Dr. Rob Miller, a young neurosurgeon in training, found himself operating late at night. He was doing delicate brain surgery to repair an anomaly in the brainstem, which is located at the brain’s base and controls key activities like breathing and heart rhythm. Despite the late hour and complexity of the operation, Rob was secure in his actions. He painstakingly peeled layers of tissue to uncover a yellowish lump deep within the brainstem. The dreaded tumor.
Suddenly, the attending surgeon, the most experienced doctor in the operating room, interrupted Rob in the middle of the process. “Dr. Miller,” he asked, pointing to a specific area, “what would happen if we made an incision just two millimeters deeper here?”
Rob’s mind raced. “Double vision?” he asked.
The attending surgeon shook his head. “No,” he replied firmly. “Locked-in syndrome.” He explained that a cut two millimeters deeper could entirely paralyze the patient, leaving just the ability to blink.
Two millimeters. The difference between tragedy and full recovery. A two millimeter error in judgment of the structure of the brain.
The first scientific studies of the structure of the brain are accredited to Herophilus and Erasistratus; both from the Graeco-Roman city of Alexandria. The reason these breakthroughs came about in Alexandria was that, for a brief period, and apparently for the first time in history, the dissection of human bodies was permitted.
Such is the nature of the most complex object in the universe: the brain. As soon as scientists believe they’ve figured it out, some new data emerges.
One of the current challenges is mental health and its devastating impact on society.
Neurosurgeons usually do procedures while the patient is conscious. The structure of the brain and the area to be operated on are precisely planned and mapped out. The operating area, for example, would be named Site 19. Any neighboring regions that may be dangerous or where different reactions can be tested are likewise labeled.
During surgery, the patient is asked to perform a variety of tasks, including sticking out the tongue, moving the left hand, reciting the alphabet, and a dozen more. This ensures that everything happens as planned. While the patient performs tasks, the surgeon will use an electrode to apply an electrical current to one of the labeled areas to observe the expected reactions.
Even during this seemingly trivial task, the brain sometimes reveals the unknown.
One spring day in 1994, Dr. Frederick Lenz, a neurosurgeon at Johns Hopkins, was operating on a patient suffering from severe hand tremors. The patient, let’s call him Benjamin Yukhandoo, was only thirty-six, but over the years his hands had come to shake so violently that the simplest of tasks—writing, drinking from a glass, or signing contracts — grew absurdly difficult.
Desperate for a return to a normal life, Yukhandoo agreed to a delicate procedure: brain surgery that would destroy cells in a small structure called the thalamus (the body’s relay station), which was already known to contribute to such excessive stimulation of the hands. The danger in this type of surgery is that it might destroy the wrong cells: the thalamic cells involved in tremor lie just fractions of a millimeter away from cells that are essential for sensation and motor activity.
The surgeon had to find the right cells by stimulating them with a gentle electric pulse. The probe was in a portion of Yukhandoo’s thalamus that Dr. Lenz labeled Site 75, and he zapped it with low voltage. Normally, zapping site 75 makes people feel a prickle in the forearm. Sure enough, this is what Yukhandoo felt. Dr. Lenz then zapped an adjacent area he labeled Site 23, where stimulation generally produces a mild and very ordinary tingling in the chest.
But Yukhandoo felt an unexpectedly far more harsh pain that made him cry out and nearly leap off the operating table. When Dr. Lenz stopped the stimulation, however, the sensation disappeared, and Yukhandoo became instantly calm again. Puzzled, Dr. Lenz zapped Site 23 once more, and it produced the same effect. He stopped, apologized to Yukhandoo for the discomfort, and went on to locate the cells controlling his tremor and cauterize them. The operation was a success.
After the operation, Dr. Lenz could not stop asking himself, “What’s up with site 23?”
Then Dr. Lenz remembered that Benjamin Yukhandoo had another big problem: for seventeen years, he had struggled with a severe panic disorder. He would experience sudden, severe chest pains, as if he were having a heart attack. At least once a week, his heart would pound, his ears would ring; he would grow short of breath, and he would have an overwhelming urge to escape. Escape from anything, everything, and nothing—all at once.
The implications might have easily been lost, but Dr. Lenz had spent many years researching pain and realized that he had witnessed an important and telling effect. The response by Yukhandoo, to the seemingly normal stimulus in Area 23 was wildly out of proportion. Torment to others was what most people found to be only a tingle. Areas of the brain governing ordinary sensations appeared to have become abnormally sensitized—set to fire in response to perfectly harmless stimuli.
Even more oddly, in Yukhandoo’s case, the pain had not begun with any bodily damage but with his panic disorder, which is understood to be a psychological condition. Dr. Lenz’s findings suggest that, in fact, all pain is “in the head” — and further that sometimes, no physical injury of any kind is needed to make the pain system go haywire. The incident on the operating table with Benjamin Yukhandoo sparked new theories of pain. New evidence suggested that we should stop thinking that pain or any other sensation is a signal passively “felt” in the brain.
It is the brain that generates the pain experience, and it can do so even in the absence of external stimuli.
In the words of the psychologist, Ronald Melzack:
If a mad scientist reduced you to nothing but a brain in a jar, you could still feel pain — indeed, you could have the full range of sensory experience.
There are two modest-size regions of the neocortex that are said to be responsible for language. Wernicke’s area is thought to be responsible for language comprehension, and Broca’s area is thought to be responsible for language production. Certain brain areas are considered near-inviolable, but the most sacrosanct regions of the cortex are those that control language.
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 is stolen forever.
One evening, a neurosurgery specialist,
Dr. Paul Kalanithi, was preparing for surgery on a patient who had a large tumor that covered the language areas. While reviewing his notes, he saw that the hospital’s tumor board—an expert panel of surgeons, oncologists, radiologists, and pathologists — had deemed the case too dangerous for surgery. So, the board deemed it too dangerous, but the attending surgeon gave the go ahead?
“
How could the surgeon have opted to proceed?” Dr. Kalanithi wondered out loud. Before he could find an answer, the patient was wheeled into the room. He fixed his eyes on the doctor and pointed to his head. “I want this thing out of my fucking brain. Got it?”
The attending surgeon strolled in and saw the expression on Dr. Kalanithi’s face. “I know,” he said. “I tried talking him out of this for about two hours. Don’t bother. Ready to go?”
Instead of the usual alphabet recital or counting exercises, the surgeons were treated throughout the surgery to a litany of profanity and exhortation. No small talk. No electrode stimulation. Nothing. The patient was doing well all by himself.
“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!”
Dr. Kalanithi 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.
“Why’d you stop? You some kinda asshole? I told you I want the fucking thing gone!”
“It’s done,” Dr. Kalanithi said. “It’s out.”
This patient left Dr. Kalanithi with more questions than answers. “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.”
I am obsessed with stories about the brain and neurosurgery in particular. My curiosity started when I had the same obsession for the study of human behavior and why people do what they do.
When I first read this story, I too had more questions than answers. How did this patient do it? How did he manage to act completely differently than any other story I’ve read before that? Was the patient even aware of how dangerous that “fucking thing in his brain” was?
As I’m writing this, years after I read the story, I’m still wondering: Did the tumor rewire his brain, or was it his creative use of language, or is it one of those anomalies that the brain will one day reveal?
All we can do is stand in awe. Complete awe.
But behind the complex procedures and scientific breakthroughs, there’s a human element to neurosurgery that inspires awe too. It’s the courage of patients like Benjamin Yukhandoo who entrust their very minds to the surgeon’s scalpel.
It’s the dedication of Dr. Kalanithi , Dr. Miller, Dr. Lenz, and countless others who navigate the delicate landscapes of the brain to heal and restore. It’s the unwavering hope that drives this field forward, pushing the boundaries of what’s possible.
The human spirit, combined with the marvels of the brain, creates a story far more remarkable than any medical textbook could capture.