双语·当呼吸化为空气 你必须对自己的技术精益求精

在神经外科，你必须对自己的技术精益求精，也需要努力确保病人的个性不受影响，仍然鲜活。决定手术，不仅是对自己的能力做出评估，也要深刻了解病人的特性，以及他／她所珍视的东西。脑中有些区域被看作是几乎不可侵犯的，比如大脑皮质运动中枢，如果遭到破坏，就会引起身体某些部位瘫痪。但最最神圣而不可触碰的皮质，是控制语言的。一般来说都在左脑，被称为韦尼克区和布罗卡氏区，一个理解语言，一个产生语言。布罗卡氏区的损伤会导致写和说的能力缺失，尽管病人对语言的理解能力依旧正常。韦尼克区的损伤会让人失去对语言的理解能力，说起话来语无伦次，句不成句，毫无意义。如果两个区都遭到损伤，病人就变成了一座孤岛，人性最核心的部分永远消失。如果有人脑部受伤或中风，导致这两个区域的损坏，外科医生都会犹豫踟蹰，犹豫该不该救这条命：要是没了语言，活着有什么意思？
Neurosurgery requires a commitment to one’s own excellence and a commitment to another’s identity. The decision to operate at all involves an appraisal of one’s own abilities, as well as a deep sense of who the patient is and what she holds dear. Certain brain areas are considered near-inviolable, like the primary motor cortex, damage to which results in paralysis of affected body parts. But the most sacrosanct regions of the cortex are those that control language. Usually located on the left side, they are called Wernicke’s and Broca’s areas; one is for understanding language and the other for producing it. Damage to Broca’s area results in an inability to speak or write, though the patient can easily understand language. Damage to Wernicke’s area results in an inability to understand language; though the patient can still speak, the language she produces is a stream of unconnected words, phrases, and images, a grammar without semantics. If both areas are damaged, the patient becomes an isolate, something central to her humanity stolen forever. After someone suffers a head trauma or a stroke, the destruction of these areas often restrains the surgeon’s impulse to save a life: What kind of life exists without language?

做医学生的时候，我第一次遇到有这个问题的病人。六十二岁的男性，长了脑瘤。一天早上查房，我们走进他的病房，住院医生问他：“麦克斯先生，今天感觉如何？”
When I was a med student, the first patient I met with this sort of problem was a sixty-two-year-old man with a brain tumor. We strolled into his room on morning rounds, and the resident asked him, “Mr. Michaels, how are you feeling today?”

“四六一八十九！”他回答，语气还挺亲切友好的。
“Four six one eight nineteen!” he replied, somewhat affably.

肿瘤扰乱了他说话的回路，所以他只能说出一串串数字。但他照样可以说得抑扬顿挫，也能充分表现自己的情感：微笑、皱眉、叹气。他又说了一串数字，这次很着急。他想跟我们说什么，但这串数字没有任何实际的交流作用，只能从语气中听出他的恐惧和愤怒。查房的队伍准备离开病房了。出于某种原因，我徘徊在他的床前。
The tumor had interrupted his speech circuitry, so he could speak only in streams of numbers, but he still had prosody, he could still emote: smile, scowl, sigh. He recited another series of numbers, this time with urgency. There was something he wanted to tell us, but the digits could communicate nothing other than his fear and fury. The team prepared to leave the room; for some reason, I lingered.

“十四一二八，”他抓住我的手，就像在哀求我，“十四一二八。”
“Fourteen one two eight,” he pleaded with me, holding my hand.“Fourteen one two eight.”

“我很抱歉。”
“I’m sorry.”

“十四一二八。”他悲伤地说，直视着我的眼睛。
“Fourteen one two eight,” he said mournfully, staring into my eyes.

接着我就离开了，跟上大部队。几个月后，他死了。他想对世界传达的信息，也随之一起被埋葬了。
And then I left to catch up to the team. He died a few months later, buried with whatever message he had for the world.

这些语言中枢遭遇肿瘤或畸形时，外科医生会采取很多预警措施：一系列各种各样的扫描，事无巨细的神经心理学检查。不过，手术却很惊险，因为病人是醒着的，还要不停地说话。等脑部暴露之后，肿瘤切除之前，外科医生会用一个手持的球尖电极传送电流，麻痹一小片皮层，同时让病人做一系列口头活动：说出各种物体的名字，背诵字母表，等等。电极将电流传送到关键皮层区域时，就会干扰病人的表达：“ABCDE呃呃呃呃啊……FGHI……”这样一来，就比较清楚脑部和肿瘤的分布，也可以判定哪些部分可以安全地割除。整个过程中病人一直是醒着的，忙着做一系列的口头活动，还跟在场的人聊天。
When tumors or malformations abut these language areas, the surgeon takes numerous precautions, ordering a host of different scans, a detailed neuropsychological examination. Critically, however, the surgery is per-formed with the patient awake and talking. Once the brain is exposed, but before the tumor excision, the surgeon uses a hand-held ball-tip electrode to deliver electrical current to stun a small area of the cortex while the patient performs various verbal tasks: naming objects, reciting the alphabet, and so on. When the electrode sends current into a critical piece of cortex, it disrupts the patient’s speech: “A B C D E guh guh guh rrrr. . . F G H I. . . ” The brain and the tumor are thus mapped to determine what can be resected safely, and the patient is kept awake throughout, occupied with a combination of formal verbal tasks and small talk.

一天晚上，我正为这样一台手术做准备，看了病人的核磁共振结果，发现肿瘤完全覆盖了语言中枢。这可不是什么好现象。我看了下资料，发现医院的肿瘤组（包括外科医生、肿瘤学家、放射治疗师和病理学家的专家团队）下了判决，说这个病例太危险了，不能动手术。那这个主治医生怎么这么一意孤行呢？我心中有些愤然：有时候，说“不”是我们的职责。病人被轮椅推着进了病房。他双眼看定我，指着自己的头：“这鬼东西要从我脑子里滚出去，听到了吗？”主治医生走进来，看到我脸上的表情。“我懂，”他说，“我花了整整两个小时劝他别做。没用的。准备好了吗？”
One evening, as I was prepping for one of these cases, I reviewed the patient’s MRI and noted that the tumor completely covered the language areas. Not a good sign. Reviewing the notes, I saw that the hospitals tumor board—an expert panel of surgeons, oncologists, radiologists, and pathologists—had deemed the case too dangerous for surgery. How could the surgeon have opted to proceed? I became a little indignant: at a certain point, it was our job to say no. The patient was wheeled into the room. He fixed his eyes on me and pointed to his head. “I want this thing out of my fucking brain. Got it?” The attending strolled in and saw the expression on my face. “I know,” he said. “I tried talking him out of this for about two hours. Don’t bother. Ready to go?”

整个手术过程中，病人没有像通常那样背字母表或者数数，而是一直不停说着脏话，还颐指气使，指手画脚。
Instead of the usual alphabet recital or counting exercise, we were treated, throughout the surgery, to a litany of profanity and exhortation.

“那鬼东西滚出我脑子没？你们怎么慢下来了？快一点！我要它赶快滚。我可以在这地方待他妈的一整天，我不管，快点把它取出来！”
“Is that fucking thing out of my head yet? Why are you slowing down? Go faster! I want it out. I can stay here all fucking day, I don’t care, just get it out!”

我慢慢地切掉那巨大的肿瘤，密切注意着他言语困难的蛛丝马迹。病人还在连珠炮似的唠叨咒骂，而肿瘤已经被放在培养皿上。他“无瑕”的大脑闪闪发光。
I slowly removed the enormous tumor, attentive to the slightest hint of speech difficulty. With the patient’s monologue unceasing, the tumor now sat on a petri dish, his clean brain gleaming.

“怎么停了？你是混蛋吗？我跟你说了，我要这鬼东西滚蛋！”
“Why’d you stop? You some kinda asshole? I told you I want the fucking thing gone!”

“做完了，”我说，“它滚蛋了。”
“It’s done,” I said. “It’s out.”

他怎么还能说话？这么大的肿瘤，在这么危险的区域，这简直不可能。根据推测，脏话和其他语言的回路可能略有不同。也许肿瘤让他的大脑进行了某种重组……
How was he still talking? Given the size and location of the tumor, it seemed impossible. Profanity supposedly ran on a slightly different circuit from the rest of language. Perhaps the tumor had caused his brain to rewire somehow. . .

但眼前要先缝合头盖骨呀。明天再慢慢想吧。
But the skull wasn’t going to close itself. There would be time for speculation tomorrow.

我的住院医生生涯到达了一个高峰。关键的手术我都做得很熟练了。我的研究获得了业内各种最高奖项。工作邀请从全国各地雪片般飞来。斯坦福有个职位在招人，完全就是我的方向，他们需要一个神经外科医生兼神经系统科学家，专攻神经调控的专业技术。我手下一个年资不高的住院医生跑到我身边说：“刚听大老板们说啦，要是他们雇了你，你就是我的专业导师哦。”
I had reached the pinnacle of residency. I had mastered the core operations. My research had garnered the highest awards. Job interest was trickling in from all over the country. Stanford launched a search for a position that fit my interests exactly, for a neurosurgeon-neuroscientist focused on techniques of neural modulation. One of my junior residents came up to me and said,“I just heard from the bosses—if they hire you, you’re going to be my faculty mentor!”

“嘘，”我说，“说了就不灵了。”
“Shhhh,” I said. “Don’t jinx it.”

我的感觉是，生理、道德、生命与死亡这些原本各自为阵的绳索，终于开始彼此交织了，慢慢成形，就算不是一个完美的道德系统，至少也是连贯一致的世界观，我在其中也占有一席之地。在要求很高的领域工作的医生们，见到病人的时候，都是他们最艰难的时候，也是最真实的时候，因为他们的生命与个性受到威胁。医生们的职责，包括去了解病人的生命因为什么而宝贵，而值得一活，并好好计划，可能的话，要尽可能保留这些东西——如果不行的话，就让病人去得安详体面。掌握这样的权力，就需要有很深的责任感，有时也掺杂着愧疚和自我责备。
It felt to me as if the individual strands of biology, morality, life, and death were finally beginning to weave themselves into, if not a perfect moral system, a coherent worldview and a sense of my place in it. Doctors in highly charged fields met patients at inflected moments, the most authentic moments, where life and identity were under threat; their duty included learning what made that particular patient’s life worth living, and planning to save those things if possible—or to allow the peace of death if not. Such power required deep responsibility, sharing in guilt and recrimination.