雙語(yǔ)·當(dāng)呼吸化為空氣 你必須對(duì)自己的技術(shù)精益求精

在神經(jīng)外科，你必須對(duì)自己的技術(shù)精益求精，也需要努力確保病人的個(gè)性不受影響，仍然鮮活。決定手術(shù)，不僅是對(duì)自己的能力做出評(píng)估，也要深刻了解病人的特性，以及他／她所珍視的東西。腦中有些區(qū)域被看作是幾乎不可侵犯的，比如大腦皮質(zhì)運(yùn)動(dòng)中樞，如果遭到破壞，就會(huì)引起身體某些部位癱瘓。但最最神圣而不可觸碰的皮質(zhì)，是控制語(yǔ)言的。一般來(lái)說(shuō)都在左腦，被稱為韋尼克區(qū)和布羅卡氏區(qū)，一個(gè)理解語(yǔ)言，一個(gè)產(chǎn)生語(yǔ)言。布羅卡氏區(qū)的損傷會(huì)導(dǎo)致寫和說(shuō)的能力缺失，盡管病人對(duì)語(yǔ)言的理解能力依舊正常。韋尼克區(qū)的損傷會(huì)讓人失去對(duì)語(yǔ)言的理解能力，說(shuō)起話來(lái)語(yǔ)無(wú)倫次，句不成句，毫無(wú)意義。如果兩個(gè)區(qū)都遭到損傷，病人就變成了一座孤島，人性最核心的部分永遠(yuǎn)消失。如果有人腦部受傷或中風(fēng)，導(dǎo)致這兩個(gè)區(qū)域的損壞，外科醫(yī)生都會(huì)猶豫踟躕，猶豫該不該救這條命：要是沒了語(yǔ)言，活著有什么意思？
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?

做醫(yī)學(xué)生的時(shí)候，我第一次遇到有這個(gè)問(wèn)題的病人。六十二歲的男性，長(zhǎng)了腦瘤。一天早上查房，我們走進(jìn)他的病房，住院醫(yī)生問(wèn)他：“麥克斯先生，今天感覺如何？”
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，語(yǔ)氣還挺親切友好的。
“Four six one eight nineteen!” he replied, somewhat affably.

腫瘤擾亂了他說(shuō)話的回路，所以他只能說(shuō)出一串串?dāng)?shù)字。但他照樣可以說(shuō)得抑揚(yáng)頓挫，也能充分表現(xiàn)自己的情感：微笑、皺眉、嘆氣。他又說(shuō)了一串?dāng)?shù)字，這次很著急。他想跟我們說(shuō)什么，但這串?dāng)?shù)字沒有任何實(shí)際的交流作用，只能從語(yǔ)氣中聽出他的恐懼和憤怒。查房的隊(duì)伍準(zhǔn)備離開病房了。出于某種原因，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。”他悲傷地說(shuō)，直視著我的眼睛。
“Fourteen one two eight,” he said mournfully, staring into my eyes.

接著我就離開了，跟上大部隊(duì)。幾個(gè)月后，他死了。他想對(duì)世界傳達(dá)的信息，也隨之一起被埋葬了。
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.

這些語(yǔ)言中樞遭遇腫瘤或畸形時(shí)，外科醫(yī)生會(huì)采取很多預(yù)警措施：一系列各種各樣的掃描，事無(wú)巨細(xì)的神經(jīng)心理學(xué)檢查。不過(guò)，手術(shù)卻很驚險(xiǎn)，因?yàn)椴∪耸切阎?，還要不停地說(shuō)話。等腦部暴露之后，腫瘤切除之前，外科醫(yī)生會(huì)用一個(gè)手持的球尖電極傳送電流，麻痹一小片皮層，同時(shí)讓病人做一系列口頭活動(dòng)：說(shuō)出各種物體的名字，背誦字母表，等等。電極將電流傳送到關(guān)鍵皮層區(qū)域時(shí)，就會(huì)干擾病人的表達(dá)：“ABCDE呃呃呃呃啊……FGHI……”這樣一來(lái)，就比較清楚腦部和腫瘤的分布，也可以判定哪些部分可以安全地割除。整個(gè)過(guò)程中病人一直是醒著的，忙著做一系列的口頭活動(dòng)，還跟在場(chǎng)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，我正為這樣一臺(tái)手術(shù)做準(zhǔn)備，看了病人的核磁共振結(jié)果，發(fā)現(xiàn)腫瘤完全覆蓋了語(yǔ)言中樞。這可不是什么好現(xiàn)象。我看了下資料，發(fā)現(xiàn)醫(yī)院的腫瘤組（包括外科醫(yī)生、腫瘤學(xué)家、放射治療師和病理學(xué)家的專家團(tuán)隊(duì)）下了判決，說(shuō)這個(gè)病例太危險(xiǎn)了，不能動(dòng)手術(shù)。那這個(gè)主治醫(yī)生怎么這么一意孤行呢？我心中有些憤然：有時(shí)候，說(shuō)“不”是我們的職責(zé)。病人被輪椅推著進(jìn)了病房。他雙眼看定我，指著自己的頭：“這鬼東西要從我腦子里滾出去，聽到了嗎？”主治醫(yī)生走進(jìn)來(lái)，看到我臉上的表情?！拔叶?，”他說(shuō)，“我花了整整兩個(gè)小時(shí)勸他別做。沒用的。準(zhǔn)備好了嗎？”
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?”

整個(gè)手術(shù)過(guò)程中，病人沒有像通常那樣背字母表或者數(shù)數(shù)，而是一直不停說(shuō)著臟話，還頤指氣使，指手畫腳。
Instead of the usual alphabet recital or counting exercise, we were treated, throughout the surgery, to a litany of profanity and exhortation.

“那鬼東西滾出我腦子沒？你們?cè)趺绰聛?lái)了？快一點(diǎn)！我要它趕快滾。我可以在這地方待他媽的一整天，我不管，快點(diǎn)把它取出來(lái)！”
“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腫瘤，密切注意著他言語(yǔ)困難的蛛絲馬跡。病人還在連珠炮似的嘮叨咒罵，而腫瘤已經(jīng)被放在培養(yǎng)皿上。他“無(wú)瑕”的大腦閃閃發(fā)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？你是混蛋嗎？我跟你說(shuō)了，我要這鬼東西滾蛋！”
“Why’d you stop? You some kinda asshole? I told you I want the fucking thing gone!”

“做完了，”我說(shuō)，“它滾蛋了?！?br>“It’s done,” I said. “It’s out.”

他怎么還能說(shuō)話？這么大的腫瘤，在這么危險(xiǎn)的區(qū)域，這簡(jiǎn)直不可能。根據(jù)推測(cè)，臟話和其他語(yǔ)言的回路可能略有不同。也許腫瘤讓他的大腦進(jìn)行了某種重組……
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. . .

但眼前要先縫合頭蓋骨呀。明天再慢慢想吧。
But the skull wasn’t going to close itself. There would be time for speculation tomorrow.

我的住院醫(yī)生生涯到達(dá)了一個(gè)高峰。關(guān)鍵的手術(shù)我都做得很熟練了。我的研究獲得了業(yè)內(nèi)各種最高獎(jiǎng)項(xiàng)。工作邀請(qǐng)從全國(guó)各地雪片般飛來(lái)。斯坦福有個(gè)職位在招人，完全就是我的方向，他們需要一個(gè)神經(jīng)外科醫(yī)生兼神經(jīng)系統(tǒng)科學(xué)家，專攻神經(jīng)調(diào)控的專業(yè)技術(shù)。我手下一個(gè)年資不高的住院醫(yī)生跑到我身邊說(shuō)：“剛聽大老板們說(shuō)啦，要是他們雇了你，你就是我的專業(yè)導(dǎo)師哦?！?br>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!”

“噓，”我說(shuō)，“說(shuō)了就不靈了?！?br>“Shhhh,” I said. “Don’t jinx it.”

我的感覺是，生理、道德、生命與死亡這些原本各自為陣的繩索，終于開始彼此交織了，慢慢成形，就算不是一個(gè)完美的道德系統(tǒng)，至少也是連貫一致的世界觀，我在其中也占有一席之地。在要求很高的領(lǐng)域工作的醫(yī)生們，見到病人的時(shí)候，都是他們最艱難的時(shí)候，也是最真實(shí)的時(shí)候，因?yàn)樗麄兊纳c個(gè)性受到威脅。醫(yī)生們的職責(zé)，包括去了解病人的生命因?yàn)槭裁炊鴮氋F，而值得一活，并好好計(jì)劃，可能的話，要盡可能保留這些東西——如果不行的話，就讓病人去得安詳體面。掌握這樣的權(quán)力，就需要有很深的責(zé)任感，有時(shí)也摻雜著愧疚和自我責(zé)備。
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.