When the Air Hits Your Brain: Tales from Neurosurgery

9. A Bit of Hard Cheese

All neurosurgical residencies require their trainees to spend at least three months on medical neurology services. Neurologists treat the nonsurgical diseases of the nervous system: migraines, multiple sclerosis, myasthenia gravis, muscular dystrophy, and so on. At one time, neurologists saw all neurological diseases, operative or otherwise, referring away those cases in need of the surgeon’s knife after an appropriate diagnosis had been made. With the advent of the CT scanner, however, the role of the neurologist in structural diseases of the brain and spine diminished greatly. The internist or general practioner can now order a brain scan on a patient complaining of headache and, if the scan reveals a tumor, send him or her to the surgeon directly.

The straight pipeline from primary care to the neurosurgeon has created friction between neurologists and neurosurgeons. The neurologists are irritated about being bypassed in favor of surgeons too anxious (in their humble opinions) to cut the patient, while the surgeons increasingly view the neurologists’ contribution to many diseases as nothing short of vestigial. The running joke among the neurosurgical residents was that neurology was a little guessing game to play while the CT films were processed.

The truth is, neurologists still play a valuable role. Not all brain afflictions yield to surgery, and neurosurgeons have little patience for nonoperative problems. As neurosurgeons, we should not mock neurology, since neurology is where our own heritage lies. Neurologists first discovered what different functions lie where in the brain, allowing surgeons some prayer of finding a brain tumor in the decades before CT scanning. A neurologist gave us cerebral angiography. Many early neurosurgeons were neurologists first. Much as I hate to admit it, neurologists understand the brain much more profoundly than most surgeons, just as an automotive engineer understands a V-8 engine better than a mechanic.

The neurosurgeon/neurologist dichotomy in brain disease is similar to the cardiac surgeon/cardiologist dichotomy in thoracic disease, or the general surgeon/internist dichotomy in abdominal disease. My old cardiac chief, Maggie, once observed that internists and other “non-procedure-oriented” specialties stored their knowledge like sugar in great, floppy sacks and we stored ours in tiny sugar cubes. They had much more of it, but ours was more user-friendly.

In our own health center, unfortunately, the tension between the neurology and neurosurgery services was so great that our department would not permit us to do our required neurology elective with the university neurologists. In fact, they went one arrogant step further and mandated that the only neurology service good enough for their residents was at a London hospital. London was the birthplace of both neurology and neurosurgery. The first full-time brain surgeon in history, the great Sir Victor Horsley, practiced there.

I had no burning desire to be in London for three months. Our department of neurosurgery “graciously” paid my airfare, but reimbursed me for nothing else. London is an expensive place to live and I could not just give up my current apartment for only three months, and so I was faced with paying rent on two residences during the rotation. This would consume all of my moonlighting money. I appealed to the department to let me do my neurology at home. They refused, and off to Merrie Olde Englande I went.

I spent my first night in London lying awake listening to the trains rumble past my bedroom window. I had an uneasy feeling, thousands of miles from home, in a country where I had no friends and no family—no one who would know if I disappeared off the face of the earth. But my discomfort soon passed. Years earlier I would have stayed terrified for weeks, but I was changing. The years of residency had begun to permeate my personality; I now looked at myself as a neurosurgeon. The James Bond feeling that sustained me in moments of clinical crisis was starting to carry over into my out-of-hospital persona as well. Endless days and nights spent summoning the nerve to stick a tube into someone’s nose, a needle into someone’s back, a drill into someone’s skull, or a knife into someone’s brain were now making it easier for me to face challenges outside the hospital as well. The next morning I confidently walked to Kensington High Street station and boarded the Circle line, headed for my first day in the birthplace of neurosurgery.

After some meandering, I finally located the quaint collection of buildings making up the London medical complex that was my final destination. The main hospital had the musty smell and vaulted ceilings of a structure dating from the previous century, with tall, wooden-framed windows still filled with original glass panes rippled by age. The walls were topped with elaborate plaster moldings. A circular stairway of trodden marble and hardwood bannisters spiraled to the first patient floor. On that floor were two large wards, male and female, each with two dozen metal-frame beds arranged in rows on either side of a long steam radiator covered by an ornate metal grill. These cavernous wards contained the neurology service.

While the foyer and hallways were heated to barely sixty degrees (considered positively balmy by U.K. standards), I found the wards to be quite warm. The increased heating of the patientcare areas was evidence that even the British didn’t believe their own hogwash about lower temperatures’ being “healthier.” In reality, the ambient temperature was directly proportional to the robustness of the government health service’s budget at the time.

This was clearly not American medicine. The wards were bigger and more chaotic than the ones at the V.A. The nurses were universally female and wore long blue and white smocks with watches pinned to the front, outfits in style during World War I. They all answered to “sister.” When I first heard this title, I was confused. Was this a Catholic hospital? In the middle of Anglican London? I later learned that this was the local idiom for “nurse” and was used with respect and admiration.

One of the “sisters” introduced me to William, a tall, pasty fellow with thick wire-rimmed glasses. William was the senior neurology registrar for the ward. Registrars are the U.K. equivalent of residents, except that the position of registrar may go on indefinitely.

In the United States, residencies have a defined length. As long as a resident meets the minimum requirements for finishing, he or she is virtually guaranteed to enter the realm of attending physician at the expected time. Not so in Great Britain, where the centralized planning of socialized medicine sets the maximum number of attending jobs available. Thus, a neurology registrar can exit training only when openings for an attending neurologist become available. This occurs when an existing neurologist retires, dies, or emigrates for a larger salary—in other words, not very often.

William, at forty-five, had already held registrar positions in internal medicine, pulmonary medicine, and pediatrics. His tactic was to keep changing specialties after four or five years, as opposed to staying as a trainee in one specialty for ten to fifteen years waiting for an opening. At the present rate, he expected to retire before he finished his training. “I’m the smartest, most overtrained, and least-employed doctor in the whole bloody world,” he once bitterly observed.

William’s assistant registrar was David, a man of thirty. David was strikingly handsome, with a granite jaw, coal black hair, and blue eyes. He had a smooth voice and cultured accent which oozed his Oxford background.

Because it was under few financial pressures to behave otherwise, the neurology service operated at a glacial pace. The lone CT scanner was usually backed up for days, even weeks, and more involved studies were even harder to come by. The rate of patient progress was so slow that the attendings rounded only once a week, compared to once or twice a day in the United States. I would come in every morning expecting the frenetic activity I had come to associate with American inpatient care, only to find the nurses and the patients staring at one another. Watching a case unfold was like watching grass grow.

One Sunday, a middle-aged man was admitted after having a subarachnoid hemorrhage during sexual intercourse with his wife. He was in excellent condition: awake, alert, and with only a trace of headache. Back in the States, we would have performed angiography and surgery to clip the ancurysm within twentyfour hours of his arrival. But this was London. We simply tucked the man into his ward bed and scheduled his cerebral angiogram—the next slot was fourteen days away. He would have to wait. Dr. Newley, the attending neurologist, saw the patient three days after he was admitted.

“Shouldn’t we get the surgeons involved?” I queried him, somewhat brashly.

He looked at me with the serene compassion of a master looking at his impudent dog. “My dear boy,” he replied, “let’s get the angiogram first and see what the chap’s got first. I hate to bother Mr. Davies with this until we’re sure.” British surgeons carry the title “mister,” a throwback to the days when surgeons weren’t physicians but barbers, farmers, blacksmiths, or anybody else a physician could con into wielding a scalpel without benefit of anesthesia or sterile technique.

Wait and see what the “chap” has got? This calm approach to subarachnoid hemorrhage disturbed me. I was accustomed to a more aggressive management style.

The “chap” waited uneventfully through the first week. The following Sunday, though, while glancing over the sports page and eating lunch, he shouted, grabbed his head, and fell forward into his bowl of vegetable soup. He burbled into the bowl for untold minutes until one of the sisters found him. She pulled him out and started CPR, but he quickly died.

“He might have had a seizure and drowned in his soup,” said William.

“Bullshit,” I interjected.

“Oh, you Americans are so wonderfully blunt,” William continued, “but I doubt we’ll ever know what really happened.”

No autopsy was performed. The following Wednesday we had weekly rounds with Dr. Newley. Afterward, the attending neurologist grabbed his overcoat and was about to leave when he suddenly turned to William and inquired about “that poor bleed fellow in the next-to-the-last bed on the right.”

“Oh, yes…he died three days ago. Fell plop, right into his soup. Probable rebleed.” William was positively blase. I shuddered to think what the boss would say if one of his hospitalized patients had died and I had waited three days to tell him about it.

The aging neurologist passed a hand through his still-red hair and grinned wickedly. “A bit of hard cheese, those aneurysms!” He walked away and never mentioned the case again.

This was going to be a long winter.

To their credit, the neurologists, neurosurgeons, and registrars I encountered tried very hard to render good care in the face of bureaucracy, overcrowding, and chronic lack of funds and equipment. Those tasks that required little or no money to do, like taking a patient history or performing a physical examination, they did superbly and with deep attention to detail. The deficiencies in technology had sharpened their personal diagnostic acumen.

On my first day, William took me to a patient’s bedside to observe the complete neurological examination on a woman with multiple sclerosis. He brought with him a large wooden box. Opening the box, he produced a small tray full of sealed vials and set it upon the patient’s nightstand. As he readied his other equipment, I picked up the vials and glanced at them. They were full of liquids and powders; one was labeled “coffee,” another “cloves,” and yet another “vanilla.”

“What are these for, William? Are we going to do some baking?”

“No,” he laughed, “these are to test the young lady’s sense of smell.”

“Sense of smell?”

“Yes, watch.” He uncapped a vial, occluded the woman’s right nostril, and told her to close her eyes while inhaling with her left nostril. As she obeyed, he thrust the open vial under her nose.

“I think…it’s orange, yes, like orange peel,” said the woman without opening her eyes.

“Excellent!” said William. “See? The sense of smell is diminished in frontal-lobe tumors, particularly meningiomas of the olfactory groove. Testing for smell is often overlooked.”

That was an understatement. Back at home, we never tested the sense of smell. But then, at home I could obtain a CT scan for an olfactory-groove tumor in less than two hours. In London, patients often waited months for elective CT scans.

As if he were performing surgery, William methodically conducted the exam over the next hour, pulling tool after tool from his wooden box. There were test tubes filled with hot and cold water to test temperature sensation; a compass to test twopoint discrimination on various skin surfaces; a long strip of black velvet with white stripes painted on it to test for optokinetic nystagmus; a rotating wheel device, which looked like a pizza cutter, to demarcate areas of decreased touch sensation; a goniometer to measure joint flexibility; little wands with red tips to test peripheral vision; an index card of nursery rhymes and riddles to test mentation. Even his reflex hammer was unique—a huge rubber wheel fixed to the end of a two-foot-long plastic stick. It looked more like a police weapon, or a truck tire fixed to a telephone pole, than a medical instrument. These hammers were standard issue in London. William claimed that the only way to test reflexes was to hit the limbs with “real momentum.”

The history-taking on the neurology service was equally fastidious. One afternoon, after taking a history from a man with headaches, I was grilled by the hospital’s chief neurologist on teaching rounds.

“What does Mr. Hughes do for a living, Doctor?” the kindly professor asked.

“He says he works in a shop.” I replied. At home, that would have been the end of the discussion on that topic.

“What sort of shop?”

“I don’t know, some sort of small store, maybe.”

“Well, what sort of shop might make a difference, don’t you think? If he works in a paint store all day mixing paint with hydrocarbon thinners, might not that be a cause of his headaches?”

“Well, yes,” I admitted.

“Does he own the shop?”

“I don’t know”

The professor removed his glasses and began cleaning them slowly, squinting up at the high ceiling as he continued his dissertation. “These facts matter a great deal. What a patient does for a living, what his background is, what level of education he has achieved…all of these issues must be addressed in great detail in order to put his complaints and his disease in the proper context. If I ask a man to take the square root of 100 and he cannot, I might take this as proof of a left-hemispheric brain tumor, unless I know that he has worked on a farm since childhood and never attended school. Likewise, I might find it normal that a patient could not tell me the current exchange rate of the pound in Japanese yen. But if I knew that person was a merchant banker, on the other hand, ignorance of this fact would indicate a grave illness indeed! Americans have grown so dependent upon their scanning toys that they fail to view the patient as a multidimensional person. To have the audacity to cut into a person’s brain without the slightest clue of his life, his occupation…I find that most simply appalling.”

These words came back to me years later in the States. I was operating on a woman for a spinal tumor when a medical student in the room casually asked me how old the patient was. I couldn’t remember! Here I was, staring at the woman’s spinal cord, and I didn’t even know how old she was! The professor was right; it was most simply appalling. I was treating an MRI image on a piece of photographic film, not a person. I’ve tried hard not to repeat that arrogance again.

Multiple sclerosis, or MS, is more common in the U.K. than it is in the United States, and we saw a great deal of it during my three months in London. The disease affects the insulating fat, or myelin, around nerve fibers, punching holes (called plaques) into the deep white matter of the brain and spinal cord. The severity of the disease depends upon where the plaques occur. A large plaque in a tolerant area of the brain, such as the right frontal lobe, may be asymptomatic, while a minuscule plaque in a critical area of the spinal cord or brain stem may leave the patient wheelchair-bound.

MS is capricious, striking quickly and then retreating in a series of random exacerbations scattered over a lifetime. The patient may be disabled for months, then recover and be unaffected for years before another episode occurs. At the time I was doing my neurology rotation, there was no accepted treatment save for high-dose steroids and physical therapy. (Other therapies are now available, such as interferon.) For most patients, fortunately, the tincture of time was the best cure.

The most dramatic MS patient I ever saw was Andrew, a Nigerian foreign exchange student at the University of London. He was admitted with his very first attack of the illness. The hospital’s newly installed MRI scanner (dedicated by the Prince of Wales himself!) disclosed a half-inch plaque dead-center in his midbrain. The midbrain sits atop the brain stem, where it serves as a conduit for the output of the hindbrain cerebellum, the main balance and coordination computer of the brain. This output had been effectively amputated by the plaque, leaving Andrew with no cerebellar function at all.

The cerebellum, or “little cerebrum,” fine-tunes the gross motor signals emanating from the upper brain. Its output is purely inhibitory: the neurons in the cerebellum serve only to dampen or inhibit the activity of other neurons in the brain. My neuroanatomy professor in medical school put this into perspective by observing that Michelangelo had carved the statue of David using only “subtraction” of stone. Thus, the big cerebrum’s motor outflow is like raw marble which the cerebellum deftly chisels into coordinated movements.

As long as Andrew kept very still, he was fine. However, the moment he tried to do even the slightest task, even to scratch his nose, his arms and legs became uncontrollable, flailing about like octopus tentacles. He had to be fed, since he could not be trusted with a fork or knife. His face was swollen from attempts to brush his teeth, attempts which resulted only in a self-inflicted pummeling. He could walk short distances, but his gait was wild. More often than not, he ended up draped over the ward’s central radiator, crying from frustration.

This uncoordinated movement, called ataxia, even involved Andrew’s speech. Although the melodic Nigerian inflections of his perfect English were still detectable, the words came out herky-jerky, with the tone monotonous and the sentences incorrectly parsed, a pattern known as cerebellar scanning speech. Scanning speech has a hollow, mechanical quality, like the diction of robots and computers in science fiction films. Like the stare of the acute schizophrenic, scanning speech is difficult to describe in words, but once you have experienced it you remember it forever.

As we sat drinking our afternoon coffee (we still called it “tea time,” although few registrars actually drank tea), William, David, and I watched Andrew as he ricocheted around the ward, walking into beds and walls and bouncing away in a different direction like a mechanical toy.

“Poor bastard,” remarked David.

“Not to worry,” observed William, “he’ll get better. They all do from the first episode, no matter how bloody awful they look. In six or eight months he’ll be back at school again. The question is how to manage him until this plaque remits. The physical therapy people have fitted him for a lead jacket.”

“A lead jacket?” I asked.

William continued. “Yes, a lead jacket. It’s a suit coat that’s been fitted with lead bars to make the arms very heavy. If Andrew has to work harder to move his arms and gets more proprioceptive feedback from them, he can control his movements a little better. Quit beating himself up all of the time. It’s quite lowtech, you know, but it works.”

“The main drawback,” added David, “is they get dreadfully tired, as you can well imagine. Ah, but just think! If he wears it for a few months, he may end up looking like the Incredible Hulk!”

The jacket was delivered the following day. It was of heavy green cloth and looked identical to the protective “burner’s jackets” worn by the acetylene torch operators in the steel mill. Numerous slots were sewn along the arms. Along with the jacket came a carton of thin lead bars to be placed into the slots, allowing us to titrate the added weight so that we could give Andrew some motor control without rendering him unable to lift his arms at all.

We spent the morning experimenting with the jacket, until finally Andrew was able to lift his arm, slowly and agonizingly, and run a comb through his short hair. His mouth blossomed into a broad African grin.

“Ah, this is very much more to my liking!” he said in his robot voice, beaming at his regained arm control.

He could only wear the jacket a few hours at a time, and by the end of each day his arms ached so much that he had to take narcotics to sleep. But he stopped crying the day he got the jacket. As William predicted, Andrew’s speech slowly returned to normal, his drunken gait began to sober, and his need for the jacket diminished weekly. Two months after he came to us a limp jellyfish of a man, the Nigerian strode out the hospital door, erect and controlled, the only remnant of his disease the increased power in his well-exercised arms. He shook our hands briskly.

“You know, I am a philosophy student,” Andrew observed just as he exited, flexing his biceps in a bodybuilder’s pose. “Nietzsche said ‘Whatever doesn’t kill me makes me stronger.’ I now know this as fact. Thank you, my friends.”

He would be back, no doubt—in a year, maybe ten, depending upon the mercy of his personal disease. Had we, as Hippocrates postulated, simply “entertained” Andrew until he got better on his own? Perhaps, but we had managed to stop his tears, and any therapy which accomplishes that feat for a suffering patient is damned good medicine.

The U.K. is hardly a classless society. Nevertheless, I was amazed at the degree to which nationality, race, and socioeconomic status factored into and at times hindered the clinical reasoning of the registrars and attending neurologists.

London has a very large number of people from the Indian subcontinent, a vestige of the days of the empire. Whenever recent immigrants from India or Pakistan showed up at our doorstep, they were immediately given the diagnosis of tuberculosis, regardless of their symptoms. A middle-aged Pakistani grocer, for example, came to the casualty department (British for ER) with a three-month history of progressive weakness and stiffness in his legs. An MRI scan revealed a mass within the center of his thoracic spinal cord, between the shoulder blades. I recognized it as an astrocytoma, a tumor arising from the spinal tissues. To my chagrin, the attending surgeon, Mr. Royston, diagnosed it as a tuberculoma, a swelling caused by the tuberculosis bacterium, even though the patient had a negative chest X ray and no other evidence or history of tuberculosis. The patient’s nationality was cited as the sole reason for this bizarre conclusion.

I went to the library the next day and could unearth only two previous cases of a solitary tuberculous mass in the spinal cord, and both of those reported cases had documented pulmonary TB. When I confronted the surgeon with this fact, he shrugged and pointed to the good clinical response the patient had made to the antituberculous antibiotics as further proof of the correctness of the original diagnosis. The patient truly was better, but I argued that the improvement could be from the steroid medication that was being administered as well. I made no headway. Three weeks later, the patient returned to the casualty department in a state of near-paraplegia and emergency surgery was performed, at which time his astrocytoma was removed and he made an uneventful recovery.

In another incident, we were gathered to hear a patient demonstration by one of the most senior and respected neurologists in all of southern England. Donning our white jackets, I and the other trainees crammed into the archaic demonstration hall, sitting in ascending concentric circles around the small exam table below. A registrar brought in the patient, a scrawny laborer in his fifth decade. The patient staggered to the table and sat down, but proceeded to bob and sway even while seated. The stately neurologist conducted a detailed interview with the man, listening keenly to his complaints: unsteady gait, dizziness, and nausea. He conducted a very cursory exam and then had the patient escorted from the lecture hall. The neurologist turned to us, paused for a dramatic effect, and asked, “What single piece of information you have heard this morning tells you what is wrong with this man?”

“His age,” answered a registrar.

“No, that’s not correct.”

“His occupation?” I volunteered.

“No, wrong once again.”

This continued for a few minutes, until the exasperated teacher told us his expected answer: “His nationality! His name is O’Brien and he’s from Belfast. Since he’s obviously of the Irish lower classes, it’s a very good bet that he’s a sot. He’s clearly afflicted with alcoholic cerebellar degeneration.”

In fact, this diagnosis was correct, but the bluntness of this deduction would not have been tolerated in America. The neurologist never even asked the patient if he drank; he simply assumed it to be true. I couldn’t see one of our, neurologists standing before an open forum of medical students and announcing that a patient must be a user of crack cocaine simply because he was black and from an urban area.

“I can’t see!” The woman spoke in a measured tone, trying to conceal her panic in proper British fashion.

“Keep calm and tell us what’s been going on,” William reassured her.

The patient, a pretty young woman still wearing her street clothes, arrived on the neurology ward just as we were returning from lunch at a local pub. The casualty department, where she had gone seeking help for progressive blindness, had sent her directly to our service.

“I was fine this morning when I woke up, but after breakfast I began having a headache, right here.” She motioned to the top of her head. “My vision began to blur, but I could still see well enough to get here. Now I can only see dark forms moving about, and things are getting darker all the time!”

William turned to David and me, speaking in low tones. “David, notify the CT scan facility that we will need an immediate pituitary study. Frank, go to the Jefferson ward and find Mr. Cunningham and bring him here at once. Quickly now.” Mr. Cunningham was a senior attending surgeon and the hospital’s pituitary specialist.

I dashed off to the Jefferson ward and found Mr. Cunningham in his office; we were back on the neurology ward within minutes. The young woman, Alice Weathers, recounted her story to the surgeon. Her health was good, although her menstrual periods had become irregular during the preceding year and she had noticed a slight discharge from her nipples recently. Unmarried, she typed for a living and lived alone in the Tottenham Court area.

Mr. Cunningham examined her vision. She could make out his large hand waving in front of her face, but she could not count his fingers or tell the color of his necktie. The surgeon’s elegant face turned dour.

“Young lady,” he began, “I believe that a tumor has hemorrhaged within your pituitary gland, that small bit of tissue located behind your eyes. We call this hemorrhaging ‘pituitary apoplexy.’ The blood clot is pushing on the optic nerves, the nerves that connect the eyes to the brain. I will have to operate immediately to remove the clot and tumor or you will remain blind.”

“Tumor? I have cancer?”

“No, no, my dear young lady. The tumor is almost certainly a benign adenoma, a growth quite common in young women. In your case, the tumor is making a hormone called prolactin. Excess prolactin hormone will produce exactly the symptoms you have noted—the irregular menstruation, the slight nipple discharge. That discharge is milk. Prolactin is a hormone normally made during pregnancy. It stimulates the fatty breast tissue to manufacture milk.”

“Do what you have to do, just don’t let me go blind. Please!”

Mr. Cunningham examined the patient’s breasts and confirmed the milk secretion. “Have her taken to the operating theaters straightaway and cancel the scan. There is little doubt what needs to be done here. I will scan her after I have decompressed the optic nerves. Be sure to administer a large dose of hydrocortisone, won’t you? I will have my senior registrar lend a hand.”

I followed the patient to the holding area outside the operating suite. She wept quietly into a handful of tissues.

“Is there anyone I can call to be with you?” I asked.

“My dad died two years ago and my mum’s got a bad heart. I’d rather not tell her anything right now.”

I couldn’t begin to imagine her despair as she faced this, crisis alone. After several minutes of waiting, an OR nurse whisked her into the room and an anesthesiologist ended her suffering with a whiff of gas.

Little more than fifty minutes had passed since she had arrived in the casualty department. British medicine at its finest. Although mired in red tape, the U.K. system avoids the legal wrangling that hamstrings American medicine. In the United States, taking a woman to the OR without objective studies, such as MRI or CT scans, invites malpractice action should anything go wrong. True, Gary had cut Billy’s spine without a myelogram, but such fortitude is rare. Back home, anesthesia would balk at doing her so soon after she had eaten breakfast. And the operating rooms would have been overbooked. In London, the mighty Mr. Cunningham spoke and things happened.

Mr. Cunningham and his registrar positioned Alice in the head clamp, then scrubbed her mouth and nose with soap. The pituitary, an embryonic relic of the nasal passages, lies buried in the hard palate, just above the uvula. The neurosurgeon approaches the gland through the nose, with the aid of a microscope and some truly long instruments. To enter the hypophysis (the correct name for the gland), the surgeon traverses the sphenoid sinus; hence the operation’s tongue-twisting name—transsphenoidal hypophysectomy.

First used by Cushing in the early twentieth century, the transsphenoidal procedure is arguably the most bizarre operation in the neurosurgeon’s repertoire. To enter the nose, the surgeon cuts under the upper lip and peels the face up and away from the “nares,” the openings of the nasal passages. Cracking the nasal septum to one side, the surgeon advances a large speculum to the base of the skull, the sphenoid sinus is removed, and the floor of the pituitary chamber is chiseled away.

Cushing had little luck with this approach and abandoned it, preferring to take the tumors out through the head rather down through the nose. Superb a technician though he was, Cushing lacked a microscope, and the fiber-optic lighting, needed to do the operation safely. Jules Hardy and his colleagues in Canada resurrected the procedure in the 1960s, with superb results, and the nasal approach soon became standard. Hardy’s use of the microscope and intraoperative X rays overcame Cushing’s difficulties.

Mr. Cunningham deftly dissected the pretty woman’s face and exposed her pituitary gland in less than an hour. The gland looked blue and taut on the video screen. With a swift poke of his pointed microblade, thick clot and purulent yellow tumor gushed from the gland and into Mr. Cunningham’s thin suction tip. He spent several minutes rummaging around with small currettes, until satisfied that all tumor and blood clot were evacuated. The task of reassembling the face fell to the registrar.

Alice’s broad smile in the recovery room told more about her eyes than any formal vision test could do. A few hours after surgery, her vision returned to normal. The nasal packing was removed on the third postoperative day and she went home on the fifth—pretty as ever. Her mother never learned of Alice’s brief flirtation with disaster.

The day of her apoplexy, as I was fetching Mr. Cunningham from his office, I noticed a wooden plaque on the surgeon’s wall. It read prophetically: SOMETIMES SURGERY DOES HELP

I returned to the United States shortly after Alice went home. My first assignment was Children’s Hospital, where surgery often did not help at all.

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