IELTS Academic Reading Practice Test 368

When Harvey Cushing began his medical career, an operation inside the skull was a desperate last resort. A few bold surgeons, among them Victor Horsley in London and William Macewen in Glasgow, had shown during the 1880s that the brain could be opened and a tumour or a blood clot removed, and some of their patients did recover. But such operations were rare, bleeding was hard to control and the risk of death was very high. Cushing's achievement, over the following three decades, was to turn a dangerous experiment into a discipline with rules, instruments and results that could be measured.

Cushing was born in Cleveland, Ohio, in 1869. He studied at Yale and then at Harvard Medical School, qualifying as a doctor in 1895, and he went on to train at Johns Hopkins Hospital in Baltimore. There he worked under William Halsted, one of the most influential surgeons of the age, whose operating theatre was run on the principles of meticulous control of bleeding, gentle handling of tissue and strict cleanliness. Halsted's team had recently adopted rubber gloves, and his habits shaped Cushing's practice for the rest of his life. Visitors to Cushing's own operating room later remarked on how slowly and deliberately he worked, and how little blood his patients lost.

In 1900 Cushing sailed for Europe and spent more than a year in the laboratory of Theodor Kocher in Bern. Kocher was studying the thyroid gland, and Cushing, working with animals, became interested in the pressure inside the skull. He noticed a consistent pattern: as that pressure rose, so did the blood pressure, while the pulse slowed. The observation, later called Cushing's reflex, gave surgeons a way of recognising dangerous swelling in a patient who could not be examined directly. He also spent some weeks in Charles Sherrington's laboratory in Liverpool, where the surface of the brain was being stimulated with electricity to map the areas that control movement.

He returned to Baltimore with an instrument he had seen in Italy, designed by Scipione Riva-Rocci, which measured blood pressure by means of an inflatable cuff wrapped around the arm. Surgeons of the period seldom measured blood pressure at all. Cushing took readings before, during and after every operation and had them recorded on a chart, along with the pulse and the rate of breathing. The charts showed, minute by minute, how a patient's condition changed under the anaesthetic, and they allowed Cushing to judge how much more of an operation a patient could tolerate.

He also designed tools. The most enduring were tiny silver clips, which could be pressed onto a bleeding vessel in the brain and left there, closing it without crushing the tissue around it. Cushing was equally attentive to the way an operation was organised: he often worked in more than one stage, stopped when a patient's condition worsened, and insisted that the anaesthetist keep him informed throughout.

In 1912 Cushing was appointed professor of surgery at Harvard and surgeon-in-chief at the new Peter Bent Brigham Hospital in Boston, which admitted its first patients the following year. He arrived with a team trained in his methods and with a determination to follow up every patient afterwards. The results he published were striking: the proportion of his brain-tumour patients who died after surgery fell steadily, and operations that had once been almost uniformly fatal became survivable.

He was drawn to the pituitary gland, a small structure at the base of the brain whose disorders produce dramatic changes in growth and hormone levels. To reach tumours there, Cushing adopted an approach through the nose, an idea first attempted in Innsbruck in 1907. Passing instruments along the nasal cavity allows a surgeon to reach the base of the skull without opening it, and Cushing refined the technique for more than a decade before abandoning it in the late 1920s in favour of an opening through the skull, which gave a wider view. The nasal route was revived long afterwards and is used today.

Another advance arrived in 1926, when Cushing began using a device built by a Harvard physicist, William Bovie. It passed a high-frequency electric current through a fine wire that cut tissue and sealed the small vessels it crossed. Cushing's first use of the instrument, to remove a brain tumour, went well, and electrosurgery quickly spread to other branches of surgery.

Cushing's influence rested as much on his records as on his hands. He kept notes, drawings and specimens from his patients, and he gave the commonest slow-growing brain tumours the name by which they are still known, meningioma. In 1932 he described a hormonal disorder caused by a small tumour of the pituitary gland, a condition that now bears his name. His collection of specimens became the Cushing Brain Tumor Registry, which was later transferred to Yale and is still consulted.

He was also a scholar and a collector. His biography of his friend Sir William Osler, the most admired physician of the age, appeared in 1925 and was awarded the Pulitzer Prize. He left Boston in 1932 and spent his last working years as Sterling Professor of Neurology at Yale, where he died in 1939.

A stroke happens when the blood supply to part of the brain is suddenly interrupted. In most cases a clot blocks an artery, and the tissue beyond it is starved of oxygen and glucose. In roughly one case in seven, the artery itself bursts and blood leaks into the brain, causing damage both through pressure and through the toxic effects of the blood. The first kind, known as ischaemic stroke, is by far the more common, accounting for about 85 per cent of cases. Both kinds produce the same sudden onset of weakness, numbness, confusion or difficulty in speaking, and both can leave a patient with a lasting disability.

Blood reaches the brain through four main arteries, two at the front of the neck and two at the back, and these join at the base of the brain in a ring of vessels called the circle of Willis, described by the English physician Thomas Willis in the seventeenth century. The arrangement is a safety feature: if one vessel narrows, blood can sometimes arrive by another route. Small connecting vessels, known as collaterals, vary greatly between individuals, which may help to explain why two people with apparently similar blockages can be affected very differently. A natural shortage of these vessels can turn a modest blockage into a catastrophe.

Whatever the cause, the cells at the centre of the affected area die quickly. Neurons have almost no fuel in reserve and cannot survive more than a few minutes without oxygen. Around this dead core, however, lies a region that is short of blood but not yet beyond help. In this zone, called the penumbra, cells may remain viable for an hour or more, and it is this tissue that treatment aims to rescue. Estimates of how long the penumbra can hold out vary from patient to patient, and the boundary shifts as swelling increases. The distinction between the core and the penumbra is central to modern stroke medicine.

The damage does not stop when the oxygen runs out. Without energy, the pumps that maintain the electrical balance of a neuron fail, and the cell discharges. That discharge releases a burst of the messenger chemical glutamate, which excites neighbouring cells and makes them discharge in turn. The result is a wave of overactivity that spreads through the tissue, a process known as excitotoxicity. At the same time, calcium floods into the cells, switching on enzymes that break down proteins and membranes, and producing unstable molecules that attack whatever they touch. Inflammation follows, and swelling can crush tissue that was not initially harmed.

The consequences depend on where the blockage occurs. A clot in the middle cerebral artery, the commonest site, may affect the areas that control movement and sensation on one side of the body and, if it occurs on the left side of the brain in most people, the ability to produce or understand language. Because the brain's functions are mapped so precisely, a blockage only a few millimetres across can leave a patient unable to read or to recognise faces. A blockage in the brainstem, where the pathways for breathing and consciousness pass, can be devastating even when it is small.

Treatment aims to reopen the artery as fast as possible. A drug that dissolves clots can be given to suitable patients, but it works best when infused within four and a half hours of the first symptoms. For larger clots, a fine tube can be threaded through the arteries from the groin and the clot pulled out with a device called a stent retriever, a procedure known as thrombectomy. Several trials published in 2015 showed a clear benefit, and later studies extended the time window to well beyond six hours for patients whose scans show salvageable tissue. Ambulance services increasingly take suspected stroke patients straight to specialist centres, because these treatments are available in few hospitals.

Scans do more than confirm the diagnosis. A plain CT scan shows whether there is bleeding, which rules out clot-dissolving treatment. Perfusion imaging, which maps blood flow, can reveal how much tissue is already dead and how much is at risk. Comparing the two helps doctors decide whether reopening the artery is worthwhile in someone who arrives many hours after the stroke began, and it is this approach that has allowed treatment to be offered to patients who wake with symptoms and cannot say when they started. Mobile scanners and telemedicine links now let specialists advise on images taken hundreds of kilometres away.

Recovery depends on the brain's ability to rewire itself, and it is slow and unpredictable. Areas around the damaged tissue can take over some functions, and rehabilitation exploits this by repeatedly practising the movements and skills that have been lost. Why one patient recovers speech while another does not is still poorly understood. Attempts to protect neurons with drugs have a long record of failure: treatments that worked in animals have repeatedly disappointed in large human trials, and researchers now suspect that the processes set off by a stroke are too interlinked for any single drug to block. Inflammation, once seen only as part of the problem, is now also studied as part of the repair.

Few subjects provoke such strong feelings among hospital patients as the food. Complaints about lukewarm soup and unidentifiable meat are a staple of conversation on the wards, and in several countries health systems have responded by drawing up standards for what hospitals should provide. Recently the argument has gone further. If hospitals exist to restore health, why do so many of them sell sweets, crisps and sugary drinks in their own shops and vending machines? Should a hospital serve only food that is good for people? The question sounds simple, and it is not.

The case for restriction begins with the purpose of the institution. A hospital is funded by public money in most countries, and much of its work consists of treating conditions that diet has helped to cause. A building that fills its vending machines with sugary drinks while its doctors warn patients to cut down on sugar is sending a mixed message. Hospitals also employ large numbers of people and feed them every day, and visitors eat there too. Those who support the idea of the 'health-promoting hospital', a movement that has spread through Europe and beyond, argue that an institution cannot teach healthy living in one room and undermine it in the next.

It is not obvious, however, that hospital meals are as bad as their reputation suggests, or that the fault lies with the menu. Studies of hospital catering in several countries have found that a large share of the food served is never eaten, and that patients who are unwell often eat far less than they need. In England, national standards for hospital food were introduced during the 2010s, and caterers have argued that they are already held to nutritional requirements that most restaurants would fail. Yet the same studies suggest that the problem is less the nutritional content of the menu than whether an unwell person feels like eating at all.

The strongest objection to a menu of nothing but healthy food is clinical. A significant minority of patients arrive at hospital already malnourished, and illness itself raises the body's demand for energy. For a frail elderly patient with a small appetite, a low-calorie salad is not a healthy choice but a prescription for further weight loss. Dietitians therefore often recommend energy-dense foods, including cream, cheese and puddings, and supplements, not because these are fashionable but because they are what the patient needs. 'Healthy' is not a property of a food in isolation: it depends on who is eating it and why.

There is also the matter of what food does for a person's state of mind. A long stay in hospital is tedious, frightening and institutional, and a familiar meal can be one of the few sources of pleasure left. Patients who are asked what matters to them often mention choice, and the freedom to eat something one enjoys is part of being treated as an adult. A rule that swept away everything except salads and steamed fish would, in the name of health, remove a small but real comfort. Some patients also have religious or cultural requirements that a narrow definition of healthy eating would not begin to accommodate.

Staff and visitors are a different matter. Nobody is being treated, and the hospital's duty to them is weaker in one sense and stronger in another: it is their workplace, and an employer can reasonably be expected to make the healthy option the easy one. If any part of a hospital's catering should be steered, it is the canteen rather than the ward. That distinction is blurred in practice, because visitors buy food for patients and staff and patients queue in the same places.

Yet steering is not the same as banning. Removing an item from a vending machine does not remove the appetite for it; staff and visitors buy it elsewhere, bring it in from home, or order it to be delivered. Restriction also tends to provoke resentment, because it treats adults as children and makes the forbidden item more attractive. Research on choice architecture points to a more promising approach: change what is easiest to choose, rather than what is permitted. Placing fruit beside the till, pricing a healthy meal attractively and making water visible all shift behaviour without an argument.

Money is the constraint that campaigners mention least often. Hospital catering runs on tight budgets, and good food costs more to buy, to cook and to staff. Kitchens that once prepared meals on site have in many places been replaced by central production and reheating, which saves money and makes fresh cooking harder. Contractors, too, have to be persuaded, since a cheaper menu is rarely a better one. Any serious proposal to improve hospital food has to be paid for, and no government has yet shown much enthusiasm for that.

My own view is that the slogan 'only healthy food' is a poor guide to policy. Hospitals should aim to make appetising, well-cooked, nutritious food the everyday default, and should be ashamed of the tired sandwiches and fizzy drinks that many still offer. But they should also keep energy-dense dishes available for patients who need them, and let a dietitian, not a catering contract, decide who does. A hospital is not a monastery, and the food it serves is part of its treatment, not a statement about virtue.