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|NI FEATURE - COMMENTARY: TIMELESS REVERBERATIONS
|Year : 2018 | Volume
| Issue : 1 | Page : 2-3
Neurosurgery as it was
Department of Neurosurgery, Bangur Institute of Neurology; IPGMER and SSKM Hospital; Park Clinic, Kolkata, West Bengal, India
|Date of Web Publication||11-Jan-2018|
Dr. R N Roy
Park Clinic, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Roy R N. Neurosurgery as it was. Neurol India 2018;66:2-3
I consider myself extremely fortunate to have been offered the opportunity to be the first Indian trainee to be trained at the very first Neurosciences centre set up in this country in 1949 by Dr. Jacob Chandy. He was, in turn, the first Indian to have been trained in the speciality by a world famous neuroscientist, Prof. Wilder Penfield of the Montreal Neurological Institute of Canada. What was neurosurgery like at that time?
During the time that we were introduced to the speciality of Neurology and Neurosurgery in this country in the middle of the twentieth century, diagnosis was based almost entirely on history and clinical examination of the patients. If, for example, the clinical examination of the patient suggested an unilateral supratentorial lesion, the investigation of choice was a cerebral angiogram performed with a direct carotid artery puncture. If the clinical examination failed to lateralise the lesion, but there was clinical evidence of raised intracranial pressure, the investigation of choice was an exploratory burr hole, followed by an air ventriculogram. In the absence of clinical suspicion about localisation of the lesion, the patients were usually screened with pneumoencephalograms. Of course, tell-tale radiological evidences regarding the location of the lesion, for example, as could be deduced from the shape of calcification in the suprasellar or sellar area, were taken care of without much ado. Vestibular schwannomas were generally diagnosed after the patient became totally deaf and plain radiographs in special views revealed enlargement of the internal auditory meatus on that side. It was rare to have a vestibular schwannoma removed in a patient who could hear on both the sides!
If the diagnosis was a dilemma, operating was, at times, a real nightmare! We had to depend on monopolar diathermy for the control of haemorrhage! There was no bipolar diathermy nor any of the haemostatic agents so widely used today. Hydrocephalus was diagnosed in children by the clinical evidence of the “sun-set” sign and had to be treated by a cerebrospinal fluid diversion procedure in the form of a shunt. Red rubber catheters were used initially as shunt systems as no sialastic tube was available. External ventricular drainage was done with red rubber catheters, and the risk of infection was incredibly high! The availability of the Upadhyaya shunt and silastic shunts were considered as revolutionary progress of those times !
I remember the time when a man in his fifties was admitted with a history of balance problems at Christian Medical College, Vellore. This was followed by gradual loss of consciousness. We made a clinical diagnosis of a posterior fossa tumour and undertook surgery on him utilizing a midline posterior fossa exposure. There was no tumour in the midline. This prompted us to search along one cerebellar hemisphere and we could, therefore, reach what was a very vascular tumour on one side. There was torrential haemorrhage and after a trying surgical exercise lasting over six hours, we finally packed the bleeding area and retreated! His post-mortem examination later showed bilateral vascular vestibular schwannomas!
How was one to learn what to do? Textbooks of Neurosurgery were few and far between, and Poppen's Treatise of Operative Surgery was the only textbook available to convey basic knowledge about neurosurgical procedures! We were, however, privileged even in the pre-internet era, to have access to some excellent monographs by Cushing, Dandy, Bailey, Buchanan and Bucy. We also were able to read the collective of works of giants in the field like Penfield, Hughling Jackson, Geoffrey Jefferson and others, which were of immense value to budding neurosurgeons desperately thirsty for knowledge.
The thing we feared the most was wound infection, and the incidence of this was not very low. Skin preparation consisted of the use of soap and water, ether, spirit, iodine, and spirit again in that religious order! The incision was marked, and the wound meticulously draped, with the drapes fixed with sutures or towel clips, keeping minimum amount of skin exposed. Needless to say that total shaving of the hair on the head was the order of the day.
Most operations were carried out under general anaesthesia with endotracheal intubation, and we were truly privileged to have the services of real experts who put our patients to sleep. Except for posterior fossa surgery and high cervical surgeries which were carried out with the patient in sitting position, all other operations were performed with the patient in a flat, supine, prone or lateral position. In spite of not having Doppler monitors, we did not have many fatal cases of air embolism in the sitting position, although haemostasis had to be an obsession during surgery.
Looking back at those times, I often wonder that necessity made us good clinicians, and fear of surgical complications made us good technicians. There was no obsession with radiological localisation, nor with gadgets for every step. The stereotaxy frame to which I had been exposed during my time in Edinburgh with Prof Gillingham, was considered the most refined form of localisation tool available, when it did eventually find its way to this country. Image guidance was, therefore, based upon a good clinical examination and a good radiographical imaging protocol, sometimes supplemented by a cerebral angiogram!
There were few neurosurgeons available and a lot of the country to cover amongst the motley crowd. I actually once had to travel in the luggage hold of an air-force aircraft from Kolkata to Port Blair braving stormy weather because the son of an important bureaucrat had suffered a head injury there. The pilot did take pity on me and finally offered me a seat in the cockpit. It all seemed to be a different world compared to the one we see in the speciality today!
Those, indeed, were interesting and challenging times for neurosurgeons of the country!