The surgical laugh

I got a little worried when he started laughing at his brotherrsquos funeral two weeks agordquo said a concerned wife as Rusi her 55yearold husband sat in front of me shaking his crossed legs with his hands clasped on his belly He wore a chequered shirt with grey pants that complemented his pepper hair and a confused look for why everyone was so perturbed about a few laughsldquoThe other day our cat had diarrhoea and defiled our expensive Persian carpet and all he did was sit on the couch and laughrdquo ldquoNot only has it been ruined it doesnrsquot smell as good anymore eitherrdquo Rusi added with a huge grin followed by a cachinnating guffawldquoSee isnrsquot this ludicrousrdquo she pointed almost instructing me to fire him for having switched from being a caring and loving man to a callous embarrassment ldquoHe chuckles at old people being unable to cross the road He laughed so much he snorted when I mentioned to him that our son and his wife got COVID19 He has started behaving like that man from the movie JokerrdquoldquoNot the Raj Kapoor onerdquoRusi interjected as I burst out into a bit of a giggle myself ldquoYes the actor whose name no one can pronounce properlyrdquo his wife concluded with exasperation as she pulled out an MRI scan of the brain that their family physician had orderedldquoSo hersquos laughing at all the wrong thingsrdquo I said summarising her woes as I plugged in the MRI into the luminance of the Xray boxldquoand this is whyrdquoWith the back of my pen I went on to circle a 35cm tumour arising from the trigeminal nerve and pressing onto the brainstem ldquoA tumour in this location in known in extremely rare cases to produce pathological laughterrdquo I explained as they looked at me befuddled ldquoWersquoll remove it and hersquoll be finerdquo my confidence coming from seeing a similar outcome in my training days of this common tumour with an arcane presentationA couple of days later we tucked under his right temporal lobe drilling into a little quadrant of bone obscuring our vision Neurosurgeons take a look into the glistening opalescence of the brain everyday but the view is a tad different on each day The brain is a variant shade of beigepink the nerves a diverse spectrum from white to yellow and the corridors to access these tumours keep changing making it a wondrous journey into enthralling nooks and crannies There is a new treasure to be excavated every day ldquoCan I cut thisrdquo is the most common question I voice aloud to the amusement of the team watching the surgery on the big screen Most often you know what yoursquore about to cut but on occasion you end up nipping something you canrsquot identify in the hope itrsquos a part of naturersquos abundanceWe peeled the tumour off the nerve it originated from and when we removed it completely the dent it had made on the brain stem gently ballooned back to take its original form ldquoYou think hersquoll stop laughing after surgeryrdquo I indulged my assistant as we closed a time of the operation where we resort to prosaic yet philosophical questions of life ldquoI think he has a great sense of humour your surgery is only going to ruin it for himrdquo came the replyThe morning after surgery when neurosurgical patients are fully awake and alert we check if they are oriented to time place and person and do a thorough neurological examination to check for motor or sensory impairment seeing if things had become better or worse In Rusirsquos case we needed to say or do something strange to see if he laughed ldquoWersquoll leave that for his wife to assess after she spends the whole day with himrdquo I decreed as we wrote orders to transfer him out of the ICU and into the ward which deemed everything was perfectTwo days later we got a call from the emergency department about a 67yearold lady who began crying violently and inconsolably for two hours after a glass of water slipped from her hand and smashed to the floor On checking further we realised that she wasnrsquot hurt nor did the glass have any emotional value for her The psychiatrist who was called into opine was also confused Our astute neurologist ordered an urgent MRI that showed a stroke in the left thalamus She was administered a clotbusting drug and we could see her tears dry up as the last few drops of medication emptied into her veinsPathological laughter and crying are uncommon manifestations of common neurological conditions They donrsquot have a motivating stimulus nor are they triggered by an impulse that would not have otherwise led to this reaction Scientists term this as ldquoemotional incontinencerdquo and it is often seen in patients with amyotrophic lateral sclerosis a form of motor neuron disease We have also seen this in patients with multiple sclerosis Parkinsonrsquos and in some brain tumoursWe went to check on Rusi on the day of his discharge I could hear a roar as I knocked on the door ldquoWe havenrsquot cured him have werdquo I turned to my colleague ldquoHi Docrdquo he smiled as the door opened ldquoIs he still laughing at stuff hersquos not supposed tordquo I turned to his wife ldquoNothing crazy so farrdquo she said her hands folded in gratitude ldquoThen what was he laughing at when we walked inrdquo I asked my curiosity piqued ldquoSomeone sent him a neurosurgeon jokerdquo ldquoLetrsquos hear itrdquo I said preparing myself to be embarrassedldquoHow many neurosurgeons does it take to change a light bulbrdquo he asked and then followed up with the answer after a sly grin from me ldquoJust one he holds the bulb and the world revolves around himrdquo I smiled shaking my head at the comical impression people have of us but appreciating the humour nonethelessThe next time you see someone laughing nonsensically donrsquot hesitate to get a scan on him If the scan is normal you can safely diagnose him to be ParsiThe writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals