Thoughts about Consciousness while Cutting in the BrainBy
Neurosurgeon Werner Doyle changes people's experience of life for the better by removing parts of their brains. Yet he knows that mind is not matter, cells are not consciousness. Novelist Joseph McElroy watches Doyle at work in the operating room, and together they ponder the mystery of brain and mind.
Not always, but often. We heal ourselves and are helped to do so, and we help others, and more than help. And often hardly know how it happens, though we have all this knowledge, some of which accumulates and grows and helps, not entirely predictably and often immeasurably. I know no more profound kind of medical intervention than the brain surgery that aims to do away with epileptic seizures, at the very least reduce their frequency, control them, give the patient, often young, a life. I am speaking of epilepsy on which drugs haven’t worked. In Dostoevsky’s day there were no effective drugs to prevent seizures—perhaps he took bromides. Treatment was speculative at best. In a letter of 1863 he complains that he got only contradictory advice from specialists in Paris and Berlin; in Russia there were no epilepsy specialists at all. The “flash of light in his brain,” “of lightning,” coming in the midst of “spiritual darkness” a minute before the epileptic fit—“the sense of life, the consciousness of self…multiplied ten times,” are fascinating as literature, but for the sufferer they are “nothing but disease” (The Idiot, 1869).
For epilepsy that drugs can’t control, we now have, and have had for half a century, a remarkable range of surgical procedures. They are not without risk, even now with all the MRI’s, the rest of the changing technology, and the teamwork between epileptologists and neuropsychologists helping to prepare for the operations which the neurosurgeon—with all the technical data and irreplaceable experience and I would say meditative concentration—will perform. Remarkable, too, because within the confines of our three-dimensionally mapped and thus not unfamiliar brain, and doubtless inseparable from it, exist the limitless-seeming space, unthinkably quick paths of branching activity, and power we call consciousness.
That is also what I sometimes imagine I’m looking at when I’m standing in an operating room at NYU Medical Center for hours. What I’m this close to. And may even speak of out loud. For the man I am watching do his work, Dr. Werner Doyle, has encouraged me to speak, to ask, to say I hardly know what, or, curiously, what is in and of, but somehow other, if not separate. For Aristotle, body is both different from and inseparable from what he calls “soul” (anima), which is the actual life of something that possesses the potential for life. A section of brain surgically removed loses that life.
I am so close physically to an exposed site of someone’s consciousness, though it is only approachable through the signs and languages by which we manifest it, not by looking at a brain. Several years ago, after a conversation in which I had expressed some interest in learning about his work but had not mentioned that I’d written a novel about a brain, Werner invited me to observe his surgery. He was at another hospital then. I was struck by some conjunction of what can be repaired and yet remains virtually imponderable. We make use of what we can know in a region that contains what we do not know. I saw several operations and I filled half a notebook with what Werner told me and what I saw, or thought I saw. And events took over, and I wrote something else. And waited, I know, for a way to write about what Werner does.
Then in February of this year we happened to meet, and the way came to me, as I shall try to explain. And that is why, if I may speak in the present tense, I am here in this O.R. on a day in April. I’m this close. But to what? What pale cellular substance, what electrochemical reality, what potential seizures, feelings, perceptions, darknesses? For at the moment, the anesthetized patient is almost certainly without what we could call consciousness. Yet it will come back. From where? one may ask.
The spectacle of the operating room is pretty routine nowadays, if you count your home TV screen tuned to “ER” as providing an encounter this close. Yet this—the four or five assistants each with a job, and the anesthesiologist sitting surrounded by equipment and near the arm of the sleeping patient, who from where I stand is completely covered by a blue tent except for this small, exposed, brightly lighted opening into an area on the left side of her brain, where the surgeon, who I think is aware of everything in the room, is going to remove a section—all this is not primarily dramatic. It is work. It is attention. It is in many respects like other operations, like much that has been done before (except I, too, am here, in scrubs); and it does not pretend that this is not so.
It is not even an emergency, Werner has observed when we were talking in his office. You think, nonetheless, of what turns upon every move he makes here with his instruments. With a suction device the slow releasing of the perimeter of the brain matter he wants to take out in one piece; en bloc is the term. Retractor forceps holding back the skin. Lower fibrous layers of dura held back by being tacked and then sutured so they don’t slip under the skin. Little bursts of steam-like smoke from a bipolar forceps used to cauterize areas of potential bleeding and operated by pedal. Electrodes seemingly printed on tiny strips inserted on certain areas of brain tissue during a previous operation after which, the wires emerging from the head with locations labeled, and the incision very carefully sewn shut and the patient returned to her bed on another floor, the electrodes will identify where subsequent seizures are coming from. Now in this second operation, the surgeon knows pretty well where he needs to section. He glances quickly back to the hand-sketched diagrammatic sector maps of numbered brain points scotch-taped to the glass wall behind me, and at the video monitor on a table at my elbow with the virtual patient MRI on the screen (a device with software Werner Doyle developed).
What can go wrong? Get too close to memory areas, to motor function where infinitesimal damage could paralyze facial muscles, arms, legs. Sometimes Werner will do an awake operation to get the patient’s response to stimulus at particular points. The work is more and more my focus, I’m with Werner, and when sometimes the back of this person who’s working three or four feet in front of me gets in the way and blocks my view, I can move around him, or I can check out three video screens strategically placed above us trained on the wound, the window on which, in which, this surgeon works, his extremely lean body rather concave-seeming, his movements quick, his bird-like hovering above the terrain of his work, quick, yet delicately slow, a workman. To be able to move freely around the O.R. is a strange privilege I mostly forget, though I mustn’t get in anybody’s way, trip over a cable, bump a table on wheels, touch a piece of paper with one of Werner’s little maps on it with my ungloved hands. The surgeon answers my question: this is probably a three-stage case—electrodes are going to be left in; sometimes you go less far than you otherwise might for caution’s sake; sometimes secondary epileptic regions are (as Werner says in an abstract for a neurosurgery journal) “expressed only after the primary focus is resected” (i.e. removed). You can take brain material out but you can’t put it back in. Transplants not yet possible here; in any case less will be more.
I feel like I’m falling, but forward, wondering why I got into this. Am I understanding enough? For some reason I’m recalling the pretext for this neurosurgery piece—what Werner told me in February, this neighborhood friendly acquaintance father husband scientist doctor, who passed through a dark period himself.
I ask if the patient is experiencing any consciousness under anesthesia. No, nothing. One of the O.R. nurses asks the question again, as if my speaking has introduced a possibility of instruction or conversation to these proceedings. No, no sense of time passed. Nothing like Buddhist emptying of mind, I tell myself to bring up later—more like death as Lucretius so lucidly and calmly imagined it. We have discussed consciousness more than once—that emergent phenomenon whose sources and nature very little is known about and which, like mathematics (as Werner has pointed out), can’t quite explain itself. Consciousness has become a huge sub-science but also rich philosophical ground in the past twenty years, its terms somewhat upstaging the old, no less profound body-mind problems not resolved either by Descartes’ attempt to locate where the separately distinct mind or soul links up with the body, or by the seductive religious paradoxes of Pascal—most famously, “The heart has its reasons which reason cannot know.” And I ask here in the O.R., with the patient’s brain opened before us, what Werner thinks of the theories of Francis Crick and Christof Koch that would reduce the organizing of consciousness—and its products—to certain neural correlates, and as one may understand how sight occurs so locate also where Will is situated, or the highlighted illusion of its resultant decisions minus (conveniently) the memory of automatic computations that led to them. Doesn’t this reduce one neural source of consciousness to its essence? I ask, knowing that static “essence” isn’t quite the word. Werner agrees. For him the brain is holistic—Buddhism agrees, I interrupt—it develops as part of the whole organism, Werner continues; and he has seen too many examples of unpredictable or even unknown connectings, of surprising resilience, to say nothing of one part remarkably taking over for another.
So the process may not be simply reducible to certain neural correlates; the generative sources multiply. Which is not to dismiss Aristotle’s patient conclusions about soul- (or mind-) body relations in his fourth-century bce lectures recorded in the notes of students and edited three centuries later. Nor, doubtless influenced by Aristotle, the propositions of Spinoza in the seventeenth century, who thought mind and body parallel attributes of one substance and from this derived an ethos of the emotions very like what Buddhism teaches.
I want to ask if Werner agrees with a Buddhist view that consciousness is disorder—the monkey at the whim of impulse, a phantasmagoria of perception, a clutter which meditation, if we concentrate well enough, may fortunately dissolve; because that seems to nullify so much of my thinking, or anyway it seems too simple, a reduction of the brain/mind’s plans, struggles, purposes, insight into tragedy, comedy, courage, idea, to say nothing of its use of memory, without which Samuel Johnson argued the mind is not engaged. For a second Werner, as if he’s heard my thought, turns in my direction. I see the eyes behind the goggles, I know the face behind the mask; I don’t need to look at him but at his work. He is suctioning carefully, cutting, cauterizing, determined to remove a small section of brain where he knows seizures have originated. And then it comes out, a pale, amorphous cube of spongy, damp material held up on the end of long, tweezer-like bayonet forceps and deposited in a labeled plastic container provided by a nurse.
How did we get to Buddhism? Werner brought it up in February—or did he? We were speaking of Iraq. He mentioned that he’d been through a critical depression a few years ago. Just like that. News to me. How had it affected his work? Not much. (Which sounds like Werner.) I wondered if that could be true. I supposed he meant the quality of his professional work. I wondered if this rough period had come out of nowhere. His life had taken a turn into depression. Into darkness, it seemed; into emptiness. Are these the right words? They’re his. His wife confirmed it. I had known him for several years since this period (though not well), and he had never mentioned it. He’s a friendly man, inherently but not obviously reserved; smiling, but not a party person; but a most interesting talker, widely informed, a generous polymath. We were off, but where were we going? What specific weight or momentum was I in the midst of? The desperate political situation wasn’t what we were really talking about. The subject matter not unusual for New York, or for Werner. Our threatened society, physics, the vastness of space and time that surrounds us; the scale and process of black holes, and somewhere in this flurry of talk, the interest some Buddhist thinkers take in science—the Dalai Lama’s discussions with Varela, Davidson, I put in (recalling that Varela worked at NYU in ’78 and ’79 and did important work on the prediction of seizures); and now we’re speaking in that shared, synoptic way about 9/11. Though that must have been later than the depressions, I said, trying to keep track. (We both live a few blocks from the former World Trade Center. Had I talked to Werner since 9/11?) It had made him, like me, rediscover where he and his family were. I had written an essay about its impact on our neighborhood, though ultimately on what you make of your experience, a family person living in Tribeca or a terrorist flying a plane into a building.
I think I have a way to write about what Werner does. Seems OK to him; we’ll be in touch. In response to my respect, he makes some compliment—I forget the words: writing a novel and all that that entails. Writing is always somewhere in my head, but not always as writing. Often as memory. More often as what happens to memory. Long ago I gave Werner a book of mine, and he mentioned a slight dyslexia he once upon a time thought he had. I made a bad joke about the left and right sides of…But now my epilepsy notebook comes back to me. What’s in it? Things Werner told me. What actually happens in the brain in a generalized seizure, i.e. on both sides? A lessening or dissolving of difference, a terrible, crashing mobilizing into stunning synchrony of the brain’s normal elaborate choreography, turned suddenly into this lockstep of breaking waves, some wriggling animal inside your head. One evening after a long day—three operations, “very minor,” the replacement of batteries in stimulators permanently implanted—Werner gets home late and phones and comes over. He mentions a boy he will operate on two days from now: a brain lesion, maybe a tumor, maybe developmental; he’s had as many as twelve seizures a day. Werner wants to talk. He is a little like Chaucer’s ecclesiastical student in the General Prologue to The Canterbury Tales: “gladly would he learn and gladly teach.” Two New York guys, Irish it occurs to me, finding a late-night moment to talk about anything. Meditation comes into it. Neither of us seems to meditate in a regular way, but I’m not sure. I wouldn’t say I meditate. Werner thinks you can meditate while you’re out walking, sometimes even at work. I see him operating on a sleeping patient. Werner gets to the hospital before 7 am and often isn’t home till the middle of the evening. He tends not to eat between surgeries. I bring up depression, his.
It was when he would come home at night to his family that it descended, spreading the totality of its unanswerable pressure upon him. I wondered if it was due to work. No, it wasn’t work. What did he do about it? I ask. He prescribed Prozac for himself and it made him feel better. He took it in the morning. Didn’t it interfere with his concentration operating? Not at all. But the depression…It went on and eventually he came through it and everything’s better now. He used to play music during surgery; no more.
Wait, I’m losing my way, I say to myself; I need to know how things happen. What did Werner come through to? It was when he came home at night?
Yes, he had always been a problem solver—from math, which he could get A’s in but never felt he deeply understood, to computer software, to physics and organic chem and then biology. And general surgery, which interested him less than neuro surgery; and then a Yale fellowship in 1991, which almost by chance drew him into epilepsy surgery. He saw his work, his life, his family, as projects he would understand and deal with at a certain clear, engaged distance. Passing through painful depression seemed at last to dissolve that distance, that separation, between himself and what he had approached in order to solve as problems. He came to a new view. He was part of, not separate from, what he would live with, not just control.
The embrace of this view, as I hear Werner state it, is real and it is mysterious. A turn not simple to chart. Something in the words I grasp but don’t get. Work you partly do on yourself.
I can come to surgery any time I like, though schedules aren’t written in stone. I have a bunch of cellphone numbers for the office, the hospital—Ed Rivera, Werner’s longtime assistant, who takes me to the men’s locker room and I change. And at other times Werner and I talk in his office. Career details. He’d always had insomnia from the time he was at Columbia Medical School and before. He actually liked not sleeping. Insomnia is a drug, Werner grants. That period of depression stands between us as a subject: there but done with. The poet Rilke speaks of these dark periods as necessary to be gone through, not drowned out; as solitudes dizzying with “an abandonment to something inexpressible [that] would almost annihilate” you, where “all distances…change,” and to explain the state of our senses the brain would have to invent “a monstrous lie…” I think often of what Buddhism has to say about displacing destructive emotions with a different focus. Good advice. Best thing to do with good advice is pass it on, Oscar Wilde quipped. At the time of the depressions, Werner’s wife, Janet Standard, a psychiatric nurse now completing her studies to be a therapist, objected that Prozac wasn’t what Werner needed.
In further talks pivotal for my sense of him, probably I wouldn’t get all I wanted, not hear the whole story. If there is one. I wouldn’t hear about—if they had occurred—moments of recovery, of vision, after which the craftsman who fixes brains, the explorer who doubtless clarifies consciousness the signs of which are only to be guessed at, finds himself again. Rilke sees our development moving “gradually—that nothing strange should befall us, but only that which has long belonged to us.” I’m a writer. I experience doubt and distrust and I get over it, or even write about it. It’s a pitfall of perception, of choice, of working transiently with others. There came a moment when I thought, Does this man, who I think is becoming my friend, really want me to write about him? He’s not always sure. He has a right to be unsure. It is perhaps his way of being open, modest. Writing can move around in time, friendship too. This piece of writing will get done on time, seeing into the present as if it were a future beyond its deadline. Words, words; yet things get communicated. We’re in Werner’s office again, in a few minutes he’s going to see patients in the consulting rooms.
“My brain is the same as theirs.” A democracy of brains? But Werner has patients who were born with disabled brains from which he has removed as much as a whole hemisphere. “What do you”—I’m saying it awkwardly—“want to leave, or have done, when you retire?” Retire? No of course not at forty-eight, but would it be…an invention like the virtual patient software?
No, it’s…he thinks all this hi-tech’s beside the point sometimes, though technology is neutral; it’s what you do with it. I reply that that’s what Veblen thought. Werner says he could go into a low-tech situation in a developing country and work there. I mention that eighty percent of epileptics in developing countries, where the stigma is worst, have no access to medication. Werner thinks ancient doctors succeeded with what they had. Herbs, psychotherapy. “I got into this because I liked helping people.” “I know you did.” “That wasn’t the only reason,” he hastens to add. “It was science, problem-solving. You can manipulate the environment.” Chemistry, physics, and at med school, biology. He wasn’t happy at Columbia. Half the students were Ivy League. He was depressed there. Depressed? I ask. He tells me how later he did a rotation in neurosurgery, and a two-year general surgery, and then at NYU general neurosurgery before he got into this. I ask if epileptics get depressed. Oh yes. Same drugs for both. Probably some connection there, Werner thinks. “My life is no different from anyone else’s. My brain is their brain. I’m living in my self.” The only option. What one is capable of doing to expand this virtual reality that connects all of us.
I ask if it feels weird that I’m writing about him for a Buddhist magazine. “No, it makes complete sense.” I the writer (with a 3 x 5 card and a ballpoint like a probe) don’t pin him down; I know he reads in Buddhism, I don’t know what. Janet has meditated for years. “I’m already dead,” I hear him say. He says he says it to practice being this way—why not allow yourself to feel OK about it, and then get on with really living the fleeting moments that are left. If one were dead, how important is so much of what we value? He feels it more and more. The intrinsic value of something is what he’s interested in, what’s “best understood as irrelevant to my being alive.”
I mention, with mixed feelings, Chogyam Trungpa on the subtle defenses of ego. I a long-lapsed Christian touched by the practice, psycho-medical tradition and humor in Buddhism, and a secular everyday bond I can’t quite name. My fourteen-year-old son Boone had a sudden seizure when he was three. The terrifying absence in his eyes; he was gone, I thought. His mother holding him. Me in the street flagging down a car, a cab, though then the ambulance came; the terrible absence in his eyes, an emptiness, an emptying out, of I hardly dared think what. Seizures went on occurring in the hospital: he called it “a snake in my brain.” The neurologist’s word for this injury or trauma is “insult.” By then we had passed through the initial onset. His courage, his young life. But at the end of a week in the hospital the seizures were diagnosed as his immune system’s over-active, over-systematic counter-attack against a virus. The seizures were real; the cause was not epilepsy, not even what is called childhood epilepsy, which may pass. Though he remained on the drug Dilantin for several weeks.
On the way out of the office I see, framed on the left side of the door, the Tibetan Doctor’s Prayer a patient gave Werner, and fleetingly I note one small part: “May all human beings interrelate fully, lovingly, compassionately and joyously with one another.” Werner and I are not much on reincarnation. Yet it seems to him associated with the multiplying effects of karma—an extended life of our actions—in turn associated with an astonishing branching growth of complexity due to what is called in current theory—e.g., Stephen Wolfram’s which we’ve both dipped into—sensitive dependence on initial conditions.
I see Werner operating on sleeping patients, their breathing of interest to him and to me as bridge between voluntary and involuntary. I hear him as he enters consulting rooms asking if the patient and the patient’s family mind my sitting in; explaining in one room why a painful section of skull put back after an operation isn’t sitting as snugly as it should but probably will; and in another why he favors a more “aggressive” second operation which will remove more brain, yet yield more life. Not easy, though, for the families to face. He is so good with them, the way he explains it all, the percentage of risk, five percent I’ve heard him say. Sometimes there’s a pause in the conversation: he is simply with them. He puts an MRI up on the wall, he shows where we are going. He is like the seventeenth-century “physicians” attending John Donne sick in bed who “by their love are grown cosmographers.” Where love means utmost attention, and the patient is a little world to be read as an explorer reads a map. “You’ll be the same person when you wake up after the operation,” Werner says to his patients. He says to me (his pronoun mysterious), “It’s a way to understand it and bridge it to interact with someone else’s virtual reality by surgery”—to have an effect on their “external milieu. …Not their brain only that’s influencing me; it’s something else.”
I ask Alyson Silverberg, a nurse practitioner who has worked with him for seventeen years, what Werner Doyle does. “He is the most compassionate surgeon I’ve ever known,” she replies. Does becomes is. Perhaps as heal is cognate with whole; as well as with, though I am not competent to speak of them, holy and sacred.
Once more in the operating room, I see a tumor removed, not uncommon for seizure patients. At the end, the suturing and stitching seem endless. Making sure to seal the wound. Though depending greatly on the patient’s immune system to prevent infection. Werner turns to me at the end. “It’s simple.” Sometimes experience seems a privilege. ©
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