The Terminal Man

"Well, then," Ellis said, "perhaps we can go on to discuss the details of stage-three surgery. Mr. Benson knows all this, so he can stay or leave, whichever he prefers."

Ross didn't approve. Ellis was showing off, the surgeon's instinct for demonstrating to everyone that his patient didn't mind being cut and mutilated. It was unfair to ask - to dare - Benson to stay in the room.

"I'll stay," Benson said.

"Fine," Ellis said. He went to the blackboard and drew a brain schematically. "Now," he said, "our understanding of the disease process is thata portion of the brain is damaged in epilepsy, and a scar forms. It's like a scar in other body organs - lots of fibrous tissue, lots of contraction and distortion. And it becomes a focus for abnormal electrical discharges. We see spreading waves moving outward from the focus, like ripples from a rock in a pond."

Ellis drew a point on the brain, then sketched concentric circles.

"These electrical ripples produce a seizure. In some parts of the brain, the discharge focus produces a shaking fit, frothing at the mouth, and so on. In other parts, there are other effects. If the focus is in the temporal lobe, as in Mr. Benson's case, you get what is called psychomotor epilepsy - convulsions of thought, not of body. Strange thoughts and frequently violent behavior, preceded by a characteristic aura which is often an odor."

Benson was watching, listening, nodding.

"Now, then," Ellis said, "we know from the work of many researchers that it is possible to abort a seizure by delivering an electrical shock to the correct portion of the brain substance. These seizures begin slowly. There are a few seconds - sometimes as much as half a minute - before the seizure takes effect. A shock at that moment prevents the seizure.'

He drew a large "X" through the concentric circles. Then he drew a new brain, and a head around it, and a neck. "We face two problems," he said. "First, what is the correct part of the brain to shock? Well, we know roughly that it's in the amygdala, an anterior area of the so-called limbic system. We don't know exactly where, but we solve that problem by implanting a number of electrodes in the brain. Mr. Benson will have forty electrodes implanted tomorrow morning."

He drew two lines into the brain.

"Now, our second problem is how do we know when an attack is starting? We must know when to deliver our aborting shock. Well, fortunately the same electrodes that we use to deliver the shock can also be used to 'read' the electrical activity of the brain. And there is a characteristic electrical pattern that precedes a seizure."

Ellis paused, glanced at Benson, then up at the audience.

"So we have a feedback system - the same electrodes are used to detect a new attack, and to deliver the aborting shock. A computer controls the feedback mechanism."

He drew a small square in the neck of his schematic figure.

"The NPS staff has developed a computer that will monitor electrical activity of the brain, and when it sees an attack starting, will transmit a shock to the correct brain area. This computer is about the size of a postage stamp and weighs a tenth of an ounce. It will be implanted beneath the skin of the patient's neck."

He then drew an oblong shape below the neck and attached wires to the computer square.

"We will power the computer with a Handler PP-J plutonium power pack, which will be implanted beneath the skin of the shoulder. This makes the patient completely self-sufficient. The power pack supplies energy continuously and reliably for twenty years."

With his chalk, he tapped the different parts of his diagram. "That's the complete feedback loop - brain, to electrodes, to computer, to power pack, back to brain. A total loop without any externalized portions."

He turned to Benson, who had watched the discussion with an expression of bland disinterest.

"Any comments? Mr. Benson?"

Ross groaned inwardly. Ellis was really letting him have it. It was flagrantly sadistic - even for a surgeon.

"No," Benson said. "I have nothing to say." And he yawned.

When Benson was wheeled out of the room, Ross went with him. It wasn't really necessary for her to accompany him, but she was concerned about his condition - and a little guilty about the way Ellis had treated him, She said, "How do you feel?"

"I thought it was interesting," he said.

"In what way?"

"'Well, the discussion was entirely medical. I would have expected a more philosophical approach."

"We're just practical people," she said lightly, "dealing with a practical problem."

Benson smiled. "So was Newton," he said. "What's more practical than the problem of why an apple falls to the ground?"

"Do you really see philosophical implications in all this?"

Benson nodded. His expression turned serious. "Yes," he said, "and so do you. You're just pretending that you don't."

She stopped then and stood in the corridor, watching as Benson was wheeled down to the elevator. Benson, Morris, and the cop waited in the corridor for the next car. Morris pushed the button repeatedly in that impatient, aggressive way of his. Then the elevator arrived and they got on. Benson waved one last time, and the doors closed.

She went back to the amphitheater.

"... has been under development for ten years," Ellis was saying. "It was first started for cardiac pacemakers, where changing batteries requires minor surgery every year or so. That's an annoyance to surgeon and patient. The atomic power pack is totally reliable and has a long lifespan. If Mr. Benson is still alive, we might have to change packs around 1990, but not before then."

Janet Ross slipped back into the room just as another question was asked: "How will you determine which of the forty electrodes will prevent a seizure?"

"We will implant them all," Ellis said, "and wire up the computer. But we will not lock in any electrodes for twenty-four hours. One day after surgery, we'll stimulate each of the electrodes by radio and determine which electrodes work best. Then we will lock those in by remote control."

High up in the amphitheater, a familiar voice coughed and said, "These technical details are interesting, but they seem to me to elude the point." Ross looked up and saw Manon speaking. Manon was nearly seventy-five, an emeritus professor of psychiatry who rarely came to the hospital any more. When he did, he was usually regarded as a cranky old man, far past his prime, out of touch with modern thinking.

"It seems to me," Manon continued, "that the patient is psychotic."

"That's putting it a little strongly," Ellis said.

"Perhaps," Manon said. "But, at the very least, he has a severe personality disorder. All this confusion about men and machines is worrisome to me."

"The personality disorder is part of his disease," Ellis said. "In a recent review, Harley and co-workers at Yale reported that fifty percent of temporal-lobe epileptics had an accompanying personality disorder which was independent of seizure activity per se."

"Quite so," Manon said, in a voice that had the slightest edge of impatience to it. "It is part of his disease, independent of seizures. But will your procedure cure it?"

Janet Ross found herself quietly pleased; Manon was reaching exactly her own conclusions.

"No," Ellis said. "Probably not."

"In other words, the operation will stop his seizures, but it won't stop his delusions."

"No," Ellis repeated. "Probably not.

"If I may make a small speech," Manon said, frowning down from the top row, "this kind of thinking is what I fear most from the NPS. I don't mean to single you out particularly. It's a general problem of the medical profession. For example, if we get a suicide attempt or a suicide gesture by drug overdose in the emergency ward, our approach is to pump the patient's stomach, give him a lecture, and send him home. That's a treatment - but it's hardly a cure. The patient will be back sooner or later. Stomach pumping doesn't treat depression. It only treats drug overdose."

"I see what you're saying, but..."

"I'd also remind you of the hospital's experience with Mr. L. Do you recall the case?"

"I don't think Mr. L. applies here," Ellis said. But his voice was stiff and exasperated.

"I'm not so sure," Manon said. Since several puzzled faces in the amphitheater were turned toward him, he explained.

"Mr. L. was a famous case here a few years ago. He was a thirty-nine-year-old man with bilateral end-stage kidney disease. Chronic glomerulonephritis. He was considered a candidate for renal transplant. Because our facilities for transplantation are limited, a hospital review board selects patients. The psychiatrists on that board strongly opposed Mr. L. as a transplantation candidate, because he was psychotic. He believed that the sun ruled the earth and he refused to go outside during the daylight hours. We felt he was too unstable to benefit from kidney surgery, but he ultimately received the operation. Six months later, he committed suicide. That's a tragedy. But the real question is couldn't someone else have benefited more from the thousands of dollars and many hours of specialized effort that went into the transplant?"

Ellis paced back and forth, the foot of his bad leg scraping slightly along the floor. Ross knew it meant he was feeling threatened, under attack. Normally Ellis was careful to minimize his disability, concealing it so that the limp was noticeable only to a trained eye. But if he was tired, or angry, or threatened, the flaw appeared. It was almost as if he unconsciously wanted sympathy: don't attack me, I'm a cripple. Consciously, of course, he was not aware of it.

"I understand your objection," Ellis said. "In the terms you present it, your argument is unanswerable. But I would like to consider the problem from a somewhat different viewpoint. It is perfectly true that Benson is disturbed, and that our operation probably won't change that. But what happens if we don't operate on him? Are we doing him a favor? I don't think so. We know that his seizures are life-threatening - to himself, to others. His seizures have already gotten him into trouble with the law, and his seizures are getting worse. The operation will prevent seizures, and we think that is an important benefit to the patient."

High up, Manon gave a little shrug. Janet Ross knew the gesture; it signaled irreconcilable differences, an impasse.

"Well, then," Ellis said, "are there other questions?"

There were no other questions.

3

"Jesus f**king Christ," Ellis said, wiping his forehead.

"He didn't let up, did he?"

Janet Ross walked with him across the parking lot toward the Langer research building. It was late afternoon; the sunlight was yellowing, turning pale and weak.

"His point was valid," she said mildly.

Ellis sighed. "I keep forgetting you're on his side."

"Why do you keep forgetting?" she asked. She smiled as she said it. As the psychiatrist on the NPS staff, she'd opposed Benson's operation from the beginning.

"Look," Ellis said. "We do what we can. It'd be great to cure him totally. But we can't do that. We can only help him. So we'll help him."

She walked alongside him in silence. There was nothing to say. She had told Ellis her opinion many times before. The operation might not help - it might, in fact, make Benson much worse. She was sure Ellis understood that possibility, but he was stubbornly ignoring it. Or so it seemed to her.

Actually, she liked Ellis, as much as she liked any surgeon. She regarded surgeons as flagrantly action-oriented, men (they were almost always men, which she found significant) desperate to do something, to take some physical action. In that sense, Ellis was better than most of them. He had wisely turned down several stage-three candidates before Benson, and she knew that was difficult for him to do, because a part of him was terribly eager to perform the new operation.

"I hate all this," Ellis said.

"Hate what?"

"The politics. That's the nice thing about operating on monkeys. No politics at all."

"But you want to do Benson..."

"I'm ready," Ellis said. "We're all ready. We have to take that first big step, and now is the time to take it." He glanced at her. "Why do you look so uncertain?"

"Because I am," she said.

They came to the Langer building. Ellis went off to an early dinner with McPherson - a political dinner, he said irritably - and she took the elevator to the fourth floor.

After ten years of steady expansion, the Neuropsychiatric Research Unit encompassed the entire fourth floor of the Langer research building. The other floors were painted a dead, cold white, but the NPS was bright with primary colors. The intention was to make patients feel optimistic and happy, but it always had the reverse effect on Ross. She found it falsely and artificially cheerful, like a nursery school for retarded children.

She got off the elevator and looked at the reception area, one wall a bright blue, the other red. Like almost everything else about the NPS, the colors had been McPherson's idea. It was strange, she thought, how much an organization reflected the personality of its leader. McPherson himself always seemed to have a bright kindergarten quality about him, and a boundless optimism.

Certainly you had to be optimistic if you planned to operate on Harry Benson.

The Unit was quiet now, most of the staff gone home for the night. She walked down the corridor past the colored doors with the stenciled labels: SONOENCEPHALOGRAPHY,

CORTICAL FUNCTION, EEG, RAS SCORING, PARIETAL T, and, at the far end of the hall, TELECOMP. The work done behind those doors was as complex as the labels - and this was just the patient-care wing, what McPherson called "Applications."

Chapter 3

Applications was ordinary compared to Development, the research wing with its chemitrodes and compsims and elad scenarios. To say nothing of the big projects, like George and Martha, or Form Q. Development was ten years ahead of Applications - and Applications was very, very advanced.