were treated on an outpatient basis, thus eliminating the need for admission, reducing the strain on hospital resources and improving patients' and caregivers' comfort. This method, later known as Varma's Technique, could be completed under local anesthesia within 20 min. Using his stereotaxy skills based on X-rays, he used the percutaneous skull base approach to Meckel's cave to reach the thalamus and chemically ablate it [Figure 5]. In 1965, he presented his work in an international conference of neurosurgeons at Copenhagen. ,
| » Further Growth of Neurosurgery and Formation of NIMHANS|| |
In 1963, he, along with Dr. GN Narayana Reddy, proposed to have a separate building, a Neurocenter, for neurosurgical and neurological patients. Dr. Varma impressed both the state and central government through a short documentary about the dramatic results of percutaneous thalamotomy in patients with Parkinsonism. This resulted in his obtaining grants from the governments and in 1965; the foundation for Neurocenter was laid by Mr. S Nijilingappa, the Chief Minister of the state. However, due to two wars and other emergency situations, Dr. Varma had to wait for around 8 years for the completion of the building [Figure 6]. Finally, the building was ready in 1973 and His Excellency Sri VV Giri, President of India inaugurated the Neurocenter on 30 th December 1973. It had 80 inpatient beds, two modern operation theaters, and housed the then state of the art neuroradiology section, blood bank, and other investigative facilities [Figure 7]. It is worth mentioning that two neurosurgeons Dr. BS Venkataramana and Dr. C Vidyasagar had also rendered invaluable service and support for the growth and development of Neurosurgery during the late 1960s and 1970s. 
|Figure 7: State of the art operation theater in Neurocenter with viewing gallery on top|
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Dr. Varma was a firm believer that the mind (mental health) and brain (neurosciences) have to go hand in hand for the holistic management of a patient with a mind or brain disorder. He worked hard for it, and this gave birth to NIMHANS following the amalgamation of the MGMH and AIIMH under the orders of the President of India on 27 th December 1974. It was inaugurated on 14 th February, 1975 by Dr. Karan Singh, the then Union Minister for Health and Family planning. Dr. RM Varma became the first Director of the newly formed NIMHANS.
Dr. RM Varma is a gifted surgeon, relentless researcher, the teacher par excellence, able administrator, visionary, and philosopher. He was awarded the Padmashri in 1970 from the President of India Sri VV Giri. His other awards include the Karnataka State Award on Rajyotsava Day (1969), Citizen Extraordinary of Bangalore Award (1967), and Sir Viswesvaraya Award (1998). He was also the Honorary Surgeon to former President of India, Sri R Venkataraman. The Bangalore Neurological Society conducts the RM Varma Oration biannually in his honor. He also holds the post of Professor Emeritus at NIMHANS. ,
Till 1974, the Department of Neurosurgery surged forward under the guidance of Dr. Varma and Dr. GN Narayana Reddy. In 1974 when Dr. Varma became the Director of NIMHANS, the responsibility of the department fell on the able shoulders of Dr. GN Narayana Reddy.
They both recognized the paramount importance of dedicated care for patients with head injury [Figure 8] and started a separate ward to treat the head injured in 1977. It started as a five-bedded ward. In order to train district level surgeons for primary management of head injuries, courses of 1-week duration were started. Basic practical and theoretical knowledge were imparted to the surgeons. In addition to regular outpatient clinics, special clinics for head injury and intractable pain were started in 1979. Further growth of the neurosurgery wing occurred during 1979-1982 with the arrival of the sophisticated Laitinen's stereotactic frame and two operating microscopes to the department. The second operating microscope with color TV monitoring and recording system was added in 1982. In order to facilitate stereotactic surgery, a system of X-ray sources in two directions was installed in the operation theater. A variety of procedures for neuropsychiatry and psychological diseases were started. With improved magnification and good illumination, many surgeries previously considered impossible, could now be done with the use of the operating microscope. Dr. GN Narayan Reddy became the Director of NIMHANS in 1979. The department was then headed by Dr. C Vidyasagar and later, Dr. V Hemalatha. Dr. Bhabani Shankar Das joined as Head of Department in 1981 and consolidated the early gains by his predecessors. Slowly over a decade and a half, the momentum of development kept on going and microsurgery for tumors, intracranial aneurysms, cerebral and spinal vascular malformations, intramedullary tumors, and intra- and extra-cranial small vessel anastomosis found place in the routine list of operations at NIMHANS. His interest in craniovertebral junction and peripheral nerve surgery is noteworthy. Transoral excision of odontoid for atlantoaxial dislocations was standardized, and an innovative technique of using contoured Steinman pins and bone graft for posterior fusion was developed. He popularized surgery for brachial plexus injury at NIMHANS. ,, After Dr. Das superannuated in 1996, Professor Kolluri Venkataramana Sastry took over the mantle of Head of Department till 2006. Under his guidance, the growth of the department further accelerated. Endoscopic surgery for hydrocephalus and intracranial lesions was being done more frequently. There was an impetus for stereotactic surgeries and vascular and spine surgeries. Dr. KVR Sastry was keen to use the latest technology available for the benefit of patients. He realized the potential benefit of radiosurgery and was instrumental in developing a Gamma Knife Facility at NIMHANS. South India got its first Gamma Knife (C model) in February 2006 when it was installed and commissioned at NIMHANS [Figure 9]. Till date, more than 2,000 cases have been done. Following his voluntary retirement, Dr. BA Chandramouli, Dr. B Indira Devi, and Dr. S Sampath had been the heads of the department in the years to follow.
| » Clinical Services|| |
Dr. GN Narayana Reddy was the Head of Department after Dr. RM Varma became the Director of NIMHANS. There was a steady increase in the patient inflow during his tenure which continues till date. In 1975, the admission to the surgical service was 1,250 and over 10 years, it increased to 2,200 per year, a rise of 68%. At present, the admissions per year are around 6,000.
Apart from the regular outpatient clinics, several specialty clinics had also been started.
In 1979, a post-trauma clinic was started to cater to the needs of head-injured patients. It was unique in that it had a neurosurgeon, a psychiatrist, and a clinical psychologist to treat both the brain and the mind.
As pediatric population consisted of about 30% of the work, an addition of a 14-bedded pediatric neurosurgical ward was done in 1980. A spina bifida clinic was also started in 1980 to evaluate and comprehensively manage children with congenital spinal disorders. Around 600-900 surgeries per year were being performed for several years prior to 1976. From then on, there has been a progressive increase in the number of surgeries performed. It was around 1,400 in 1981 & 2,323 in 1991, and in 2013-2014, it was 6,390 surgical procedures.
| » Training and Research|| |
The MCh course for Neurosurgery was started in 1971. Annually, two students were inducted for training. From 1977, it was increased to four students per year. Dr. C Vidyasagar, after his training in Manchester, UK (where he obtained a Ph.D.), returned to India and joined the Neurosurgery Department in 1974. At the same time, Dr. V Hemalatha, who had an interest in pediatric neurosurgery and who had undergone training in Sheffield, UK, also joined the department. These two doctors, along with Dr. AK Reddy, founded a structured training program and contributed to the early growth of the department. , Considering the need for trained neurosurgical manpower in the country, the intake was increased to six per year from 2001 and to eight from 2012. Till date, 140 students have graduated from NIMHANS in Neurosurgery.
Despite the heavy workload and limited resources, the department did respectable work in the field of research right from the formative years. Studies on head injury prognostication, hydrocephalus, arteriovenous malformations, tuberculosis, congenital malformations of the central nervous system (CNS) and craniovertebral junction anomalies were done. Early in the development of NIMHANS, an animal lab was established that encouraged animal experiments for research and microneurosurgical training. Several experiments in the field of head and spinal cord injuries, forebrain ischemia models, peripheral nerve regeneration, hydrocephalus models, and recently, blast injury and subarachnoid hemorrhage models have been developed. ,
The growth of the Department of Neurosurgery has been one of exemplary vision, struggle, dedication, and passion toward neurosurgery and service to mankind. The department is growing steadily from strength to strength and at present the neurosurgery team has a faculty strength of 13, supported by 39 MCh residents, three faculty members in gamma knife surgery, and a group of enthusiastic senior and junior research officers and PhD students all providing dedicated service to the people with brain, spine, and peripheral nerve disorders.
| » Acknowledgments|| |
Department of Publication and Department of Health Education NIMHANS, Bengaluru, India.
| » References|| |
NIMHANS Commemorative Volume: 20 th
Anniversary 1974-1994. In: Channabasavanna SM, editor. National Institute of Mental Health and Neurosciences, Bangalore; 1994.
NIMHANS Golden Jubilee Commemorative Volume. GDS: Murthy P, Jain S, Chandrashekar CR, editors. 2004.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]