The Surgical Obesity

A tiny tumour within the pituitary gland, discovered nearly a century ago by Harvey Cushing, continues to be the bane of existence for many women

“I have put on an incredible amount of weight in the past two years,” said 38-year-old Tanya Patel, plonking herself on my office chair after barely managing a few steps on her own. She was bruised all over. “Even a minor bump causes my skin to discolour and swell,” she said showing me her arms that had the words ‘today I escape’ inscribed in Sanskrit. “I’ve had three fractures and two miscarriages and now I can’t even conceive,” she lamented, her eyes welling up. “I have hair growing all over my body and I am ashamed to even look at myself in the mirror,” she burst out crying, covering her acne in the palms of her hands.

“I’ve had PCOD (polycystic ovarian disease) for years, and doctors are attributing all my symptoms to that. My periods are irregular and I’ve been on hormonal medication forever but I’m tired and exhausted and annoyed and irritated and depressed!” she exclaimed, as she emptied a bag full of pain killers, oestrogen and progesterone tablets, drugs for diabetes and hypertension, and mood elevators for her bipolar disorder. “My sugars are all over the place, my wounds don’t heal, and I bleed profusely if and when my period decides to come!” she said, exasperated.

I examined her thoroughly after some more questioning. She had a very typical physiognomy. Her obesity was mainly truncal, while her arms and legs were lean. Her face was round like the moon. She had a bulge on her upper back where fat had deposited – in medical jargon we call this a ‘buffalo hump’, classical of a certain ailment. I held her hands in mine and noticed that certain parts of it were very darkly pigmented. My suspicion grew stronger. “I think you may have Cushing’s Disease,” I decreed.

“It’s a condition where you get a bunch of these symptoms because of a tumour of the pituitary gland producing excess cortisol. You can also see several of these features in people who are put on long-term steroids for either asthma or rheumatoid arthritis. But as you’re not taking any, it’s probably your body over-producing cortisol from either your brain or your adrenal glands. We must do some testing and get an MRI of the brain. If it is what I think it is, we’ll have an answer to all your problems,” I left her with hope. After all that she had been through, that was the least I could provide for the time being.

She came back with her extended family a few days later, completing the myriad tests that had been ordered. “Bingo!” I snapped my fingers. The MRI showed an 8 mm tumour within the pituitary gland, off to the left. I pointed to it with a pen. “That’s the enemy,” I smiled. “That tiny thing is doing this to me?” she asked, aghast. I nodded, confirming after checking all the biochemical tests to collaborate my findings. “We’ll remove this via the nose using an endoscope and you’ll be cured. In the place I trained, we probably did more of these than anywhere else in the world,” I said to boost her confidence. She looked at me with incredulity, still unable to believe that such a tiny thing can cause so much havoc.

A few days later, along with my ENT colleague, we made our journey through the nose. Navigating our way through the turbinates, we broke the posterior part of the nasal septum and entered a cavernous structure. “That’s the sphenoid sinus,” I demonstrated in 4k on a giant screen to some medical students interested in neurosurgery who were visiting us, standing on their toes with excitement. I had gotten them to see Tanya before surgery and explained her MRI to them. They were shocked to know that a brain tumour can be removed through the nose.

I drilled the floor of the sella, the bony saucer that cradles the pituitary gland. “You have to be very careful while you drill,” I cautioned them, “as on either side of the sella are the carotid arteries, the main blood vessel of the brain, and if I damage it, the patient could die in an instant,” I narrated to add some shock and awe value and keep them engaged. “Shubh shubh bolo, sir,” my assistant prodded. I cut the dura covering the gland widely and there it was – 8 mm of a cheese ball that we curreted fastidiously and removed completely. “That’s the normal pituitary gland to the right, pinkish and fleshy, a stark contrast from the tumour, which is soft and squishy,” I explained.

“Do you know who Harvey Cushing was?” I questioned the medical students while we closed in a meticulous fashion. “He was the father of modern neurosurgery,” one of them replied. I was impressed. “Cushing called this condition the ‘diabetes of bearded women,’” I enlightened them further. “And do you know what his contributions were besides naming this disease over a 100 years ago?” They remained silent.

“He was the youngest of 10 children who augmented neurology and neurosurgery to the respect it has now. He used X-rays to diagnose brain tumours at the time and introduced to the United States blood pressure measurement that he saw being practiced in Italy. He described a definitive condition of raised intracranial pressure where there is a triad of bradycardia, hypertension, and irregular breathing and named it Cushing’s Reflex. He worked at both Johns Hopkins and Harvard, writing numerous papers on several important discoveries he made, designing several surgical instruments, describing new procedures, teaching surgical trainees, and maintaining detailed records of his 2,000 brain tumour surgeries,” I lectured.

Harvey Cushing was nominated for the Nobel prize in physiology and medicine 38 times, but never won. However, he won a Pulitzer Prize in 1926 for the biography of Sir William Osler. He died of a heart attack. Interestingly, his autopsy revealed a tumour-like cyst in the brain.

After Tanya was discharged, her care was taken over by an endocrinologist to finetune her medication. But we stayed in touch over the phone and became friends. She came to me for a follow up a year later looking unrecognizable. She had lost 30 kg and looked well-toned, with glowing skin and dazzling hair. “I’m 2 months pregnant and I only have you to thank!” she said, holding hands with her husband. “Please don’t thank me, the nose was the only orifice I entered,” I joked. “Either thank him,” I said, directing my gaze to her husband, “or thank Cushing, without whom we’d still be treating you for PCOD.” “Cushing Zindabad!” she cheered, and gave me a tight hug.


22 Comments on “The Surgical Obesity
  • Laina says:

    What a story. Amazing. Given how popular PCOD is as a diagnosis, this story hit different.

  • Chaitaniya A Karnik says:

    Super! Maybe check me out too for this

  • Cashmira says:

    Wonderful amazing work …. Again I look forward to
    Your article’s so so well written. You make brain surgery which is something 90% of people can’t even understand – sound like a very interesting story. Great dr and a writer.

  • Ralecha Mmatli Botswana 🇧🇼 says:

    Dr Mazda this article on Tanya, represents a million of us who passed through your hands together with your team of specialists colleagues, and you were able to restore us to reasonable livelihoods and put a smile on our faces and our families too. Thank you fir making that rare difference in our lives. Please God- keep our Neurosurgeons for us!!

  • Chandan Rumi Sanjana says:

    Another superbly written article Mazda. Cannot imagine what a little tumor like this can do to a person. Thanks to doctor Cushing who discovered and pioneered this surgery. The thought of going through the nose to reach the gland is rather frightening. Glad this lady got her normal life back and was able to have a baby.

  • Natwar Panchal says:

    Superb Dr.

  • Dr A S Randhawa-N Surgeon says:

    Wonderfully written.

  • Indrajeet Singh says:

    Dear Sir,
    I’m had been diagnosed with Tuberculosis in brain, which has been calcified after taking ATT for 25 months.
    I have got the problem of feeds, therefore taking Levipil 500 TD. There seems to have impact on my memory.
    I have been diagnosed cholesterol and heart related issues too.
    Please guide, whether it can be of similar kind of problem

  • Rita singh says:

    Very interesting surgery Dr.It must have been very good class for the students. Wishing you all the best for ur future brain adventures.

  • Clera Menezes says:

    Superb Sir….
    Sharing your live experiences in articals and inspiring people those who loose their hopes in life due to these brain tumors.
    You are a charm in neuro surgery which i witness everyday.
    I should not be forgetting to appreciate the expert ENT surgeon who always supports and gives 100% of her best in your endoscopic pituitary surgeries .
    God always bless you both .
    Keep up the good work and best practices for your patients .

  • Atman Daftary says:

    Good case with an excellent dash of humour ar d end sir.

  • Burzin Panthaki says:

    Well written piece as always. The way it is described it looks as if the surgery was done in front of our eyes.

  • Dr Mrs Faozat Aderonke Olabisi Bello says:

    Welldone on the successful surgery. Welldone & keep up your good work.

  • Zarine Bahmani says:

    I don’t know why but i had a lump in my throat when i read this article…it was such a positive read. Thank you…
    God bless you dear Dr Mazda with steady hands, excellent health and a brilliant and humorous brain for years to come!

  • Porus k Chinoy says:

    Phenomenal as usual. God bless you Doctor

  • T George Koshy says:

    Very well written and thank God ..and u..that it ended happily for her ..appreciation for the ENT surgeon and endocrinologist too

  • Germaine Boatwala says:

    Wow, at first I was squeamish to even read – going up the nose – but it was worth every word! Does this intrusive surgery not affect the blood/brain barrier? Since that is considered the villain of many brain conditions, it seems interesting that you can bypass that during this procedure.
    What an incredibly steady hand great surgeons have! And hand eye coordination. Else the danger you spoke of town the students, would be a fatal flaw!
    It’s tremendous how she lost weight and became safely pregnant too. God bless her and the family. And God bless you for these efforts!
    The story of the father of neurosurgery, with the unexpected ending, added a poignant note too. 😊

  • Anjali Patki says:

    Great article, giving insights into your work. Interesting for those in both medical and non medical fields..makingvit enjoyable since it’s laced with that subtle humour. Good work dr mazda

  • Avinash karnik says:

    Dear Dr.Mazda
    Your skill in diagnosis seems to be par excellence.
    What an article!
    And at the end your humour makes this article all the more interesting. A true combination of intelligence and wit.

  • Marzian Mowji says:

    Gosh. That was some diagnosis.
    The Lucky woman. She came to you and was saved a lifetime of grief.
    I really am very impressed.

    I have learnt a lot through reading your articles and it gives me great comfort to know you.

    Thank you for being you.

  • Dr. Anil Patwardhan says:

    Very nice article recognising the great neurosurgeon Harvey Cushing. Your praise by the patient is very well deserved. You have a great sense of humour! Thanks for the informative article.


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