I was trained in what might be described as the middle-ages—no, not as in ancient history—a time in neurosurgery that was quite different from the current day. I want to tell you a true and illustrative story that will illuminate your understanding of a bygone era.

First, a disclaimer. This is a true story; and because that is so, I am not going to tell you where it happened, when it happened, or who was directly involved other than myself. This is to protect the guilty. To set the stage, a little background is in order. Intracerebral aneurysms are dangerously thin blisters on brain arteries that have a nasty habit of bursting and causing a massive hemorrhage inside the skull, and all too often leading to maiming or death. The principle of surgery (a craniotomy) is to isolate the blister and to put a fine steel clip across its neck, thereby preventing recurrent hemorrhage. One of the surgical issues is that sometimes there is not much of a neck, or everything is too thick to close it off successfully.

Prior to the time of my story, there was not much that could be done to ligate such an aneurysm. Then, the clever Japanese invented a much more successful and powerful liquid glue that could cause an essentially permanent union of two surfaces in a matter of seconds. Serendipity struck a great many neurosurgeons resulting in a rush to Japan to buy the glue by the boxful. The glue was not yet approved for sale in the United States for any purpose, let alone for medical use. It was the great little secret shared by aneurysm surgeons.

A middle-aged man presented to the emergency room after suffering a sudden, massive, lightening-like strike of headache accompanied by excruciating pain in the back of his neck. He was alert, screaming in pain, but able to give a decent history, and was neurologically intact. The most prominent feature of his physical examination was an extraordinary tenderness to any attempt to flex his neck. His response to the attending neurosurgeon’s gentle attempt to do so was immediate and terrible—what neurosurgeons call the “chandelier sign.” When the test was made, the patient tried to leap away and to hang from the chandelier. Gynecologists use the same name for the response of women to a pelvic examination when they suffer from acute pelvic inflammatory disease.

The diagnosis was made by finding blood in his spinal fluid on a lumbar puncture, and by doing a cerebral angiogram. The spinal tap reduced the blood and the fluid pressure and granted a modicum of relief. The angiogram revealed generally constricted arteries and arterioles in the cerebral vasculature and an angry looking little anterior communicating artery aneurysm.

The anterior communicating artery is a short connecting vessel which passes from the anterior cerebral artery on the left to the one on the right. For surgical purposes, it is located in tiger country. It is small, thin, and lies immediately over the optic chiasm and adjacent to the main arteries feeding the anterior portions of the brain. The oculomotor nerves are in the immediate vicinity. The entire surgical space is less than the size of a demitasse cup. Any surgeon with any sense fears that aneurysm.

In those days, the presence of the narrowed arteries strongly suggested the risk of causing generalized cerebral ischemia and a large stroke if the surgical manipulation of the vessels excited more constriction or bleeding. If manipulation of the aneurysm results in recurrent bleeding, the potential for death or severe neurological impairment looms prominently.

For that reason, it was elected to wait and watch for twenty-one days, trying to weigh the risk of recurrent bleeding during that fretful period of time versus the significant danger of provoking trouble from already excitable vessels. We made the right choice in that gentleman’s case, and he was in excellent condition for the brain operation.

What we had not been able to see on the angiogram was that the aneurysm had no real neck, certainly nothing we could ligate with suture or with a steel clip. I was the lowly first year resident and was relegated to holding retractors to keep the two frontal lobes separated to allow the approach to the ACAs [anterior cerebral arteries]. The approach was done with the utmost care—as the surgeon said, “like butterflies making love on a thin wet leaf.” The ugly little ACA aneurysm was dissected as well as possible, but the only choice seemed to be to ligate the feeding vessels and thereby risk a unilateral or even a bilateral stroke. About that time, I began to rethink my choice of careers and wondered why I hadn’t given more thought to dermatology.

The professor had heard about Japanese glue but did not think any was available in the university hospital; and even if it were available, would it be worth the medico-legal risk to use the unapproved, essentially illegal, glue? He had never seen it used. It just so happened that I had seen it used in a hospital where I moonlighted to make ends meet and from where I had purloined a couple of tubes.

I squeaked up and said that I just might know where to get a tube. I did not elaborate on the fact that it was in my pants pocket in the locker room. The chief was an adventurous soul, and he leaped at the idea and sent me forthwith to fetch my precious little stash.

I tried to explain what I knew about how the glue should be used, the precautions necessary, and the very untoward results of failing to heed such advice. I, however, was the bottom man on the totem pole and was roundly ignored by any and all present—none of whom had ever seen the glue used anywhere and certainly not in an aneurysm surgery.

I held my piece for the time being, grinding my teeth. We suctioned out almost all of the crystal-clear cerebrospinal fluid in the operative pocket making the aneurysm and its feeders dry.

“There,” said the Chief, “the glue should work great in this dry field.”

For my sake, I certainly hoped so.

He gingerly held the sterilized glue tube over the aneurysm and squeezed out a couple of fairly large drops of the crystal-clear fluid onto the aneurysm and its surrounding vessels.

The CSF started to return, and the Chief said that the glue must have been washed away.

I said, “No, Sir. It’s there. You just can’t see it. Please don’t put any more in. Stuff will stick to it.”

The Chief Resident gave me the “is-that-the-cretini-speaking-look?” and shushed me. The attending considered the source of the interruption and ignored me. He poured out a generous dollop of the instantly drying adhesive and smiled under his mask.

“Think we got it, _____?” he asked the Chief Resident, who did not have a clue.

I mistakenly spoke up again, “Please, no more. That’s tons. Just hope we can get out of there.”

I know the Chief wanted to give me the lecture on how I had had less than a year’s experience, and he had had thirty years. Who do you think knows best? But, being a civil and patient man, he ignored me.

“I’m going to do a little test,” the main surgeon said and picked up a sterile blunt toothpick to poke around a little.

I remonstrated weakly and no one noticed.

Then, the unthinkable happened. The tip of the toothpick adhered to the top of the aneurysm and was there until a “death do us part” kind of marriage. The Chief controlled himself with difficulty.

He said, “There.”

He said that because one of the strict rules of neurosurgery is that we never say, “oops.” He then set out to correct the situation. He had the nurse hand him a flat wooden retractor—actually a sterilized popsicle stick. Yes, it stuck to the aneurysm…hard and fast.

“Help me, ____,” he demanded of the Chief Resident.

The assistant was a quick thinker. He picked up a cotton-tipped swab and moved it into place to sweep away all the accumulating detritus. Yes, the swab found a big enough area to plant itself and become another skinny tree in the now growing forest.

“Hand me the thing with a hole in it,” demanded the now flustered Chief.

The thing with a hole in it was actually an Olivacrona periosteal elevator, a useful dissecting device which had no place in that little wooden forest. The Chief and Swedish Professor Olivacrona were not on speaking terms; so, we were enjoined never to say his name.

I now got brave and put my hand on the instrument nurse’s wrist to prevent her from passing it to the Chief.

“We don’t need a piece of steel sticking to that aneurysm and which we will have to bring out through a hole in the skull flap. Won’t look right for him to go around with an expensive steel barb poking out of his forehead like a modern-day unicorn.”

That seemed to carry the day, and a semblance of order and thinking took over. The ashen faced nurse handed the Chief a tiny circulating saw. The rest of us held on to the protuberances for dear life, and the Chief gnawed the long sticks down to about a quarter of an inch long.

“There,” he said, “______, you and Doug close up, and come by my office and let me know how it went.”

The gentleman woke from the anesthesia and never turned a hair postoperatively. I followed him for five years in neurosurgery clinic, and he had a perfect outcome—no infections from the assorted foreign bodies deep in his brain, no aneurysm perforation from the operative site–now encased for eternity in a clear thick dome of plastic–no cranial nerve signs; and, by the Chief’s dictum, he was never troubled with any anxiety or worry over knowing about having a lot of strange stuff standing up in his brain.

There is another surgical aphorism you should know, “It’s better to be lucky than good.” Maybe next time, I will tell you about the first time I was the surgeon in a craniotomy—a particularly memorable time for me.