Brain

Chapter 3

Dr. Martin Philips leaned his head against the wall of the control room; the coolness of the plaster felt good. In front of him four third-year medical students were pressed against the glass partition, watching in total awe as a patient was being prepared for a CAT scan. It was the first day of their radiology elective; they were starting with neuroradiology. Philips had brought them to see the CAT scanner first because he knew it would impress and humble them. Sometimes medical students tended to be smartalecky.

Within the scanner room the technician was bending over, checking the position of the patient's head in respect to the gigantic doughnut-shaped scanner. He straightened up, peeled off a length of adhesive tape, and bound the patient's head to a Styrofoam block.

Reaching over to the counter, Philips took the requisition form and the patient's chart. He scanned both for clinical information.

"The patient's name is Schiller," said Philips. The students were so absorbed in the preparations that they did not turn to face him while he spoke. "Chief complaint is weakness of the right arm and right leg. He's forty-seven." Philips looked at the patient. Experience told him that the man was probably tremendously frightened.

Philips replaced the requisition form and chart while inside the scanner room the technician activated the table. Slowly the patient's head slid into the orifice of the scanner as if he were to be devoured. With a final glance at the position of the head, the technician turned and retreated to the control room.

"Okay, step back from the window for a moment," said Philips. The four medical students obeyed instantly, moving to the side of the computer, whose lights were blinking in anticipation. As he had surmised, they were impressed to the point of submission.

The technician secured the communicating door and took the mike from its hook. "Stay very still, Mr. Schiller. Very still." With his index ringer the technician depressed the start button on the control panel. Within the scanning room the huge doughnut-shaped mass surrounding Mr. Schiller's head began abrupt, intermittent rotational movements like the action of the main gear of a gigantic mechanical clock. The clunking sound, loud to Mr. Schiller, was muffled for those on the other side of the glass.

"What's happening now," said Martin, "is that the machine is making two hundred and forty separate X-ray readings for each single degree of rotational movement."

One of the medical students made a face of total incomprehension to his colleague. Martin ignored the gesture and placed his face in his hands with his fingers over his eyes, rubbing carefully and then massaging his temples. He hadn't had his coffee yet and felt groggy. Normally he'd stop in the hospital cafeteria, but this morning he hadn't had time because of the medical students. Philips, as Assistant Chief of Neuroradiology, always made it a point to handle the medical students' introduction to neuroradiology. His compulsiveness in this regard had become a pain in the ass because it cut into his research time. The first twenty to thirty times he had enjoyed impressing the students with his exhaustive knowledge of the anatomy of the brain. But the novelty had worn off. Now it was enjoyable only if a particularly smart student came along, and in neuroradiology that didn't happen very often.

After a few minutes the doughnut-shaped scanner halted its rotational movement, and the computer console came alive. It was an impressive setup like a control panel in a science-fiction movie. All eyes switched from the patient to the blinking lights, except for Philips, who glanced down at his hands and tried to dislodge a small tab of dead skin alongside the nail of his index finger. His mind was wandering.

"In the next thirty seconds the computer simultaneously solves forty-three-thousand-two-hundred equations of tissue-density measurements," said the technician, eager to take over Philips' role. Philips encouraged this. In fact he merely gave the students their formal lectures, allowing the practical teaching to be done by the neuroradiology fellows, or the superbly trained technicians.

Lifting his head, Philips watched the medical students, who were transfixed in front of the computer console. Turning his gaze to the leaded window, Philips could just see Mr. Schiller's bare feet. Momentarily the patient was a forgotten participant in the unfolding drama. For the students the machine was infinitely more interesting.

There was a small mirror over a first-aid cabinet, and Philips looked at himself. He hadn't shaved yet and the day-old stubble stood out like bristles on a brush. He always arrived a good hour before anyone else in the entire department, and he'd developed the habit of shaving in the surgical locker room. His routine was to get up, jog, shower and shave in the hospital and stop for coffee in the cafeteria. This usually gave him two hours to work on his research interests without interruption.

Still looking in the mirror, Philips ran a hand through his thick sandy hair, pushing it back. There was such a difference between the lightness of the ends and the darker blond of the roots that some of the nurses kidded Philips about highlighting it. Nothing could have been further from the truth. Philips rarely thought about his looks, occasionally butchering his hair himself when he didn't have time to go to the hospital barber. But despite his inattention, Martin was a handsome man. He was forty-one and the recent lines that had formed about his eyes and mouth only enhanced his appearance, which earlier had seemed a bit boyish. Now he looked harder, and a recent patient had remarked that he seemed more like a cowboy on TV than adoctor. The comment had pleased him and it wasn't altogether without basis. Philips was just under six feet tall with a slight but athletic build, and his face did not give the impression of an academician. It was angular, with a ruler-straight nose and expressive mouth. His eyes were a lively light blue, and they, more than anything else, reflected his basic intelligence. He'd graduated summa cum laude from Harvard, class of 1961.

The cathode-ray tube on the output console came to life as the first image appeared. The technician hastily adjusted the window width and the density to give the best image. The medical students crowded around the small TV-like screen as if they were about to see the Super Bowl, but the picture they saw was oval with a white border and a granular interior. It was a computer-constructed image of the inside of the patient's head, positioned as if someone was looking down on Mr. Schiller after the top of his skull had been removed.

Martin glanced at his watch. It was a quarter to eight. He was counting on Dr. Denise Sanger to arrive at any moment and take over shepherding the medical students. What really was on Philips' mind this morning was a meeting with his research collaborator, William Michaels. Michaels had called the day before, saying that he was coming over early in the morning with a little surprise for Philips. By now Martin's curiosity had been honed to a razor's edge, and the suspense was killing him. For four years the two men had been working on a program to enable a computer to read skull X rays, replacing the radiologist.

The problem was in programming the machine to make qualitative judgments about the densities of specific areas of X rays. If they could succeed, the rewards would be incredible. Since the problems of interpreting skull X rays were essentially the same as interpreting other X rays, the program would be eventually adaptable to the entire field of radiology. And if they accomplished that…Philips occasionally let himself dream of having his own research department, and even the Nobel Prize.

The next image appeared on the screen bringing Philips' mind back to the present.

"This slice is thirteen millimeters higher than the previous image," intoned the technician. With his finger, he pointed to the bottom section of the oval. "Here we have the cerebellum and…"

"There's an abnormality," said Philips.

"Where?" asked the technician, who was seated on a small stool in front of the computer.

"Here," said Philips, squeezing in so that he could point. His finger touched the area the technician had just described as the cerebellum. "This lucency here in the right cerebellar hemisphere is abnormal. It should have the same density as the other side."

"What is it?" asked one of the students.

"Hard to say at this point," said Philips. He leaned over to look at the questionable area more closely. "I wonder if the patient has any gait problem?"

"Yes, he does," said the technician. "He's been ataxic for a week."

"Probably a tumor," said Philips, standing back up.

The faces of all four medical students immediately reflected dismay as they stared at the innocent lucency on the screen. On the one hand they were thrilled to see a positive demonstration of the power of modern diagnostic technology. On the other hand, they were frightened by the concept of a brain tumor; the idea that anybody could have one; even they.

The next image began to wipe off the previous one.

"Here's another area of lucency in the temporal lobe," said Philips, quickly pointing to an area already being replaced by the next image. "We'll see it better on the next slice. But we are going to need a contrast study."

The technician got up and went in to inject contrast material into Mr. Schiller's vein.

"What does the contrast material do?" asked Nancy Mc-Fadden.

"It helps outline lesions like tumors when the blood brain barrier is broken down," said Philips, who had turned to see who was coming into the room. He'd heard the door to the corridor open.

"Does it contain iodine?"

Philips hadn't heard the last question because Denise Sanger had come in and was smiling warmly at Martin behind the backs of the engrossed medical students.

She slipped out of her short white coat and reached up to hang it next to the first-aid cabinet. It was her way of getting down to work. Its effect on Philips was the opposite. Sanger had on a pink blouse, pleated in the front and topped with a thin blue ribbon tied in a bow. As she extended her arm to hang her coat, her breasts thrust against her blouse, and Philips appreciated the image as a connoisseur appreciated a work of art, for Martin thought Denise was one of the most beautiful women he had ever seen. She said she was five-five, whereas actually she was five-four. Her figure was slight, one hundred and eight pounds, with breasts that were not large but wonderfully shaped and firm. She had thick shiny brown hair, which she usually wore pulled back from her forehead and clasped with a single barrette on the back of her head. Her eyes were lighter brown with flecks of gray, giving her a lively mischievous appearance. Very few people guessed that she had been first in her medical school graduating class three years previously, nor did many believe that she was twenty-eight years old.

With her coat taken care of, Denise brushed past Philips, giving his left elbow a furtive squeeze. It was so fast that Philips couldn't respond. She sat down at the screen, adjusted the viewing controls to her liking, and introduced herself to the students. The technician returned and announced that the contrast material had been given. He prepared the scanner for another run.

Philips leaned over so that he had to support himself on Denise's shoulder. He pointed to the image on the screen. "Here's a lesion in the temporal lobe, and at least one, maybe two, in the frontal." He turned to the medical students. "I noted in the chart that the patient is a heavy smoker. What does all this suggest to you?"

The students stared at the image afraid to make any gesture. For them it was like being at an auction without money; any slight movement could have been interpreted as a bid,

"Let me give you all a hint," said Philips. "Primary brain tumors are usually solitary, whereas tumors coming from other parts of the body, what we call metastasis, can be single or multiple."

"Lung cancer," blurted one of the students as if he were on a TV game show.

"Very good," said Philips. "At this stage you can't be one hundred percent sure, but I'd be willing to put money on it."

"How long does the patient have to live?" asked the student, obviously overwhelmed by the diagnosis.

"Who's the doctor?" asked Philips.

"He's on Curt Mannerheim's neurosurgical service," said Denise.

"Then he doesn't have long to live," said Martin. "Mannerheim will operate on him."

Denise turned quickly. "A case like this is inoperable."

"You don't know Mannerheim. He operates on anything. Especially tumors." Martin again bent over Denise's shoulder, smelling the unmistakable aroma of her freshly washed hair. It was as unique to Philips as a fingerprint, and despite the professional setting, he felt a faint stirring of passion. He stood up to break the spell.

"Doctor Sanger, can I speak to you for a moment," he said suddenly, motioning her over to a corner of the room.

Denise complied willingly, with a bewildered expression.

"It's my professional opinion…" said Philips in the same to entertain the idea of leaving the Med Center for another hospital where he would have a shot at the top.

Martin turned down the corridor leading to surgery. He passed through the double swinging doors, whose sign warned visitors that they were entering a restricted area, and went through another set of swinging doors, to the patient-holding room. Here stood a swarm of gurneys filled with anxious patients awaiting their turn to be dissected. At the end of this large area was a long built-in white Formica desk guarding the entrance to the thirty operating rooms and to the recovery area. Three nurses in green surgical scrub dresses were busy behind the desk making sure the right patient got into the right room so he'd get the right operation. With almost two hundred operations in any twenty-four-hour period, this was a full-time job.

"Can someone tell me about Mannerheim's case?" asked Philips as he leaned over the desk.

All three nurses looked up and began to speak at once. Martin, being one of the few eligible doctors, was a welcome visitor to the OR. When the nurses realized what had happened, they laughed and then made an elaborate ceremony of deferring to one another.

"Maybe I should ask someone else," said Philips, pretending to leave.

"Oh, no," said the blond nurse.

"We can go back in the linen closet to discuss it," suggested the brunette. The OR was the one place in the hospital where inhibitions were relaxed. The atmosphere was totally different from any other service. Philips thought that perhaps it had something to do with everyone wearing the same pajama-like clothing, plus the potential for crisis, where sexual innuendos provided a relief valve. Whatever it was, Philips remembered it very well. He'd been a surgical resident for one year before deciding to go into radiology.

"Which one of Mannerheim's cases are you interested in?" asked the blond nurse. "Marino?"

"That's right," said Philips.

"She's right behind you," said the blond nurse.

Philips turned. About twenty feet away was a gurney supporting the covered figure of a twenty-one-year-old woman. She must have heard her name through the fog of her preoperative medication because her head slowly rolled in Philips' direction. Her skull was totally shaved in anticipation of her surgery, and the image reminded Philips of a small songbird without its feathers. He'd seen her briefly twice before when she was having her preoperative X rays, and Philips was shocked how different she looked now. He had not realized how small and delicate she was. Her eyes had a pleading quality like an abandoned child, and Philips had all he could do to turn away, directing his attention back to the nurses. One of the reasons he'd switched from surgery to radiology had been a realization he couldn't control his empathy for certain patients.

"Why haven't they started her?" he asked the nurse, angry the patient was being left to her fears.

"Mannerheim's been waiting for special electrodes from Gibson Memorial Hospital," said the blond nurse. "He wants to make some recordings from the part of the brain he's going to remove."

"I see…" said Philips, trying to plan his morning. Manner-heim had a way of upsetting everyone's schedules.

"Mannerheim's got two visitors from Japan," added the blond nurse, "and he's been putting on a big show all week. But they'll be starting in just a couple of minutes. They've called for the patient. We just haven't had anybody to send with her."

"Okay," said Philips, already starting back across the patient-holding area. "When Mannerheim wants his localization X rays, call my office directly. That should save a few minutes."

As he retraced his steps, Martin remembered he still had to shave and headed for the surgical lounge. At eight-ten it was almost deserted since the seven-thirty cases were all under way and the "to follow" cases could not hope to begin for some time. Only one surgeon was there talking on the telephone to his stockbroker while absentmindedly scratching himself. Philips passed into the changing area and twirled the combination to his foot-square locker, which Tony, the old man who took care of the surgical area, had allowed him to keep.

As soon as he had his face completely lathered, Philips' beeper went off making him jump. He hadn't realized how taut his nerves were. He used the wall phone to answer, trying to keep the shaving cream from the receiver. It was Helen Walker, his secretary, informing him that William Michaels had arrived and was waiting for him in his office.

Philips went back to his shaving with renewed enthusiasm. All his excitement about William's surprise came roaring back. He splashed himself with cologne and struggled back into his long white coat. Passing back through the surgical lounge, he noticed the surgeon was still on the phone with his broker.

When Martin reached his office he was at a half run. Helen Walker looked up from her typing with a start as the blurred image of her boss passed by her. She began to get up, reaching for a pile of correspondence and phone messages, but stopped when the door to Philips' office slammed shut. She shrugged and went back to her typing.

Philips leaned against the closed door, breathing heavily. Michaels was casually leafing through one of Philips' radiology journals.

"Well?" said Philips excitedly. Michaels was dressed as usual in his ill-fitting, slightly worn tweed jacket, which had been purchased during his third year at M.I.T. He was thirty but looked twenty, with hair so blond that it made Philips' look brown by comparison. He smiled, his small impish mouth expressing satisfaction, his pale blue eyes twinkling.

"What's up?" he said, pretending to go back to the magazine.

"Come on," said Philips, "I know you're just trying to rile me. The trouble is that you're being too successful."

"I don't know what…" began Michaels, but he didn't get any further. In one swift motion, Philips stepped across the room and tore the magazine from his hands.

"Let's not play dumb," said Philips. "You knew that telling Helen you had a 'surprise' would drive me crazy. I almost called you last night at four A.M. Now I wish I had. I think you deserved it."

"Oh, yeah, the surprise," teased Michaels. "I almost forgot." He leaned over and rummaged in his briefcase. A minute later he had pulled out a small package wrapped with dark green paper and tied with a thick yellow ribbon.

Martin's face fell. "What's that?" He'd expected some papers, most likely computer print-out paper, showing some breakthrough in their research. He never expected a present.

"It's your surprise," said Michaels, reaching toward Philips with the package.

Philips' eyes moved back to the gift. His disappointment was so acute it was almost anger. "Why the hell did you buy me a present?"

"Because you've been such a wonderful research partner," said Michaels, still holding the package toward Philips. "Here, take it."

Philips reached out. He had recovered from the shock enough to be embarrassed about his reaction. No matter how he felt he didn't want to hurt Michaels' feelings. After all, it was a nice gesture.

Philips thanked him while feeling the weight of the package. It was light and about four inches long and an inch high.

"Aren't you going to open it?" asked Michaels.

"Sure," said Philips, studying Michaels' face for an instant. Buying a present seemed so out of character for this boy genius from the Department of Computer Science, It wasn't that he wasn't friendly or generous. It was just that he was so completely involved with his research that he usually overlooked amenities. In fact, during the four years they'd been working together, Philips had never seen Michaels socially. Philips had decided that Michaels' incredible mind never turned off. After all, he had been singled out to head the newly created Division of Artificial Intelligence for the university at twenty-six. He'd completed his Ph.D. at M.I.T. when he was only nineteen.

"Come on," said Michaels impatiently.

Philips pulled off the bow and dropped it ceremoniously among the debris on his desk. The dark green paper followed. Beneath was a black box.

"There's a little symbolism there," said Michaels.

"Oh? "said Philips.

"Yeah," said Michaels. "You know how psychology treats the brain: like a black box. Well, you get to look inside."

Philips smiled weakly. He didn't know what Michaels was talking about. He pulled off the top of the box and separated some tissue. To his surprise he extracted a cassette case labeled Rumors by Fleetwood Mac.

"What the hell," smiled Philips. He hadn't the foggiest idea why Michaels would buy him a recording by Fleetwood Mac.

"More symbolism," explained Michaels. "What's inside is going to be more than music to your ears!"

Suddenly the whole charade made sense. Philips flipped open the case and pulled out the cassette. It wasn't a musical recording. It was a computer program.

"How far did we get?" asked Philips almost in a whisper.

"It's the whole thing," said Michaels.

"No!" said the incredulous Martin.

"You know the last material you gave me? It worked like a charm. It solved the problem of density and boundary interpretation. This program incorporates everything you've included in all your flow sheets. It will read any skull X ray you give it, provided you put it into that piece of equipment over there." Michaels pointed to the back of Philips' office. There on the top of Philips' worktable was a TV-sized electrical apparatus. It was obvious that it was built as a prototype rather than production model. The front was made of a plain stainless steel plate and its attaching bolts protruded. In the upper left-hand corner was a slot that was made to take the program cassette. Two electrical trunks protruded from its sides. One trunk fed into a typewriter input/output device. The other came from a rectangular stainless steel box about four feet square and one foot high. On the front of this metal apparatus was a long slot with visible rollers for the insertion of an X-ray film.

"I don't believe it," said Philips, afraid that Michaels was teasing him again.

"Neither do we," admitted Michaels. "Everything just suddenly fell together." He walked over and patted the top of the computer unit. "All the work you'd done in breaking down the problem-solving and pattern-recognition aspects of radiology not only made it apparent we needed new hardware but also suggested the way to design it. This is it."

"Looks simple from the outside."

"As usual, appearances are deceptive," said Michaels. "The innards of this unit are going to revolutionize the computer world."

"And think what it's going to do to the field of radiology if it can really read X rays," said Martin.

"It will read them," said Michaels, "but there could still be bugs in the program. What you have to do now is run the program against as many skull X rays as you can find that you have read in the past. If there are problems, I think they will be in the area of false negatives. Meaning the program will say the X ray is normal when pathology is really present."

"That's the same problem with radiologists," said Philips.

"Well, I think we'll be able to eliminate that in the program," said Michaels. "It's going to be up to you. Now to work this thing, first turn it on. I think even a doctor of medicine will be able to do that."

"Without doubt," said Philips, "but we'll need a Ph.D. to plug it in."

"Very good," Michaels laughed. "Your humor is improving. Once the unit is plugged in and turned on, you insert the cassette program into the central unit. The output printer will then inform you when to insert the X-ray film into the laser scanner."

"What about the orientation of the film?" asked Philips. "Doesn't matter, except the emulsion side has to be down. "Okay," said Philips, rubbing his hands together and eyeing the unit like a proud parent. "I still can't believe it."

"I can't, either," said Michaels. "Who would have guessed four years ago that we could have made this kind of progress? I can still remember the day you arrived unannounced in the Department of Computer Science, plaintively asking if anyone was interested in pattern recognition."

"It was just pure luck that I bumped into you," returned Philips. "At the time I thought you were one of the undergraduates. I didn't even know what the Division of Artificial

Intelligence was."

"Luck plays a role in every scientific breakthrough," agreed Michaels. "But after the luck, there's lots of hard work, like what's facing you. Remember the more skull films you run with the program, the better it will be, not only to debug the program, but also because the program is heuristic."

"Let's not pull any big words on me," said Philips. "What do you mean 'heuristic'?"

"So you don't like some of your own medicine," laughed Michaels. "I never thought I'd hear a doctor complain about incomprehensible words. A heuristic program is one that is capable of learning."

"You mean this thing will get smarter?"

"You got it," said Michaels, moving toward the door. "But it's up to you now. And, remember, the same format will be applicable to other areas of radiology. So in your spare time, as if you're going to have any, start the flow sheet for reading cerebral angiograms. I'll talk to you later."

Closing the door behind Michaels, Philips went over to the worktable and eyed the X-ray-reading apparatus. He was eager to begin to work with it immediately, but he knew the burden of his daily routine proscribed it. As if in confirmation, Helen walked in with a pile of correspondence, telephone messages, and the cheerful news that the X-ray machine in one of the cerebral angiography rooms wasn't functioning properly. Reluctantly Philips turned his back on the new machine.