Terminal Man (3 page)

“Three months ago, Benson was arrested on charges of assault and battery. The victim was a twenty-four-year-old topless dancer, who later dropped charges. The hospital intervened slightly on his behalf.

“One month ago, drug trials of morladone, para-amino benzadone, and triamiline were concluded. Benson showed no improvement on any drug or combination of drugs. He was therefore a stage two—drug-resistant ADL syndrome. And he was scheduled for a stage-three surgical procedure, which we will discuss today.”

She paused. “Before I bring him in,” she said, “I think I should add that yesterday afternoon he attacked a gas-station attendant and beat the man rather badly. His operation is scheduled for tomorrow and we have persuaded the police to release him in our custody. But he is still technically awaiting arraignment on charges of assault and battery.”

The room was silent as she turned, and went to bring in Benson.

Benson was just outside the doors to the amphitheater, sitting in his wheelchair, wearing the blue-and-white
striped bathrobe the hospital issued to its patients. When Janet Ross appeared, he smiled. “Hello, Dr. Ross.”

“Hello, Harry.” She smiled back. “How do you feel?”

Of course, she could see clearly how he felt. Benson was nervous and threatened: there was sweat on his upper lip, his shoulders were drawn in, his hands clenched together in his lap.

“I feel fine,” he said. “Just fine.”

Behind Benson was Morris, pushing the wheelchair, and a cop. She said to Morris, “Does he come in with us?”

Before Morris could answer, Benson said lightly, “He goes anywhere I go.”

The cop nodded and looked embarrassed.

“All right,” she said.

She opened the doors, and Morris wheeled Benson into the amphitheater, over to Ellis. Ellis came forward to shake Benson’s hand.

“Mr. Benson, good to see you.”

“Dr. Ellis.”

Morris turned the wheelchair around so Benson was facing the amphitheater audience. Ross sat to one side and glanced at the cop, who remained by the door trying to look inconspicuous. Ellis stood alongside Benson, who was looking at a wall of frosted glass, against which a dozen X-rays had been clipped. He seemed to realize that they were his own skull films. Ellis noticed, and turned off the light behind the frosted glass. The X-rays became opaquely black.

“We’ve asked you to come here,” Ellis said, “to answer some questions for these doctors.” He gestured
to the men sitting in the semicircular tiers. “They don’t make you nervous, do they?”

Ellis asked it easily. Ross frowned. She’d attended hundreds of grand rounds in her life, and the patients were invariably asked if the doctors peering down at them made them nervous. In answer to a direct question, the patients always denied nervousness.

“Sure they make me nervous,” Benson said. “They’d make anybody nervous.”

Ross suppressed a smile. Good for you, she thought.

Then Benson said, “What if you were a machine and I brought you in front of a bunch of computer experts who were trying to decide what was wrong with you and how to fix it? How would you feel?”

Ellis was flustered. He ran his hands through his thinning hair and glanced at Ross, and she shook her head fractionally
no.
This was the wrong place to explore Benson’s psychopathology.

“I’d be nervous, too,” Ellis said.

“Well, then,” Benson said. “You see?”

Ellis swallowed.

He’s being deliberately irritating, Ross thought. Don’t take the bait.

“But, of course,” Ellis said, “I’m not a machine, am I?”

Ross winced.

“That depends,” Benson said. “Certain of your functions are repetitive and mechanical. From that standpoint, they are easily programmed and relatively straightforward, if you—”

“I think,” Ross said, standing up, “that we might take questions from those present now.”

Ellis clearly didn’t like the interruption, but he was
silent, and Benson mercifully was quiet. She looked up at the audience, and after a moment a man in the back raised his hand and said, “Mr. Benson, can you tell us more about the smells you have before your blackouts?”

“Not really,” Benson said. “They’re strange, is all. They smell terrible, but they don’t smell
like
anything, if you get what I mean. I mean, you can’t identify the odor. Memory tapes cycle through blankly.”

“Can you give us an approximation of the odor?”

Benson shrugged. “Maybe … pig shit in turpentine.”

Another hand in the audience went up. “Mr. Benson, these blackouts have been getting more frequent. Have they also been getting longer?”

“Yes,” Benson said. “They’re several hours now.”

“How do you feel when you recover from a blackout?”

“Sick to my stomach.”

“Can you be more specific?”

“Sometimes I vomit. Is that specific enough?”

Ross frowned. She could see that Benson was becoming angry. “Are there other questions?” she asked, hoping there would not be. She looked up at the audience. There was a long silence.

“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 in ADL is that a portion of the brain is damaged, 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 acute disinhibitory lesion syndrome—strange thoughts and sometimes 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 may be incorrect to think of episodes of disinhibition in ADL as seizures in the usual sense. They may simply be intermittent periods of brain malfunction that result from organic damage. Nevertheless these episodes tend to have a characteristic pattern in the way they occur, and so for convenience we speak of them as seizures. We know it is possible to abort a seizure by delivering an electrical shock to the critical portion of the brain substance. There are a few seconds—sometimes as much as half a minute—before the
disinhibition takes full 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? In the case of ADL patients, 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 closed loop without any externalized portions.”

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

“Any comments? Mr. Benson? Anything you want to say, or add?”

Ross groaned inwardly. She knew Ellis was only trying to be considerate to his patient, but it was wrong to ask any patient to comment before such frightening surgery, as if the patient himself were not about to undergo it. It was too much to ask.

“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 did that go?”

“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. “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 life span. 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.”

“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 ADL sufferers 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 say so,” 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. 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?”