Chapter 1 Chapter 1

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Scientist and Mechanic

The brain is soft. Some of my colleagues compare it to toothpaste, but that’s not quite right. It doesn’t spread like toothpaste. It doesn’t adhere to your fingers the way toothpaste does. Tofu—the soft variety, if you know tofu—may be a more accurate comparison. If you cut out a sizable cube of brain it retains its shape, more or less, although not quite as well as tofu. Damaged or swollen brain, on the other hand, is softer. Under pressure, it will readily express itself out of a hole in the skull made by a high-speed surgical drill. Perhaps the toothpaste analogy is more appropriate under these circumstances.

The issue of brain texture is on my mind all the time. Why? I am a neurosurgeon. The brain is my business. Although I acknowledge that the human brain is a refined, complex, and mysterious system, I often need to regard it as a soft object inhabiting the bony confines of a hard skull. Many of the brains I encounter have been pushed around by tumors, blood clots, infections, or strokes that have swollen out of control. Some have been invaded by bullets, nails, or even maggots. I see brains at their most vulnerable. However, whereas other brain specialists, like neurologists and psychiatrists, examine brain images and pontificate from outside of the cranium, neurosurgeons boast the additional manual relationship with our most complex of organs. We are part scientist, part mechanic.

The scientist in me revels in the ethereal manifestations of the brain: the mind, consciousness, memory, language. The mechanic in me is satisfied by the clear fluid that rushes out of the end of a tube I insert into a patient’s brain to relieve excessive pressure. In everyday surgical practice, the science may take a backseat to the handiwork, and that’s okay. If you have an expanding blood clot in your head, you want a skilled brain mechanic, and preferably a swift one. You don’t care if your surgeon published a paper in Science or Nature.

I’ll give you an example of a most straightforward and manual case. I was paged to the emergency room a few years ago during my training and received the following brief report over the phone: “carpenter coming in with a nail stuck in the left frontal region of his head . . . neurologically intact.” What is going through my mind at this point? Do I hark back to my studies of frontal lobe circuitry and mull over the complex neural networks involved in language and memory? No. I’m thinking concrete, surgical thoughts: nails are sharp; the brain is full of blood vessels; the nail may have snagged a vessel on the way in. These thoughts are instantaneous, of course. I spell out the simple logic here purely for effect.

What I encountered in the ER was a young man, in his thirties, sitting up on an emergency room gurney. Perfectly awake and alert, arms crossed in repose and still in his construction boots, he smiled nervously when I walked in. Was he the right patient? He looked too good.

He was the right one. The carpenter explained that he and his friend were both on ladders along the side of a house. His friend was working a few rungs above. They were driving heavy-duty nails into the siding with automatic nail guns. His friend’s hand slipped upon firing in one of the nails, and the nail entered the left frontal region of my patient’s head below. For the first few moments after impact, the carpenter doubted what had happened. Although he noticed a stinging sensation...