Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial (K.E.M.) Hospital, Mumbai
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/neuroindia.NI_523_17
Source of Support: None, Conflict of Interest: None
Keywords: History, KEM Hospital, Mumbai, neurosurgeons
Grant Medical College and Sir Jamsetjee Jejeebhoy Hospital (J. J. H.) were established in 1845 and were the first modern medical institutions in Bombay. As graduates of these institutions became senior consultants, they sought appointments as teachers in their alma mater. This was strongly resisted by the officers of the Indian Medical Service (IMS) that governed all medical colleges and hospitals in India. The antipathy towards appointing Indians was so great that the IMS preferred appointing one of their own faculty members, who was a professor of material medica (Pharmacology), to teach Obstetrics and Gynecology in the next year.
Nationalist Indians strove to correct this injustice. One of the more vocal amongst them was Dr. K. N. Bahadurji, the first Indian to obtain the M.D. of the University of London. When he was denied the post of Professor of Medicine at Grant Medical College, an IMS officer holding only the diploma of the Licentiate of the Royal College of Physicians, being appointed instead, Dr. Bahadurji advocated the establishment of a new medical college in the city, staffed by Indian doctors.
The death of Edward VII on 6 May 1910 was followed by the raising of funds to build hospitals in his memory. One such hospital was to be built in Bombay. Three years earlier, the Government of Bombay had entrusted the work of medical relief in the city to the Municipal Corporation of the city. The secretaries of the King Edward Memorial Committee asked the Municipal Corporation to use the sum of Rs. 5,75,000 collected by it to build the hospital in Parel, where labourers in the textile mills worked and dwelt. The Government donated 50,000 square yards of land on the estate of the erstwhile Government House in Parel for this purpose. Fortuitously, at this juncture, Sir Pherozshah Mehta, Sir Chimanlal Shah and Sir Narayan Chandavarkar helped to settle a dispute among the successors of Seth Gordhandas Sunderdas of the Mulji Jetha family. As a token of gratitude, the heirs offered Rs. 1, 20, 000 for the foundation of a medical college. At the instance of Sir Pherozshah Mehta, the donors made it a precondition that 'the professors and teachers to be employed should all be properly qualified independent Indian gentlemen not in government service.' The college and hospital were inaugurated in 1925.
Neurosurgical operations were attempted by some senior surgeons even before the formation of a specialised department and almost from the inception of the hospital in 1925.
Drs. A. P. Bacha, G. V. Deshmukh, Rustom N. Cooper, A. V. Baliga and Arthur DeSa had performed surgery upon tumours of in the brain and spinal cord but these were sporadic operations [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d,[Figure 1]e.,,,
Dr. Rustom Cooper was Dr. Ginde's mentor Dr. Ginde (1954) points out that 'the development of cranial surgery, fascinating as it is, was met with many difficulties. For quite a long time, therefore, it attracted only the stout-hearted members of the staff, viz. the late Dr. A. P. Bacha and the veteran Dr. G. V. Deshmukh. The late Dr. Bacha operated in 1927 and again in 1929 on patients with suspected brain tumours. In the first case, the biopsy proved it to be a glioma which was confirmed at autopsy, and in the second case, a suboccipital decompression was done and a tuberculoma was demonstrated at autopsy. The hospital records show that after an apparent decompression for a suspected brain tumour by Dr. Deshmukh in 1930, the patient lived for 16 days and the diagnosis of a meningioma was confirmed at autopsy.' Dr. Ginde concluded this section of his description by stating, 'Stray attempts have been made from time to time but unfortunately they all ended alike. Trepanation for depressed fractures, blood clots etc., were not so disappointing.'
Drs. Cooper and Ginde had studied the effects of head injuries on the blood pressure of dogs. Dr. A. V. Baliga successfully treated trigeminal neuralgia surgically in 1940 and inserted the first tantalum plate for cranioplasty in 1950. Dr. R. N. Cooper performed the first prefrontal leucotomy in 1945 using the route described by Drs. Freeman and Watts. Dr. Bacha successfully removed an intraspinal chondroma from the lower thoracic region of a school teacher in 1935 Drs. Cooper and Ginde removed the first spinal cord tumour in 1940, the localisation having been made by air myelography., Drs. Cooper and Ginde performed a laminectomy for prolapsed lumbar disc at L2-3 level in 1945. The disc contents were excised through the transdural approach.
Dr. Arthur DeSa removed a disc through a hemilaminectomy in 1946. He reported on a series of 7 tuberculomas (1949). The same year, Dr. Baliga analysed 59 proven brain tumours from the hospital records, 16 of them having been accidentally discovered at autopsy. In his personal series of 19 patients, 6 survived surgery. Although he was disappointed by his results, he presented them, emphasizing the need for improved techniques and perseverance.
Dr. Cooper published papers on head injuries (1946), tumours of spinal cord (1948) and brain (1949)., Dr. Homi Dastur recalls Dr. Cooper's lectures on pathology and surgery, which stood him in good stead when he appeared for his primary examination for the F.R.C.S.
The Times of India (21 May 1964) recalled Dr. Baliga's services to poor patients: 'Specialising in Thoracic Surgery and Neurosurgery, he was sought by the highest, but his compassion and generosity were such that he almost became known as the poor man's surgeon…'
Dr. Baliga was responsible for getting Dr. Dastur to rejoin his alma mater.
Dr. Ram G. Ginde
Full-fledged Neurosurgery at the K. E. M. Hospital had to await the return of Dr. Ram G. Ginde from Montreal. Dr. Ginde made an attempt to set up a Department of Neurosurgery and he was well suited for this task. He had been a student and resident surgeon under such giants as Dr. Rustom N. Cooper. He was trained in Neurosurgery by Dr. Wilder Penfield and Dr. William Cone at Montreal Neurological Institute. He was a fine clinician. He returned to his alma mater with hopes that were, unfortunately, frustrated.
In his essay (1989), Dr. Ginde noted: 'In Bombay, neurosurgical work was started from the beginning of 1951, again as part of general surgery. More than 80% of the allotted 25 beds were occupied by neurosurgical cases within the first 6 months. After a considerable struggle, a separate and independent Department of Neurology and Neurosurgery was opened in the fall of 1953… with… an independent operation theatre… In spite of increasing amount of work that was being done under very trying circumstances, the Department of Neurosurgery was … closed about the middle of 1956…'
In 1954, Ginde had reported 813 neurosurgical operations between 1926 and 1953, 707 of which were classified as major. 482 of these were cranial, of which 84 were on tumours. In his own series at the K. E. M. Hospital, Dr. Ginde had a mortality rate of 13.8% in 132 major procedures [Figure 2].
The Municipal Corporation of Bombay, never famed for its far-sightedness, could not see its way to meeting Dr. Ginde's requirements as regards income and he left, eventually setting up the Departments of Neurosurgery at Breach Candy and Bombay Hospitals.
Dr. Ginde also deserves renown as the first historian on the development of neurosciences in Bombay and in India. Among many other honours, Dr. Ginde was elected President of the Neurological Society of India.
His departure left a void. The department he had tried to establish lay in the doldrums.
Dr. Homi M. Dastur
Dr. A. V. Baliga used his position as Acting Dean to call upon his pupil, Dr. Homi Dastur, then working with Mr. (later Sir) Wylie McKissock at Atkinson Morley's Hospital. His simple plea highlighting the plight of patients needing neurosurgery at the K. E. M. Hospital was effective [Figure 3] and [Figure 4].
Dr. Dastur joined his alma mater as a neurosurgeon in 1957 although Mr. McKissock had offered him a teaching appointment on his own staff. The Department of Neurosurgery effectively dates to his return and can be deemed to have started in October that year.
In his postscript, Dr. Baliga had assured Dr. Dastur that he could 'always go abroad to the various neurosurgical centres in Sweden, States etc.' His successor as Dean and the Municipal Corporation did not honor this commitment.
Difficult early days
The treatment meted out to Dr. Dastur was worse. At least, a separate operation theatre had been provided to Dr. Ginde. Dr. Dastur w as not even provided an exclusive neurosurgical operation theatre and had to use the general surgery operation theatre after the surgeons had completed all their operations. As always, the general surgeons scheduled their septic procedures at the end of their lists. As their operations concluded around 4 p.m., Dr. Dastur had to start cleaning and sterilizing the theatres then and could start his own operations only around 6 p.m. every day. He told us of having to perform emergency burr holes to relieve life-threatening intracranial pressure in the corridors outside the operation theatres.
Eventually, he was permitted to share the operation theatres used by the plastic surgeons – a great improvement over those used by general surgeons as asepsis was meticulously observed there all the time.
He was granted his own suite of operation theatres only around 1967. He soon developed two inter-connected theatres and equipped them with lights, machines, instruments and other equipment needed for neurosurgery.
Development of Neuroradiology
The Department of Radiology of the hospital was engrossed in its own work and that of departments such as cardiac surgery. Utilizing the expertise he had gained from Mr. McKissock and Dr. James Bull, Dr. Dastur set up his own Neuroradiology unit, obtaining a 90-90 tilting table for myelography and a Schoenander skull unit for cranial radiology. To the latter machine, he added the rapid film changer invented by George Schoenander in 1946. As younger readers may be unaware of this unit, I quote from a review: 'The rapid film changer is a box which allowed a series of cassettes to be exposed at a fast rate (the so called movie rate) of two cassettes per se cond. The technique was later improved in 1953 to allow the exposure of up to six cassettes per se cond. This allowed many films to be exposed in quick succession, so it was no longer necessary for physicians to stare directly at x-rays.' Angiography through the carotid and vertebral arteries was then performed through percutaneous punctures of these arterial trunks in the neck.
The myelography table had a single x-ray tube, making it necessary to change its position from the antero-posterior to lateral view for each set of exposures. Images were viewed on a fluoroscopy screen before deciding on those to be recorded on film. It was only in 1969 that Pribram et al., devised the biplanar unit along with an image-intensifier.
Dr. Anil D. Desai
The path-breaking appointment of Dr. Anil D. Desai as a consultant neurologist in the Department of Neurosurgery not only ensured that he could help out with the clinical care of patients in the department but also enabled him to embark on his studies on epilepsy and diseases of muscle [Figure 5].
Dr. Homi Dastur started stereotaxic surgery in 1959. Dr. Dastur used the free-hand technique at the start. Inspired by the efforts of Dr. Narabayashi, Dr. Desai travelled to Japan in 1962 to learn from the master. On his return, he fabricated Dr. Narabayashi's apparatus in Bombay. He also developed the technique for making and coating the electrodes needed for deep brain stimulation, collaborating with experts at the Institute of Technology, Bombay, for the purpose. Stereotaxy was now performed using this instrument.
In 1970, Dr. Dastur obtained an echo-encephalography unit for the department as a donation from the Lions Club International. Detection of the third ventricular echoes helped to determine whether the disease lay in the right or left cerebrum. The cryosurgery brain probe and associated equipment were also obtained and used in the operation theatres to freeze vascular intracranial tumours before removing them. Both these instruments were used here for the first time in Bombay. An ethylene oxide sterilizer was purchased and several items used in the operation theatre were sterilized using this dry technique.
Setting new standards
Dr. Dastur broke several traditions. He insisted on having daily sessions in the outpatient department even though this meant increasing his own workload. When administrative protests met this proposal as all other departments had their outpatient clinics just once a week, he showed how many of his patients had travelled long distances, at times hundreds of kilometres, to come to the hospital. When they did reach it, they were often in a precarious state with severely raised intracranial pressure or severe compression of the spinal cord. If made to wait till the next weekly outpatient clinic, they would either die or be rendered paraplegic. His request was granted.
He asked for and obtained a stenotypist for the department so that proper records could be maintained. Every doctor referring a patient to the department was sent a detailed reply when the patient was ready to go home, describing the clinical diagnosis, findings on tests and at surgery, and recommendations regarding further treatment after the patient returned to his doctor. This resulted in a growing band of general practitioners and consultants in Maharashtra, Gujarat, Goa, Madhya Pradesh, Andhra Pradesh and Rajasthan referring a steady stream of patients to him.
Drs. Dastur and Desai set up a system of medical records unrivalled in the country even today. Using a simple system of indexed annual registers linked to typed case records and x-ray folders, they made it possible for anyone to pull these out within minutes of the patient coming to the department even decades after his first attendance. When you recall that this was in the days when computers were not even a distant dream and that even today this system continues to prove its worth, you will get a sense of this achievement.
All case notes, histology and other reports (and in the case of patients who died in the hospital, the autopsy notes) were bound together in separate volumes each year. X-ray folders were arranged by the year of compilation in separate cupboards.
Younger readers of this journal may find it of interest that almost up to the 1970s, we had no access to much that is taken for granted today.
Pre-sterilised and packaged gloves were extremely expensive and difficult to obtain. As with other departments in the hospital, we used latex gloves that were sterilized in our theatre autoclaves. After use, they were carefully washed, powdered, placed in hand-made paper envelopes and re-sterilised. This reuse continued till they gave way. Unfortunately, repeated exposure to heat damaged the rubber and they perished after they were used just a few times.
In 1974, the Bhabha Atomic Energy Research Centre (BARC) in Trombay set up ISOMED, its gamma ray sterilization facility and offered to help us out. We were quick to seize this opportunity and started off with latex gloves. This increased the life span of these gloves considerably and reduced expense on their purchase. We then progressed to other items. Gauze pieces were cut, folded and earlier packed in large drums for autoclaving. This meant that once a drum was opened, the unused gauze pieces had to be re-sterilised. We now sealed just the requisite number of gauze pieces for an operation in a plastic pack and sent these packs for gamma irradiation. Still later, we added packets of lyophilized dura (see below). Large cardboard cartons travelled to and from Trombay each week with items needed for our theatres, easing the burden on our theatre sisters and other workers.
The various hand washes, betadine liquid and other bottled chemicals used in pre-operative preparation of the skin were not even dreamt of in the 1950s and remained unavailable for a further three decades. We used toilet soap to scrub up. The operation theatre sister would slice each cake of toilet soap into two and place just one half for use as the entire cake was often spirited away by theatre cleaners and attendents for use at home!
The skin at the site of surgery was sterilized as follows. Ether was used to remove the grease and grime. Tincture iodine was then used to paint the skin. All residents were taught that iodine takes time to disinfect the skin. They were asked to wait for the evaporation of ethanol in which potassium iodide had been dissolved. The end point was identified by a change from the shiny fluid applied to the skin to a dull coat of powder. Methylated spirit (coloured by gentian violet) was then used to wipe the iodine away. (The spirit was coloured to dissuade theatre attendents who might otherwise consider drinking it.) Sterile drapes were now applied. The rate of infection using these simple, inexpensive substances was no higher than it is with the very expensive materials considered de riguer today.
Cerebrospinal fluid shunts to drain fluid away from the ventricles in patients with hydrocephalus were unavailable in the 1950s and 60s. Those manufactured abroad were too expensive for our patients.
In February 1970, the Journal of Neurosurgery carried a technical note on a new shunt manufactured by Denver Biomaterials Inc. in Denver Colorado. Dr. Dastur wrote to the company, explaining our plight. We were offered these shunts at a concessional rate. At last, we were able to offer satisfactory treatment to our hydrocephalic patients. Within a few months, we noted a problem. Many of the babies whom we were treating were severely under-nourished with a very thin scalp over the tense, enlarged skull. The round shunt chamber ulcerated through the temporal scalp. We consulted Dr. C. V. Mehendale, our consultant plastic surgeon. He devised a scalp flap under which the chamber could be placed. Since the scalp was raised by the chamber, there was a lateral raw area. This was filled in using a split skin graft.
Whilst this solved our problem, we remained dissatisfied. Photographs of the scalp being ulcerated by the shunt were sent to Denver Biomaterials with a request for the manufacture of a shunt chamber with a lower, semicircular profile. They were prompt in acceding to our request and sent us a few shunts with flat-bottomed chambers. These did not cause any ulceration and were then used routinely in our pediatric patients.
The first Indian shunts were devised and produced in 1969 by Dr. Purushottam Upadhyaya, Professor of Pediatric Surgery at the All India Institute of Medical Sciences in New Delhi. Since they were hand-made, the numbers available were few. Thus, they were initially made available only to his parent institute.
From the inception of his department, Dr. Dastur had insisted on making strenuous efforts at obtaining an autopsy on every patient who died in the department. The Coroner's Act of 1871 (modified in 1956) in Bombay helped in this endeavor. It made autopsies mandatory when a death was due to an unnatural cause. Surgery was an unnatural cause. As a consequence, we averaged over 90% autopsies on patients dying in our wards. This was a very important source for learning the natural course of disease and in identifying a faulty diagnosis or treatment. Our neuropathologists – Dr. Ilona Bubelis, Dr. D. H. Deshpande, Dr. A. P. Desai and their successors – studied the nervous system in our patients diligently. The brain and, where necessary, the spinal cord, were carefully preserved in formaldehyde. At the weekly 'brain cutting sessions', staff members from our department together with those from the Departments of Neurology and Radiology gathered in the neuropathology office. The clinical features, radiological findings, diagnosis, and details of surgery were discussed in detail before the brain was unveiled and carefully sectioned. The histological findings in the patients studied the previous week were demonstrated the next week.
Dr. Dastur's principal contributions to Indian Neurosurgery were in the fields of craniovertebral anomalies, apoplexy in pituitary tumours, tuberculomas,,, tuberculous meningitis  and fungal diseases in the brain. He reported what appears to have been the first case of cystic cerebral tuberculoma. He also described extradural spinal arachnoid cysts, diffuse cerebellar hypertrophy,, spinal epidural haemorrhage, epidermoid tumours of the central nervous system, ectopic pinealoma with diffuse meningeal spread, and primary melanoma of the leptomeninges [Figure 6].,
Dr. Dastur also initiated what we now term endovascular interventional therapy when he embolised carotico-cavernous fistulae by floating small pieces of muscle through an opening in the cervical carotid artery. A silk thread was tied to the muscle piece before it was inserted into the artery so that it could be rapidly pulled out if an untoward finding was noted. When properly placed with disappearance of the bruit and ocular pulsation, the silk thread was divided and the opening in the carotid artery closed. During the initial procedures, he sought the help of Dr. Sharad Panday, our cardiovascular surgeon.
Whilst Dr. Anil Desai was the editor of Neurology India, he oftenhe often expressed gratitude for the help rendered by Dr. Dastur. Each reference quoted in every paper accepted for publication was checked in the library for accuracy – title, authors, year of publication, volume number and page numbers. In the absence of facilities we now take for granted, such meticulousness meant spending hours each day in the library, hunting for the original publications.
Dr. Dastur headed the department from 1957 to 1974 when the growing needs of his family forced him to move to the private sector at Jaslok Hospital. As Emeritus Professor at both Seth G. S. Medical College and Jaslok Hospital, he is now enjoying his richly deserved retirement [Figure 7] and [Figure 8].
Organization of the department
Dr. Dastur's immediate successors – Drs. Ranjit Nagpal, Anil Karapurkar and Sunil Pandya – were blessed by the inheritance of a department that they were proud of. Patient care of the highest possible standard was the top priority. Next came the training of resident surgeons in the department and elsewhere in the hospital and last, but not the least, was simple clinico-radiological-pathological research. Everything needed for these three purposes was in place. The outpatient clinic was next to the Neurosurgery office with Ward 10 for male patients, Ward 33 for women and pediatric patients, and the Neuroradiology unit and the operation theatres were within easy reach. It was a matter of a minute or so for any staff member to move from one section to another, when required. The department had its own comprehensive library with journals and volumes on every aspect of the neurosciences from history to the latest developments. This library was later enriched by the addition of books and reprints from Dr. Ginde's personal library, gifted by his son, Vijay.
Thanks to the courtesy of the late Dr. Manohar Keswani, consultant plastic surgeon at the nearby Bai Jerbai Wadia Children's Hospital, we were able to prepare our own lyophilized dura in the late 1970s. He had developed this facility to lyophilize potato skin, which he used successfully to cover the burnt surfaces in children.
Lyophilisation is a process that removes water by first freezing the material within a lyophilizer. The ambient pressure within the lyophilization chamber is then reduced and the temperature slowly increased to allow frozen water to sublimate. The resultant product retains its shape and physical characteristics and remains stable over a long period.
Since we performed a large number of autopsies at K. E. M. Hospital, we could harvest as much intracranial dura as we needed. The dura was carefully cleansed of all blood and other particulate matter and preserved in sterile saline. It was then taken to Wadia Hospital where it was cut into the requisite shapes and sizes and underwent the process of lyophilisation. Once the dry products were available, they were sealed in polyethylene bags and sent for gamma ray sterilization at BARC. Bacteriological studies were performed on samples from each batch to ensure sterility.
We were, thus, able to use lyophilised dura in our patients at around the same time that Macfarlane and Symon did at Queen Square. They wrote about their experiences in the Journal of Neurology, Neurosurgery and Psychiatry (1979;42:854-858).
Sterile bone grafts
Dr. Ralph Cloward established his bone bank at the Queen's Hospital, Honolulu, Hawaii in 1946. (He described the creation and operation of such a bank in the Journal of Neurosurgery 1970;33:682-688). Dr. Gajendra Sinh invited Dr. Cloward to demonstrate his spinal operations at Jaslok Hospital and later visited his centre in Honolulu. On his return, he set up the first bone bank in Bombay. We obtained bone harvested from the iliac bones at autopsy at the K. E. M. Hospital and got it processed in Dr. Gajendra Sinh's bank. We, thus, had access, free of cost, to a variety of sterile bone grafts for use for the skull (to repair bone defects) and for the spine (for fusions).
The Tata Memorial Hospital, in our neighbourhood, set up its tissue bank in 1988. We collaborated with it, supplying harvested tissues from our autopsy room, and obtaining sterile lyophilized dura and preserved bone from it at no cost. (The unit at Wadia Hospital had closed down by then).
Dr. Sunil Pandya
Dr. Pandya's neurosurgical training was under the guidance of Dr. Gajendra Sinh at their alma mater – the J. J. Hospital. Wishing to pursue a full-time career in neurosurgery, he then moved to the K. E. M. Hospital, where Dr. Homi Dastur took him under his wings [Figure 9].
Dr. Dastur facilitated the award of a Commonwealth Scholarship to Dr. Pandya. This enabled him to spend a year with Mr. Valentine Logue, Mr. Lindsay Symon and Dr. George Du Boulay at the Institute of Neurology at Queen Square; and, with Drs. Kenneth Till and Norman Grant at the Great Ormond Street Hospital for Sick Children in London. Mr. Logue made it possible for him to visit Mr. John Hankinson, Mr. Laurence P. Lassman and Mr. Robin P. Sengupta at the Newcastle General Hospital; Mr. Bryan Jennett and Mr. Graham Teasdale at the Southern General Hospital in Glasgow; and, Mr. Huw Griffith at Frenchay Hospital in Bristol.
Steps taken from 1974 to obtain the Neurodiagnost® x-ray unit by Philips bore fruit in 1978. It was a major expense for the Municipal Corporation but the facilities for tomography (during studies on the craniovertebral anomalies, ventriculography, pneumoencephalography and whilst performing air studies on the spinal cord) were unparalleled. The image intensifier showed us events in real time and we could now take several images per se cond, if needed. The chair in which the patient was made to sit, at times under anaesthesia, could be electrically rotated and tilted to facilitate entry of air into the part of the ventricular system that we wished to study. The unchanging focus of the x-ray beam with reference to the head, regardless of the position of the trunk of the patient, and the precision of these movements, yielded very useful images. We later used this machine for catheter angiography and interventional radiology, freeing up the 90-90 table for spinal studies.
At the same time, the department acquired an OPMI 1 (Zeiss) operating microscope as a donation by the Consulate of West Germany. (Later, with the help of Dr. C. K. Deshpande, Dean, Seth G. S. Medical College, OPMI 6 was obtained using funds from the Municipal Corporation of Greater Bombay.)
Microneurosurgery in the department received a big boost when, in 1979, Drs. H. W. Pia and Ernst Grote of the University of Giessen, Germany, conducted a workshop on microneurosurgery in our department. The surgery of aneurysms, arteriovenous malformations and intracranial tumours, associated with or in close proximity to cranial nerves and important blood vessels, was now possible with greater accuracy and safety.
Drs. Pandya and Nagpal followed the lead given by Dr. Dastur in the use of therapeutic arterial embolization. In 1976, they described embolization of arterial feeders from the external carotid artery to decrease the vascularity of cerebral convexity meningiomas. Two years later, they were faced with a large, vascular functioning glomus jugulare chemodectoma in a 24-year old patient. Embolisation of its arterial feeders from the external carotid artery was followed by infarction of the tumour, cerebellar herniation and death. In retrospect, it was felt that a decompressive suboccipital craniectomy prior to embolization might have helped save his life. As will be noted below, Dr. Anil Karapurkar has advanced these early efforts to develop interventional neuro-radiology of international standards in India.
Reviews of atlanto-axial dislocations, congenital fourth ventricular blocks, and of intracranial neoplasms in patients between the ages of 0 and 2 years; pleas for conservative treatment of intracranial tuberculomas  and for prolonged treatment of tuberculous meningitis, and the description of an operation on the pons for a tuberculoma that had developed caseative necrosis  may provide some material for future historians in India.
Collaboration with Drs. B. K. Bachhawat and Nilima Kshirsagar resulted in the production of indigenous liposomal amphotericin. Dr. Kshirsagar and her colleagues in the Clinical Pharmacology department of the Seth G. S. Medical College developed the formulation under strict aseptic conditions. It has been patented and is now being manufactured in India. On his retirement on superannuation, Dr. Pandya joined the Jaslok Hospital and Research Centre, where he continues to work.
Dr. Ranjit Nagpal
Dr. Nagpal trained under Dr. Homi Dastur at their alma mater and was the first doctor to obtain the M. Ch. degree in Neurosurgery from the University of Bombay [Figure 10].
He joined Dr. Dastur as Lecturer in Neurosurgery and retired as Professor in 1995. He has, since, worked as Consultant Neurosurgeon in Jaslok Hospital and Research Centre.
During his visit to the department, Dr. H. W. Pia was impressed by his competence and his silent, hard work. He invited Dr. Nagpal to spend some time in his department in Giessen and helped him obtain a grant from the Deutsche Akademischer Austausdienst (DAAD – the German Academic Exchange Service) for the purpose. The months spent in Giessen, Munich, Wurzbirg and at Queen Square in 1978-1979 enriched his capabilities and enabled him to perform operations such as trans-nasal excision of pituitary tumours and anastomoses between the superficial temporal and middle cerebral arterial branches that were not possible in our department earlier. On his return, he was the first person in Bombay to practice these operations successfully. Dr. Pia invited him to contribute a chapter in his book on spontaneous intracerebral haematomas.
Dr. Ranjit Nagpal rapidly gained expertise in surgery on tumours of the pituitary gland and of those located in the cerebello-pontine angle, and in the management of intracranial venous thrombosis. He also helped in the early stages of the development of therapeutic embolization on intracranial tumours. He also described our experiences with cerebral gumma, surgery on syringomyelia, brain stem tumours, and craniopharyngiomas.
Dr. Anil Karapurkar
After training in Neurosurgery with Dr. Homi Dastur, Dr. Karapurkar joined the department and steadily rose from the post of Lecturer to Professor [Figure 11]. His initial special interest was on craniosynostosis and he worked from 1982 onwards with Dr. K. S. Goleria, our honorary Plastic Surgery to help those children with severe increase in intraorbital and intracranial pressure. Hitherto, our operations had involved supratentorial decompression of the brain by craniectomies. This worsened the intraorbital pressure and proptosis. The shift to operations that incorporated the advancement of a low frontal bony bar including the upper orbital rims and roof was a major advance.
Side by side, Dr. Karapurkar was drawn to selective angiography and therapeutic embolization.
Dr. M. Tayabali, consultant radiologist at Breach Candy Hospital, with expertise in selective angiography, provided a boost to our neuro-radiology work. He kindly volunteered to come to our department once a week and taught each of us the technique of femoral arterial catheterisation. Once we had acquired this expertise, it was no more necessary to perform direct punctures of the carotid and vertebral trunks in the neck. We remain grateful to him for his help at a crucial juncture. Dr. Tayabali has since retired to his home in Cambridge, England.
Dr. Karapurkar developed super-selective catheterisation of individual branches of the carotid and basilar arteries. He then studied the intercostal and lumbar arteries to delineate spinal arteriovenous malformations and their components. He introduced balloon catheters and progressively sophisticated forms of embolization of tumour feeders and arterioles feeding the nidi of arteriovenous malformations. The obliteration of intracranial aneurysms through the femoral artery followed.
Progressive involvement in catheter angiography of the brain and spinal cord and training with Dr. Luc Picard in France resulted in his conducting workshops on interventional neuroradiology along with Dr. Picard and later, with Dr. Jacques Moret, in our department in 1982, 1985 and 1989. These workshops had talks, discussions and live demonstrations on patients with such illnesses as giant aneurysm of the intracavernous internal carotid artery, aneurysm of a persistent trigeminal artery, carotid artery – cavernous sinus fistula, brain stem and spinal arteriovenous malformations. His subsequent work on enabling other centres in India to develop this specialty is well-known. Dr. Karapurkar has written on the surgery of craniosynostosis and endovascular therapy of aneurysms, arteriovenous malformations and occlusive arterial disease.
He left the department to head the Interventional Neuroradiology Department at Apollo Indraprastha Hospital in New Delhi. Currently, he is back in Mumbai and works principally at the Breach Candy Hospital. He is a respected guest speaker at almost every neurological meeting in India.
Dr. Atul Goel
Dr. Goel graduated in medicine from the Government Medical College and Hospital, Nagpur. He joined the department as Lecturer and rose to become the Head of the Department in 1998 [Figure 12] and [Figure 13]. Even before he was appointed lecturer, he had embarked on studies on craniovertebral anatomy in collaboration with Dr. V. J. Lahiri of the Department of Orthopaedics in B. Y. L. Nair Hospital. As is common knowledge, these studies blossomed and now form the pillar of treatment of diseases involving the craniovertebral junction.,,,, Most of the techniques, concepts and philosophy of treatment of craniovertebral junction currently in use in the world have his stamp of contribution. His numerous internationally recognized and quoted papers on the subject have produced changes in the way we look at and treat congenital craniovertebral anomalies.
In the year 1988, he first travelled to London to work with Dr. Alan Crockard, who was then the doyen of transoral surgery, and then to Pittsburgh to work with renowned surgeons that included Drs. Peter Janetta, Laligam Sekhar, Chandranath Sen and their colleagues. This was the start of his work on surgery for lesions along the base of the skull. He developed original operations on several intracranial tumors in general, and skull base tumors in particular. His work on cavernous sinus tumors is path breaking. For the first time in the literature, he described the extradural approach to tumors involving the cavernous sinus,,, the inter-dural approach to trigeminal neurinomas,, and the extradural subgasserian ganglion approach to clival chordomas. His concepts of dural relationship of pituitary tumors to diaphragm sellae and particularly of its extensions into the cavernous sinus assisted in advancement of surgical techniques. His book that was published by the famed publisher Churchill Livingstone in 1997 entitled 'Neurosurgery of complex tumors and vascular lesions' was a monographic presentation and contained description of more than 100 original techniques and several surgical concepts published by him. This hugely successful book was written in collaboration with Drs. Shigeaki Kobayashi and Kazuhiro Hongo, both renowned and respected neurosurgeons of Japan.
He put forth innovations in the way in which we treat basilar invagination, Chiari malformation,, syringomyelia, cervical spondylosis, ossified posterior longitudinal ligament and a host of other spinal diseases.,,,,, His work has been responsible for relegating transoral surgery into the realm of history. His current work on Chiari malformation and syringomyelia has already made significant waves in the field. He foresees that foramen magnum decompression may also soon become a historical operation. His book on The Craniovertebral Junction: Diagnosis, Pathology, Surgical Techniques published in the year 2011 by Georg Thieme Verlag is considered to be a bible on the subject. His bibliography outstrips that of almost every contemporary Indian neurosurgeon and rivals that of such masters as Drs. B. Ramamurthi and Prakash N. Tandon.
He forged a partnership with Dr. Manu L. Kothari in the Department of Anatomy and had many fascinating discussions on a variety of subjects. Some of these resulted in joint editorials and publications on teleology, developmental anatomy and unconventional ideas on the structure and function of cerebrospinal fluid, meninges and intervertebral discs. They also wrote a paper on ethics in Neurosurgery. These may be found in the Journal of Postgraduate Medicine and Neurology India.
Even before he headed the department, he had started a microneurosurgery laboratory in a small room in Ward 33. This grew and soon attracted postgraduates from all over India, neighbouring countries, and then from much further afield. The innovations in surgical technique and the vast numbers of patients now treated annually have made the department a Mecca for aspiring neurosurgeons the world over.
His encouragement led Dr. Aadil Chagla to specialize in the treatment of intracranial aneurysms, Dr. Bhatjiwale in stereotaxic surgery, Dr. Trimurti Nadkarni in encephalo-myo-synangiosis and the treatment of moyamoya disease, Dr. Muzumdar in the surgery of epilepsy and Dr. Ketan Desai in peripheral nerve repair.
He has many other achievements to his credit. He turned an almost moribund Journal of Postgraduate Medicine (JPGM) – the scientific organ of Seth G. S. Medical College and K. E. M. Hospital – into a nationally and internationally respected publication. In this, he was greatly helped by Dr. Devkumar Sahu.
Dr. Sahu – a graduate of Seth G. S. Medical College – also felt inspired to revitalize JPGM. He put his formidable organizational skills whole-heartedly into this effort with brilliant success. This venture served as a springboard for his eventual debut as a national and international publisher of medical journals and the formation of Medknow Publications.
Drs. Goel and Sahu went on to revitalize Neurology India, when Dr. Goel was elected its editor. The concept of online article submission and reviewing process was introduced first by Neurology India even before reputed journals like the Journal of Neurosurgery and Neurosurgery. Under the leadership of Dr. Goel, the impact factor of Neurology India reached nearly 1.2. Subsequently, Dr. Goel created new journals such as the Journal of Craniovertebral Junction and Spine. Dr. Goel is now on the editorial boards of several prestigious international Neurosurgery journals.
Dr. Goel is a much sought after speaker at international Neurosurgery conferences and is an honoured guest member of several Neurosurgery societies of the world.
Recognition of Dr. Goel's abilities by such awards as Dr. B. C. Roy award, Shakuntala Devi Amirchand Prize, Amrut Mody Unichem award (of the Indian Council of Medical Reasearch) and the award of honour by the Mayor of Mumbai has only spurred him on to greater effort [Figure 14].
Dr. Aadil Chagla
Dr. Aadil Chagla heads Unit 2 of the department [Figure 15]. He studied at St. Mary's School in Mazagaon and then at St. Xavier's College. Undergraduate education at the Grant Medical College and Sir Jamsetjee Jejeebhoy Hospital was followed, after obtaining the M.B. B.S. degree in 1982, by training in General Surgery and the acquisition of the M.S. degree in 1988. He trained in Neurosurgery at the Sree Chitra Tirunal Institute for Medical Sciences and Technology in Thiruvananthapuram in 1992. All along, he has also displayed his talent in sport (cricket, badminton and squash), music and art. His chief hobby is looking after his vintage car.
He has taught postgraduate students in Neurosurgery at LokmanyaTilak Municipal Medical College and Hospital in Sion. He then joined the department at K. E. M. Hospital, where he now holds the post of Professor. Whilst performing all neurosurgical operations, he finds surgery on sellar and suprasellar tumours and orbit, lesions in vital areas such as the motor strip and speech area and intracranial aneurysms, of special interest.
His research studies have included the evaluation of mannitol delivered through the carotid arteries for more effective reduction of brain swelling.
He is currently setting up trauma centres along the highways around Mumbai, manned by local experts, to ensure adequate care within the shortest possible time to victims of automobile accidents.
Some other vignettes
Staff members in the department have always had excellent colleagues – anaesthetists, neuropathologists, residents, nurses, physiotherapists, occupational therapists, social workers, technicians and other staff. They have ensured that our patients received care at least as good as, or perhaps better than was available to patients in the very expensive rooms and suites of private hospitals [Figure 16] and [Figure 17].
The wife of a senior and respected lawyer provided an example of the ethos of the department. The Parsi gentleman had coaxed his wife to attend our hospital as she was suffering from severe sciatic pain due to compression of the cauda equina by a protruding lumber disc in a stenotic spinal canal. When it was time for the patient to go home, she requested a personal chat. She then told us of the high stratum of society in which she lived and her husband worked. 'When my husband told me that I was to be admitted to this hospital, I asked him why I should go to a beggar's sanctuary. I confess to you now that I am ashamed of ever having harboured such a thought. I was earlier admitted to a large and reputed private hospital in one of their expensive rooms. The consultant neurosurgeon had no time to answer my queries and the resident doctors made fleeting visits. In K. E. M. Hospital, the consultants and resident doctors have lavished care on me and the nurses have attended to my every need. As I leave you I am humbled and am very grateful for all that has been done for me – and that too at no cost!'
The late Dr. Noshir Antia, Director of the Foundation for Community Health (FRCH) and Foundation for Medical Research (FMR), asked his colleagues to conduct a research project comparing the costs and quality of neurosurgical care in a public sector hospital and that in the private sector. Our department was chosen to represent the public sector hospitals. Researchers from FMR-FRCH had free access to all our patients, staff members and patient records whilst carrying out the study. Their report was illuminating and is worthy of study. It stands as an outstanding testimony of the standards set up by Drs. Dastur and Desai.
The gallant band of resident doctors in this department served its patients with sincerity and devotion and most have gone on to work wonders under difficult circumstances. Surat, Nagpur, Poona, Kolhapur, Raipur, Bhopal, Panjim, Ahmedabad, Aurangabad… are just some of the places (apart from Mumbai) where they have kept the flag unfurled by Dr. Dastur flying high.
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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], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]