When the Air Hits Your Brain: Tales from Neurosurgery Read Online Free PDF

come out of the OR from a head trauma case.
    “Gary,” I said, breathless, “that guy, Rathman, in room fifteen, he’s here for a cervical discectomy, but his disc is on the wrong side! And he has a Horner’s sign! Go look for yourself!”
    “What guy? What the hell are you talking about? You’re babbling. It’s ten o’clock. Go home.” He bolted down a carton of chocolate milk and walked away. I chased after him.
    “No, wait, I’m telling you that this guy is on the OR schedule for seven-thirty tomorrow morning and it’s all wrong. He has a Horner’s sign; you don’t get that from a disc. Just go and look at him.”
    The iris functions like a camera diaphragm, limiting the amount of light entering the eye. Powered by small muscles, the iris becomes paralyzed if its nerve supply fails. If the iris is paralyzed, the pupil remains small. In bright light, when the normal pupil constricts to the same size as a paralyzed iris, the abnormality can be masked. In dim light, however, the normal iris dilates while the paralyzed pupil remains small—an asymmetry known as the Horner’s sign. The difference between the paralyzed and normal iris is so pronounced that even a novice like myself could see it in dim light. When the staff surgeon had examined Mr. Rathman in a bright examination room, the Horner’s sign was not there.
    The nerves to the iris don’t come from the cervical, or neck, nerves, but from the upper chest. This sounds bizarre—eye nerves coming from the chest—but the human body’s blueprints can be hard to decipher at times. Mr. Rathman’s C56disc wasn’t causing his pupillary asymmetry. Something was going on deep in his chest, gnawing at the nerves to his right arm and amputating the iris nerves. In a middle-aged smoker, the most likely explanation was also the most grim: lung cancer.
    Gary paused. “Didn’t he have a pre-op chest X ray?”
    “Yes, it was read as bilateral apical pleural thickening.”
    “Hmmm, I guess a Pancoast tumor could be hiding at the apex under that pleural thickening and be missed on routine X ray,” he muttered, almost to himself. “Well, let’s have a look.” He walked down the corridor to the patient’s room.
    Mr. Rathman, medicated with morphine, dozed as we entered. Gary gently shook him awake. The junior resident grasped the drowsy man’s chin and turned his head left and right, squinting to see his pupils in the low light.
    “I’m sorry, Mr. Rathman, go back to sleep.”
    Gary walked sullenly to the nurses’ station without saying another word. He sat in a chair by a ward phone, reached into his pocket, and produced a portable phone directory. After finding a number, he punched the buttons and waited for an answer.
    “Hello? Is Dr. Atkins in?…Dr. Atkins, Gary from the hospital…Listen, sorry to bother you, but this Rathman guy you have on for tomorrow, did you know he has a Horner’s sign on the right…No, it’s pretty obvious…uh-huh…Yeah, a Pancoast tumor is a real possibility. Sure…no, don’t thank me, it was the medical stud who found it…OK, so long.”
    He hung up the phone and grabbed the patient’s chart, opening to a physician’s order sheet. He wrote:
    “Cancel OR. Polytomography of the right apex of lung in A.M.”
    Gary looked up at me with a stern face. “That’s the easy part. The hard part is explaining to him why we are cancelinghis surgery.” He got up and began the walk down the corridor again, this time more slowly. “I’ll take care of it, Frank, that’s why they pay me. Go home.”
    He didn’t need to tell me twice.
    Mr. Rathman’s lung studies showed the expected crablike growth at the tip of his right lung, a Pancoast lesion. A needle biopsy confirmed a squamous-cell lung carcinoma. No thought was given to removing it; his arm pain and Horner’s sign were proof that the tumor had escaped his lung and was encasing his brachial plexus, the network of nerves in the shoulder. There was no hope of cutting