by Jerry
I booted and scanned first thing the next morning, but Rayno and Georgie still hadn’t come on. So I went down and had an utter silent breakfast and sent Mom and Dad off to work. I offed school and spent the whole day finishing the war and working on some tricks and treats programs. We had another utter silent meal when Mom and Dad came home, and after supper I flagged. Rayno had been in the Net and left a remark on when to find him.
I finally got him on line around eight, and he said Georgie was getting trashed and probably heading for permanent downtime.
Then I told Rayno all about how I outlooped my old man, but he didn’t seem real buzzed about it. He said he had something cooking and couldn’t meet me at Buddy’s that night to talk about it, either. So we got offline, and I started another war and then went to sleep.
The snoozer said 5:25 when I woke up, and I couldn’t logic how come I was awake ’til I started making sense out of my ears. Dad was taking apart the hinges on my door!
“Dad! You cut that out or I’ll purge you clean! There won’t be backups this time!”
“Try it,” he growled.
I jumped out of my sleepsack, powered up, booted and—no boot. I tried again. I could get on line in my smartterm, but I couldn’t port out. “I cut your cable down in the basement,” he said.
I grabbed the Starfire out of my closet and zipped it inside my jumper, but before I could do the window, the door and Dad both fell in. Mom came in right behind, popped open my dresser, and started stuffing socks and underwear in a suitcase.
“Now you’re fritzed!” I told Dad. “I’ll never give you back your files!” He grabbed my arm.
“Michael, there’s something I think you should see.” He dragged me down to his den and pulled some bundles of old paper trash out of his desk. “These are receipts. This is what obsolete old relics like me use because we don’t trust computer bookkeeping. I checked with work and the bank; everything that goes on in the computer has to be verified with paper. You can’t change anything for more than 24 hours.”
“Twenty-four hours?” I laughed. “Then you’re still fritzed! I can still wipe you out any day, from any term in CityNet!”
“I know.”
Mom came into the den, carrying the suitcase and kleenexing her eyes. “Mikey, you’ve got to understand that we love you, and this is for your own good.” They dragged me down to the airport and stuffed me in a private lear with a bunch of old gestapos.
I’ve had a few weeks now to get used to the Von Schlager Military Academy. They tell me I’m a bright kid and with good behavior, there’s really no reason at all why I shouldn’t graduate in five years. I am getting tired, though, of all the older cadets telling me how soft I’ve got it now that they’ve installed indoor plumbing.
Of course, I’m free to walk out any time I want. It’s only three hundred miles to Fort McKenzie, where the road ends.
Sometimes at night, after lights out, I’ll pull out my Starfire and run my fingers over the touchpads. That’s all I can do, since they turn off power in the barracks at night. I’ll lie there in the dark, thinking about Lisa, and Georgie, and Buddy’s All-Night Burgers, and all the fun we used to pull off. But mostly I’ll think about Rayno, and what great plans he cooks up.
I can’t wait to see how he gets me out of this one.
1984
TISSUE ABLATION AND VARIANT REGENERATION: A Case Report
Michael Blumlein
At seven a.m. on Thursday Mr Reagan was wheeled through the swinging doors and down the corridor to operating room six. He was lying flat on the gurney, and his gaze was fixed on the ceiling; he had the glassy stare of a man in shock. I was concerned that he had been given analgesia, but the attendant assured me that he had not. As we were talking, Mr Reagan turned his eyes to me: the pupils were wide, dark as olives, and I recognized the dilation of pain and fear. I felt sympathy, but more, I was relieved that he had not inadvertently been narcotized, for it would have delayed the operation for days.
I had yet to scrub and placed my hand on his shoulder to acknowledge his courage. His skin was coarse beneath the thin sheet that covered him, as the pili erecti tried in vain to warm the chill we had induced. He shivered, which was natural, though eventually it would stop—it must—if we were to proceed with the surgery. I removed my hand and bent to examine the plastic bag that hung like a showy organ from the side of the gurney. There was nearly a litre of pale urine, which assured me that his kidneys were functioning well.
I turned away, and entering the scrub room, once more conceptualized our plan. There were three teams, one for each pair of extremities and a third for torso and viscera. I headed the latter, which was proper, as the major responsibility for this project was mine. We had chosen to avoid analgesia, the analeptic properties of excruciating pain being well known. There are several well-drawn studies that conclusively demonstrate the superior survival of tissues thus exposed, and I have cited these in a number of my own monographs. In addition, chlorinated hydrocarbons, which still form the bulk of our anesthetics, are tissue-toxic in extremely small quantities. Though these agents clear rapidly in the normal course of post-operative recovery, tissue propagation is too sensitive a phenomenon for us to have risked their use. The patient was offered, routinely, the choice of an eastern mode of anesthesia, but he demurred. Mr Reagan has an obdurate faith in things American.
I set the timer above the sink and commenced to scrub. Through the window I watched as the staff went about the final preparations. Two large tables stood along one wall, and on top of them sat the numerous trays of instruments we would use during the operation. Since this was the largest one of its kind any of us at the center had participated in, I had been generous in my estimation of what would be needed. It is always best in such situations to err on the side of caution, and so I had ordered duplicates of each pack to be prepared and placed accessibly. Already an enormous quantity of instruments lay unpacked on the tables, divided into general areas of proximity. Thus, urologic was placed beside rectal and lower intestinal, and hepatic, splenic, and gastric were grouped together. Thoracic was separate, and orthopedic and vascular were divided into two groups for those teams assigned to the extremities. There were three sets of general instruments—hemostats, forceps, scissors, and the like—and these were on smaller trays that stood close to the operating table. Perched above them, and sorting the instruments chronologically, were the scrub nurses, hooded, masked, and gloved. Behind, and throughout the operating room circulated other, non-sterile personnel; these were principally nurses and technicians, who carefully avoided the sterile field being constructed about the perimeter of the operating table but otherwise roamed freely, thus functioning as the extended arm of the team.
For the dozenth time I scrubbed my cuticles and the space between fingernail and fingertip, then scoured both sides of my forearms to the elbow. The sheet had been removed from Mr Reagan, and his ventral surface—from neck to foot—was covered by the yellow suds of antiseptic. His pubic parts, chest, and axilla, had been shaved earlier, although he had no great plethora of hair to begin with. The artificial light striking his body at that moment recalled to me the jaundiced hue I have seen at times on certain dysfunctional gall bladders, and I looked at my own hands. They seemed brighter, and I rinsed them several times, then backed into the surgical suite.
A nurse approached with a towel, whose comer I grabbed, proceeding to dry methodically each finger. She returned with a glove, spreading the entrance wide as one might the mouth of a fish in order to peer down its throat. I thrust my fingers and thumb into it and she snapped it upon my forearm. She repeated the exchange with the other, and I thanked her, then stood back and waited for the final preparations.
The soap had been removed from his skin, and now Mr Reagan was being draped with various-sized linens. Two of these were used to fashion a vertical barrier at the mid-point of his neck; behind this, with his head, sat the two anesthesiologists. Since no anesthetic was to be used, their res
ponsibility lay in monitoring his respiratory and cardio-vascular status. He would be intubated, and they would make periodic measurements of the carbon dioxide and oxygen content of his blood.
I gave them a nod and they inserted the intracath, through which we would drip a standard, paralytic dose of succinylcholine. We had briefly considered doing without the drug, for its effect, albeit minimal, would still be noticeable on the ablated tissues. Finally, though, we had chosen to use it, reasoning—and experience proved us correct—that we could not rely on the paralysis of pain to immobilize the patient for the duration of the surgery. If there had been a lull, during which time he had chosen to move, hours of careful work might have been destroyed. Prudence dictated a conservative approach.
After initiating the paralytic, Dr Guevara, the senior anesthesiologist, promptly inserted the endotracheal tube. It passed easily for there was little, if any, muscular resistance. The respirator was turned on and artificial ventilation begun. I told Mr Reagan, who would be conscious throughout, that we were about to begin.
I stepped to the table and surveyed the body. The chest was exposed, as were the two legs, above which Drs Ng and Cochise were poised to begin.
“Scalpel,” I said, and the tool was slapped into my palm. I transferred it to my other hand. “Forceps.”
I bent over the body, mentally drawing a line from the sternal notch to the symphysis pubis. We had studied our approaches for hours, for the incisions were unique and had been used but rarely before. A procedure of this scale required precision in every detail in order that we preserve the maximal amount of viable tissue. I lifted the scalpel and with a firm and steady hand made the first cut.
He had been cooled in part to cause constriction of the small dermal vessels, thus reducing the quantity of blood lost to ooze. We were not, of course, able to use the electric scalpel to cut or coagulate, nor could we tie bleeding vessels, for both would inflict damage to tissue. Within reason, we had chosen planes of incision that avoided major dermal vasculature, and as I re-traced my first cut, pressing harder to separate the more stubborn fascial layers, I was re-assured by paucity of blood that was appearing at the margins of the wound. I exchanged my delicate tissue forceps for a larger pair, everting the stratum of skin, fat, and muscle, and continuing my incision until I reached the costochondral junction in the chest and the linea alba in the belly. I made two lateral incisions, one from the pubis, along the inguinal ligament, ending near the anterior superior iliac spine, and the other from the sternal notch, along the inferior border of the clavicle to the anterior edge of the axilla. There was more blood appearing now, and for a moment I aided Dr Biko in packing the wound. Much of our success at controlling the bleeding depended, however, upon the speed at which I carried out the next stage, and with this in mind, I left him to mop the red fluid and turned to the thorax.
Pectus hypertrophicus occurs perhaps in one in a thousand; Billings, in a recent study of a dozen such cases, links the condition to a congenital aberration of the short arm of chromosome thirteen, and he postulates a correlation between the hypertrophied sternum, a marked preponderance of glabrous skin, and a mild associative cortical defect. He has studied these cases; I have not. Indeed, Mr Reagan’s sternum was only the second in all my experience that would not yield to the Lebsche knife. I asked for the bone snips, and with the help of Dr Biko was finally able to split the structure. My forehead dripped from the effort, and a circulating nurse dabbed it with a towel.
I applied the wide-armed retractor, and as I ratcheted it apart, I felt a wince of resistance. I asked Dr Guevara to increase the infusion of muscle relaxant, for we were entering a most crucial part of the operation.
“His pupils are fixed and dilated,” he announced.
I could see his heart, and it was beating normally. “His gases?” I asked.
“O285, CO2, pH 7.37.”
“Good,” I said. “It’s just agony then. Not death.”
Dr Geuvara nodded above the barrier that separated us, and as he bent to whisper words of encouragement to Mr Reagan, I looked into the chest. There I paused, as I always seem to do at the sight of that glistening organ. It throbbed and rolled, sensuously, I thought, majestically, and I renewed my vows to treat it kindly. With the tissue forceps I lifted the pericardium and with the curved scissors punctured it. It peeled off smoothly, reminding me fleetingly of the delicate skin that encloses the tip of the male child’s penis.
In rapid succession I ligated vena cava and cross-clamped the descending aorta, just distal to the bronchial arteries. We had decided not to use our bypass system, thus obviating cannulations that would have required lengthy and meticulous suturing. We had opted instead for a complete de-vascularization distal to the thoracic cavity, reasoning that since all the organs and other structures were to be removed anyway, there was no sense in preserving circulation below the heart. I signalled to my colleagues waiting at the lower extremities to begin their dissections.
I isolated the right subclavian artery and vein, ligated them, and did the same on the left. I anastomosed the internal thoracic artery to the ventral surface of the aortic arch, thus providing arterial flow to the chest wall, which we planned to preserve more or less intact.
I returned to the descending aorta, choosing 3-0 Ethilon to assure occlusion of the lumen, and oversewed twice. I released the clamp slowly: there was no leakage, and I breathed a sigh of satisfaction. We had completed a crucial stage, isolating the thoracic and cephalic circulation from that of the rest of the body, and the patient’s condition remained stable. What was left was the harvesting of his parts.
I would like to insert here a word on our behalf, our in the larger sense of not just the surgical team but the full technical and administrative apparatus. We had early on agreed that we must approach the dissection assiduously, meaning that in every case we would apply a greater, rather than a lesser, degree of scrupulousness. At the time of the operation no use—other than in transplantation—had been found for many of the organs we were to resect. Such parts as colon, spleen, and vasculature had not then, nor have they yet, struck utilitarian chords in our imaginations. Surely, they will in the future, and with this as our philosophy we determined to discard not even the most seemingly insignificant part. What could not immediately be utilized would be preserved in our banks, waiting for a bright idea to send it to the regeneration tanks.
It was for this reason, and this reason alone, that the operation lasted as long as it did. I would be lying if I claimed that Mr Reagan was not in constant and excruciating pain. Who would not be to have his skin fileted, his chest cracked, his limbs meticulously dissected and dismembered? In retrospect, I should have carried out a high transection of the spinal cord, thus interrupting most of the nerve fibers to his brain, but I did not think of it beforehand and during the operation was too occupied with other concerns. That he did survive is a testimony to his strength, though I still remember his post-operative shrieks and protestations. We had, of course, already detached his upper limbs, and therefore we ourselves had to dab the streams of tears that flowed from his eyes. At that point, there being no further danger of tissue damage, I did order an analgesic.
After I had successfully completed the de-vascularization procedure, thus removing the risk of life-threatening hemorrhage from our fields, I returned to the outer layer of thorax and abdomen. With an Adson forceps I gently retracted the thin sheet of dermis and began to undermine with the scalpel. It was painstaking, but after much time I finally had the entire area freed. It hung limp, drooping like a dewlap, and as I began the final axillary cut that would release it completely, I asked Ms Narciso, my scrub nurse, to call the technician. He came just as I finished, and I handed him the skin.
I confess that I have less than a full understanding of the technology of organ variation and regeneration. I am a surgeon, not a technologist, and devote the major part of my energies toward refinement and perfection of operative skills. We do, however, live in an age o
f great scientific achievement, and the icono-clasm of many of my younger colleagues has forced me to cast my gaze more broadly afield. Thus it is that I am not a complete stranger to inductive mitotics and controlled oncogenesis, and I will attempt to convey the fundamentals.
Upon receiving the tissue, the technician tranports it to the appropriate room wherein lie the thermos-magnetic protein baths. These are organ specific, distinguished by temperature, pH, magnetic field, and substrate, and designed to suppress cellular activity; specifically, they prolong dormancy at the GI stage of mitosis. The magnetic field is altered then, such that each cell will arrange itself ninety degrees to it. A concentrated solution of isotonic nucleic and amino acids is then pumped into the tank, and the bath mechanically agitated to diffuse the solute. Several hours are allowed to pass, and the magnetic field is again shifted, attempting to align it with the nucleic loci that govern the latter stages of mitosis. If this is successful, and success is immediately apparent for failure induces rapid and massive necrosis, the organ system will begin to reproduce. This is a macroscopic phenomenon, obvious to the naked eye. I have been present at this critical moment, and it is a simple, yet wondrous, thing to behold.
Different organs regenerate, multiply, in distinctive fashion. In the case of the skin, genesis occurs quite like the polymerization of synthetic fibers, such as nylon and its congeners. The testes grow in a more sequential manner, analogous perhaps to the clustering of grapes along the vine. Muscles seem to laminate, forming thicker and thicker sheets until, if not separated, they collapse upon themselves. Bone propagates as tubules; ligaments, as lianoid strands of great length. All distinct, yet all variations on a theme.