Harvey Cushing – A life in surgery – A Review (Day -266)

Dr Harvey Cushing - A Life in Surgery

As the first biography I have ever read cover to cover this book was absolutely gripping with me wanting to find out what happened next.

Many people may have heard of Cushings Syndrome or Disease which is where the pituitary gland often has a tumour which increases the amount of hormone released from it. This increased secretions has a big effect on the rest of the body and was defined by Dr Harvey Cushing. However in addition to this Dr Cushing was also the founder of modern brain surgery.

Back in 1887 when Cushing looked to train as a surgeon there was no such thing as neurosurgery – actually there were no requirements other than money for the fees to get into medical school. The medical schools were run by practicing doctors from the local area that did it to supplement their income. Surgery back then however was only an emergency last attempt – there was no elective surgery – and when it happened the odds of the patient surviving were tiny. Not just from the actual surgery itself which was often only amputations but from the infections that occurred afterwards.

Dr Cushing started his studies at Yale before moving to Harvard and in 1896 was planning to travel to Europe to study when instead he was offered a place to study with Dr Halsted at the new John Hopkins Hospital after being initially denied. Learning from Dr Halsted the techniques of haemostasis, good surgical dissection and aseptic surgery.

When the skull was opened here the patient in most cases suffered from something called fungus cerebri which is infection of the brain. In 2016 there are neurosurgeons that have had entire careers without seeing such a thing. This is largely thanks to the careful use of aseptic technique that Dr Cushing had learned from Dr Halsted.

Something that really interested me was the use of dogs within the surgery training courses at these medical schools. Initially they started as just using dogs for trying out new techniques, then for the training of new surgeons, however these training centres evolved into the first veterinary hospitals with human doctors treating dogs for surgical diseases not treated before. Some of the research that evolved from dogs has been instrumental in developing modern neurosurgery.

For example the Cushing reflex which says that when the pressure inside the skull raises, then the blood pressure will rise as well to compensate and keep the brain oxygenated. Dr Cushing investigated this by opening a dogs skull and replacing a section with glass so that he could see the vessels of the brain as he increased the pressure in the skull. He noticed that as he increased the pressure the vessels initially became compressed, however then the blood pressure of the body increased to force blood back into these brain vessels.

The thing that Dr Cushing is most known for however is that of Cushings syndrome or disease which is where a tumour on the pituitary gland at the base of the brain causes excess hormone release into the rest of the body causing clinical signs. Dr Cushing did a range of experiments here both on dogs and with human patients looking for a way to treat those suffering from acromegaly which is increased growth. At the time the function of the pituitary gland was unknown, so this work was ground breaking.

I would highly recommend that anyone interested in the history of surgery reads this book.

What did I do? (Day -272)

Vet Student Operating

Last night I spent laid awake wondering about the kitten that I operated on. I read recently a quote I in relation to Dr Harvey Cushing that resonated here with me:

“no one has any right to undertake the care of any patient unless he is willing to give that patient all of the time and thought that is necessary, and of which he is capable.”

Did I give the kitten enough time?

Enough thought?

And was I really capable to do what I had done?

Did I know what was going happen once the skull had been covered. Was there going be pressure trapped inside? Was the skin going be enough to protect the brain? Should I have done anything else?

Were my sutures too tight? Is the blood supply to my flap enough? Will it heal?

If I could I would have spent the entire night watching the kitten. The kitten would have been hospitalised. Instead circumstances prevented this; however the kitten was watched carefully by the foster carer that had been caring all week.

I spent hours and hours during the week reading every surgical book I could find with a chapter covering the brain, head or skull. I spent hours looking for case studies and relevant articles in the literature. There was so little. Either it is so common that no one thinks it is worth writing about, or it is so uncommon that no one has had the chance to write about it.

I reached out to some of my contacts asking for advice and got some great support.

There were instructions that the minute anything happened I was to be called. Any time. So in this case no news is good news. However I still laid wondering.

Tomorrow I will see the kitten again to check the wound. And so far today no news really has been good news.

I realise that I love surgery – however it is the outcomes that give me the biggest satisfaction. Knowing that my impact has helped the life of another being is such a reward. However it comes with great responsibility that I must accept.  Every single time that I step up to an operating table I am responsible. That responsibility is why I am laid awake.

I do not yet know whether what I have done is good or bad.

Covering the brain (Day -273)

Rotation flap to close kitten skin

This afternoon I performed the most delicate operation that I have performed to date. I was allowed to perform a skin flap to close up the skin over the kitten with the hole in its head that I wrote about a week or two ago.

Since then the kitten has had two surgeries – the first to clean up the wound and soft tissue as it was very dirty. Then following this a second surgery was performed to remove the fragments of the skull bone that were unfortunately not viable. Since then the kitten has been on antibiotics – and we were waiting for a clean wound so that we could close the skin over the hole in the skull to cover the brain.

This was a relatively simple operation to move some skin from one place to another. However in doing so I was using a scalpel blade just millimetres away from the kittens brain tissue – a single slip wouldn’t really be a good thing.

Now there are many different techniques that could be used for creating and using the skin flap, however I believe that simple is best, and so I created what is called a rotation flap. This is where I take the skin next to the wound and rotate it over the defect.
Rotation flap to close kitten skin

Here you can see where the defect was originally, and then I made my incision along the dotted line on the middle image before then moving this piece of skin over to cover the hole. Different people suture wounds like this in different ways, however in this case I like the half theory. I started my first suture in the top left corner of the wound, then placed my next suture halfway between this and the end. And then placed my further sutures halfway between these spaces as well. For me doing it this way makes a lot of sense as I can see where things are going go bad without losing too much time, or having to change too many sutures to fix them.

So after this the hope is that the skin heals and as the kitten is still growing that the defect in the skull will close up with time.