雙語·當呼吸化為空氣 你必須對自己的技術精益求精

在神經(jīng)外科，你必須對自己的技術精益求精，也需要努力確保病人的個性不受影響，仍然鮮活。決定手術，不僅是對自己的能力做出評估，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，比如大腦皮質運動中樞，如果遭到破壞，就會引起身體某些部位癱瘓。但最最神圣而不可觸碰的皮質，是控制語言的。一般來說都在左腦，被稱為韋尼克區(qū)和布羅卡氏區(qū)，一個理解語言，一個產(chǎn)生語言。布羅卡氏區(qū)的損傷會導致寫和說的能力缺失，盡管病人對語言的理解能力依舊正常。韋尼克區(qū)的損傷會讓人失去對語言的理解能力，說起話來語無倫次，句不成句，毫無意義。如果兩個區(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消失。如果有人腦部受傷或中風，導致這兩個區(qū)域的損壞，外科醫(yī)生都會猶豫踟躕，猶豫該不該救這條命：要是沒了語言，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)學生的時候，我第一次遇到有這個問題的病人。六十二歲的男性，長了腦瘤。一天早上查房，我們走進他的病房，住院醫(yī)生問他：“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，語氣還挺親切友好的。
“Four six one eight nineteen!” he replied, somewhat affably.

腫瘤擾亂了他說話的回路，所以他只能說出一串串數(shù)字。但他照樣可以說得抑揚頓挫，也能充分表現(xiàn)自己的情感：微笑、皺眉、嘆氣。他又說了一串數(shù)字，這次很著急。他想跟我們說什么，但這串數(shù)字沒有任何實際的交流作用，只能從語氣中聽出他的恐懼和憤怒。查房的隊伍準備離開病房了。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?！?br>“I’m sorry.”

“十四一二八?！彼瘋卣f，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。幾個月后，他死了。他想對世界傳達的信息，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.

這些語言中樞遭遇腫瘤或畸形時，外科醫(yī)生會采取很多預警措施：一系列各種各樣的掃描，事無巨細的神經(jīng)心理學檢查。不過，手術卻很驚險，因為病人是醒著的，還要不停地說話。等腦部暴露之后，腫瘤切除之前，外科醫(yī)生會用一個手持的球尖電極傳送電流，麻痹一小片皮層，同時讓病人做一系列口頭活動：說出各種物體的名字，背誦字母表，等等。電極將電流傳送到關鍵皮層區(qū)域時，就會干擾病人的表達：“ABCDE呃呃呃呃啊……FGHI……”這樣一來，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。整個過程中病人一直是醒著的，忙著做一系列的口頭活動，還跟在場的人聊天。
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，我正為這樣一臺手術做準備，看了病人的核磁共振結果，發(fā)現(xiàn)腫瘤完全覆蓋了語言中樞。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、腫瘤學家、放射治療師和病理學家的專家團隊）下了判決，說這個病例太危險了，不能動手術。那這個主治醫(yī)生怎么這么一意孤行呢？我心中有些憤然：有時候，說“不”是我們的職責。病人被輪椅推著進了病房。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)生走進來，看到我臉上的表情?！拔叶?，”他說，“我花了整整兩個小時勸他別做。沒用的。準備好了嗎？”
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?”

整個手術過程中，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？你們怎么慢下來了？快一點！我要它趕快滾。我可以在這地方待他媽的一整天，我不管，快點把它取出來！”
“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，“它滾蛋了。”
“It’s done,” I said. “It’s out.”

他怎么還能說話？這么大的腫瘤，在這么危險的區(qū)域，這簡直不可能。根據(jù)推測，臟話和其他語言的回路可能略有不同。也許腫瘤讓他的大腦進行了某種重組……
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)生生涯到達了一個高峰。關鍵的手術我都做得很熟練了。我的研究獲得了業(yè)內(nèi)各種最高獎項。工作邀請從全國各地雪片般飛來。斯坦福有個職位在招人，完全就是我的方向，他們需要一個神經(jīng)外科醫(yī)生兼神經(jīng)系統(tǒng)科學家，專攻神經(jīng)調(diào)控的專業(yè)技術。我手下一個年資不高的住院醫(yī)生跑到我身邊說：“剛聽大老板們說啦，要是他們雇了你，你就是我的專業(yè)導師哦?！?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，“說了就不靈了?！?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。在要求很高的領域工作的醫(yī)生們，見到病人的時候，都是他們最艱難的時候，也是最真實的時候，因為他們的生命與個性受到威脅。醫(yī)生們的職責，包括去了解病人的生命因為什么而寶貴，而值得一活，并好好計劃，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。掌握這樣的權力，就需要有很深的責任感，有時也摻雜著愧疚和自我責備。
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.