Tuesday, February 22, 2005

Breaking the Taboo

Breaking the Taboo

I'm feeling pretty good today, so for a change I reward what possible readers this blog might have with a post they won't have to cringe at..

Most people (including most neurologists) think of the brain as untouchable. We neurosurgeons don't claim to comprehend the inner workings of the brain (here's where you turn to the neurologists and psychiatrists) -- but we are manual workers, and for us the brain is accessible. We know that the brain is modular. We know that we can touch the brain, even remove parts of it, and we have a pretty good idea what it will mean to the patient. By modular I mean that the brain is not some complex neural network where everything is interconnected and nothing can be touched without damaging the whole network. For instance, if I remove someone's occipital lobe, I know that the person will suffer from partial loss of vision, but otherwise he will be the same as before. If I remove a cancerous tumor from the motor region representing the left hand, I know that there is a risk of paralysis of the left hand, but that's it - the person will be the same otherwise. I know that I can remove a part of the frontal lobe without any noticeable changes in the individual's personality or physical performance. This is what makes brain surgery possible. We know what will happen to the patient if some part of the brain is damaged, and we know what will not happen. And with modern techniques, such as microsurgery, we can access any part of the brain causing minimal or no damage.

Certain regions of the brain are especially important to daily living. We call these the "eloquent" brain areas. These include the speech, motor, and visual areas. If there is even the slightest damage to eloquent brain tissue, the results can be disastrous to the quality of life of the individual. We think twice before operating in these areas. Other regions of the brain are more redundant. Take the anterior (front) part of the temporal lobe, for instance. Removing nearly the entire temporal lobe on one side will cause no harm to the patient. Not even a skilled neuropsychologist can detect any changes after a succesful temporal lobe removal.

The ancient motto of the medical profession is "Primum non nocere", which means: First, do no harm. This is the ultimate test for the neurosurgeon: Often we need to do harm in order to heal. We must decide whether the benefits are greater than the harm done. There are great risks involved in brain surgery, and the difference between success and disaster is literally microscopic.

Inevitably, great failures happen. The most difficult part of being a neurosurgeon is learning to live with one's failures. When a disastrous complication occurs, and they do, the burden is great. The patient was in my hands, and whatever happened was the direct consequence of my actions, and the responsibility is mine alone. The way I've learned to live with it is by the realization that all of medicine is about probabilities, not about absolutes. There is always a certain inherent element of failure and misjudgment, which can never be eliminated.



Janine said...

Hey there -
I am a nurse up in Canada, and find your blog quite interesting. Keep up the great entries!

Anonymous said...


I understand that removing a dangerous cancer is more important than certain regions of the brain, but you underestimate the importance of manual work to the health of the brain:

"If I remove a cancerous tumor from the motor region representing the left hand, I know that there is a risk of paralysis of the left hand, but that's it - the person will be the same otherwise."

I mean, using the weak hand, e.g. due to paralysis of the dominant one, can cause massive cerebral damage. I am not sure, but i think that I am experiencing it. (Motorical weakness, legastheny, difficulty in oral expression etc.). There must be literature, not only here in Germany. (If not, look for Sattler or Cicek)

OK, that's it, do not think I did not have great respect for neurosurgeons! All I know from my former work in hospital in Germany were nice persons.

Nice to have found your page, Martin