Hammond looked at me and said, "John, are you out of your mind?"
"No," I said.
We entered Angela"s room. She was turned away from us, rolled over on her side. I took the ampoule of nalorphine from Hammond and set it with the syringe on the table just alongside her bed; I wanted to be sure she read the label.
Then I walked around to the other side of the bed, so her back was to me.
I reached across her and picked up the ampoule and syringe. Then I quickly filled the syringe with water from the cup.
"Would you turn around, Angela, please?"She rolled onto her back and held out her arm. Hammond was too astonished to move; I put the tourniquet on her arm and rubbed the veins in the crook of her elbow until they stood out. Then I slipped the needle in and squeezed out the contents. She watched me in silence.When it was done, I stood back and said, "There now."She looked at me, then at Hammond, then back to me."It won"t be long," I said."How much did you give me?""Enough.""Was it ten? Did you give me ten?"She was becoming agitated. I patted her arm rea.s.suringly. "There"s nothing to worry about.""Was it twenty?""Well, no," I said. "It was only two. Two milligrams.""Two!""It won"t kill you," I said mildly.She groaned and rolled away from us."Disappointed?" I said."What are you trying to prove?" she said."You know the answer to that, Angela.""But two milligrams. That"s-""Just enough to give you symptoms. Just the coldsweats and the cramps and the pain. Just the beginnings of withdrawal.""Jesus.""It won"t kill you," I said again. "And you know it.""You b.a.s.t.a.r.ds. I didn"t ask to come here, I didn"t ask to be-""But you are here, Angela. And you have nalorphine in your veins. Not much, but enough."She began to break out into a sweat. "Stop it," she said."We can use morphine.""Stop it. Please. I don"t want it.""Tell us," I said. "About Karen.""First stop it." No.Hammond was bothered by all this. He started forward toward the bed. I pushed him back."Tell us, Angela.""I don"t know anything."
"Then we"ll wait until the symptoms start. And you"ll have to tell us while you scream from the pain."
Her pillow was soaked with sweat. "I don"t know, I don"t know.""Tell us.""I don"t know anything."
She began to shiver, slightly at first, and then more uncontrollably, until her whole body shook.
"It"s starting, Angela."She gritted her teeth. "I don"t care.""It will get worse, Angela."
"No ... no ... no. . . ."I produced an ampoule of morphine and set it on the table in front of her."Tell us."
Her shivering got worse, until her whole body was wracked with spasms. The bed shook violently. I would have felt pity if I had not known that she was causing the reaction herself, that I had not injected any nalorphine at all.
"Angela.""All right," she said, gasping. "I did it. I had to.""Why?""Because of the heat. The heat. The clinic and the heat.""You"d been stealing from the surgery?""Yes . . . not much, just a little . . . but enough . . .""How long?""Three years . . . maybe four ...""And what happened?""Roman robbed the clinic . . . Roman Jones.""When?""Last week.""And?""The heat was on. They were checking everybody . . .""So you had to stop stealing?""Yes . . .""What did you do?""I tried to buy from Roman.""And?""He wanted money. A lot.""Who suggested the abortion?""Roman.""To get money?""Yes.""How much did he want?"I already knew the answer. She said, "Three hundred dollars.""So you did the abortion?""Yes . . . yes . . . yes. . . .""And who acted as anesthetist?""Roman. It was easy. Thiopental.""And Karen died?""She was all right when she left. . . . We did it on my bed . . . the whole thing. ... It was all right, everything ... on my bed. . . .""But later she died.""Yes . . . Oh G.o.d, give me some stuff. . . .""We will," I said.
I filled a syringe with more water, squeezed out the air until a fine stream shot into the air, and injected it intravenously. Immediately she calmed. Her breathing became slower, more relaxed.
"Angela," I said, "did you perform the abortion?""Yes.""And it resulted in Karen"s death?"A dull voice. "Yes.""All right." I patted her arm. "Just relax now."
WE WALKED DOWN THE CORRIDOR. Tom Harding was waiting there with his wife, smoking a cigarette and pacing up and down.
"Is she all right, Doctor? Did the tests-""Fine," I said. "She"ll recover beautifully.""That"s a relief," he said, his shoulders sagging."Yes," I said.Norton Hammond gave me a quick glance, and I avoided his eyes. I felt like h.e.l.l; my headache was much worse and I was beginning to have moments when my vision blurred. It seemed much worse in my right eye than my left.But someone had to tell them. I said, "Mr. Harding, I am afraid your daughter has been implicated in business that involves the police."He looked at me, stunned, disbelieving. Then I saw his face melt into a peculiar acceptance. Almost as if he had known it all along. "Drugs," he said, in a low voice."Yes," I said and felt worse than ever."We didn"t know," he said quickly. "I mean, if we had . . .""But we suspected," Mrs. Harding said. "We never could control Angela. She was a headstrong girl, very independent. Very self-reliant and sure of herself. Even as a child, she was sure of herself."HAMMOND wiped the sweat from his face with his sleeve. "Well," he said, "that"s that.""Yes."Even though he was close to me, he seemed far away. His voice was suddenly faint and insignificant. Everything around me was insignificant. The people seemed small and faded. My headache now came in bursts of severe pain. Once, I had to stop for a moment and rest. away. His voice was suddenly faint and insignificant. Everything around me was insignificant. The people seemed small and faded. My headache now came in bursts of severe pain. Once, I had to stop for a moment and rest."What"s the matter?""Nothing. Just tired."He nodded. "Well," he said, "it"s all over. You should be pleased.""Are you?"We went into the doctors" conference room, a small cubbyhole with two chairs and a table. There were charts on the walls, detailing procedure for acute emergencies: hemorrhagic shock, pulmonary edema, MI, burns, crush injuries. We sat down and I lit a cigarette. My left hand felt weak as I flicked the lighter.Hammond stared at the charts for a while; neither of us said anything. Finally, Hammond said, "Want a drink?""Yes," I said. I was feeling sick to my stomach, disgusted, and annoyed. A drink would do me good, snap me out of it. Or else it would make me sicker.
He opened a locker and reached into the back, producing a flask. "Vodka," he said. "No smell. For acute medical emergencies." He opened it and took a swallow, then pa.s.sed it to me.
As I drank, he said, "Jesus. Tune in, turn on, drop dead. Jesus.""Something like that."I gave the flask back to him."She was a nice girl, too.""Yes."
"And that placebo effect. You got her into withdrawal on water, and you snapped her out of it with water."
"You know why," I said."Yeah," he said, "she believed you.""That"s right," I said. "She believed me."I looked up at a chart ill.u.s.trating the pathological lesion and emergency steps for diagnosis and treatment of ectopic pregnancy. I got down to the place where they talked about menstrual irregularity and cramping right-lower-quadrant pain when the words began to blur."John?"It took me a long time to answer. It seemed as if it took me a long time to hear the words. I was sleepy, slow-thinking, slow-acting."John?""Yes," I said. My voice was hollow, a voice in a tomb. It echoed."You O.K.?""Yes, fine."I kept hearing the words repeated in a kind of dream: fine, fine, fine. . . ."You look terrible.""I"m fine. . . ." Fine, fine, fine . . ."John, don"t get mad-""I"m not mad," I said and shut my eyes. The lids were hard to keep open. They stuck down, were heavy, sticking to the lower lids. "I"m happy.""Happy?""What?""Are you happy?""No," I said. He was talking nonsense. It meant nothing. His voice was squeaky and high like a baby, a chattering, childish voice. "No," I said, "I"m not mad at all.""John-""Stop calling me John.""That"s your name," Norton said. He stood up, slowly, moving in dreamy slowness, and I felt very tired as I watched him move. He reached into his pocket and produced his light and shined it into my face. I looked away; the light was bright and hurt my eyes. Especially my right eye."Look at me."The voice was loud and commanding. Drill sergeant"s voice. Snappish and irritable."f.u.c.k off," I said.Strong fingers on my head, holding me, and the light shining into my eyes."Cut it out, Norton.""John, hold still."
"Cut it out." I closed my eyes. I was tired. Very tired. I wanted to sleep for a million years. Sleep was beautiful, like the ocean washing the sand, lapping up with a slow, beautiful, hissing sound, cleaning everything.
"I"m O.K., Norton. I"m just mad.""John, hold still."John, hold still.John, hold still. still.John, hold still."Norton, for Christ"s sake-""Shut up," he said.Shut up, shut up.
He had his little rubber hammer out. He was tapping my legs. Making my legs bounce up and down. It tingled and irritated me. I wanted to sleep. I wanted to go fast, fast asleep.
"Norton, you son of a b.i.t.c.h.""Shut up. You"re as bad as any of them."
As any of them, as any of them. The words echoed in my head. As any of what? I wondered. Then the sleep, creeping up on me, fingers stretching out, plastic, rubbery fingers, closing over my eyes, holding them shut. . . .
"I"m tired.""I know you are. I can see.""I can"t. I can"t see anything."Anything.Can"t see.I tried to open my eyes. "Coffee. Need coffee.""No," he said."Give me a fetus," I said and wondered why 1 said it. It made no sense. Did it? Didn"t it? So confusing. Everything was confused. My right eye hurt. The headache was right behind my right eye. Like a little man with a hammer, pounding the back of my eyeball."A little man," I said."What?""A little man," I explained. It was obvious. He was stupid not to understand. It was perfectly obvious, a reasonable statement from a reasonable man. Norton was just playing games, pretending he didn"t understand."John," he said, "I want you to count backward from one hundred. Subtract seven from one hundred. Can you do that?"I paused. It wasn"t easy. In my mind, I saw a piece of paper, a shining white piece of paper, with pencil on it. One hundred minus seven. And a line, for the subtraction."Ninety-three.""Good. Continue."That was harder. It needed a new piece of paper.I had to tear the old one off the pad before I couldbegin with a new piece. And when I had torn the old one off, I had forgotten what was on it. Complicated. Confusing."Go on, John. Ninety-three.""Ninety-three minus seven." I paused. "Eighty-five. No. Eighty-six.""Go on.""Seventy-nine.""Yes.""Seventy-three. No. Seventy-four. No, no. Wait a minute."
I was tearing off pieces of paper. So hard. And so very confusing. It was so much work work to concentrate. to concentrate.
"Eighty-seven.""No.""Eighty-five.""John, what day is this?" Day?
What a silly question. Norton was full of silly questions today. What day is this?
"Today," I said."What is the date?""The date?""Yes, the date.""May," I said. It was the date of May."John, where are you?""I am in the hospital," I said, looking down at my whites. I opened my eyes a fraction, because they were heavy and I was groggy and the light hurt my eyes. I wished he would keep quiet and let me sleep. I wanted to sleep. I needed the sleep. I was very, very tired."What hospital?""The hospital.""What hospital?""The-" I started to say something, but couldn"t remember what I intended to say. My headache was fierce now, pounding on the right eye, on the front of my head on the right side, a terrible pounding headache."Raise your left hand, John.""What?""Raise your left hand, John."I heard him, heard the words, but they were foolish. No one would pay attention to those words. No one would bother."What?"The next thing I felt was a vibration, on the right side of my head. A funny rumbling vibration. I opened my eyes and saw a girl. She was pretty, but she was doing strange things to me. Brown fluffy things were falling off my head. Drifting down. Norton was watching and calling for something, but I did not understand the words. I was nearly asleep, it was all very strange. After the fluff came a lather.
And the razor. I looked at it, and the lather, and I was suddenly sick, no warning, no nothing, but vomit all over and Norton was saying, "Hurry it up, let"s go."
And then they brought in the drill. I could barely see it, my eyes kept closing, and I was sick again.The last thing I said was "No holes in my head."I said it very clearly and slowly and distinctly.I think.FRIDAY, SAt.u.r.dAY & SUNDAYOCTOBER 14, 15 & 16ONE IT FELT LIKE SOMEBODY had tried to cut off my head and hadn"t done a very good job. When I woke up I buzzed for the nurse and demanded more morphine. She said I couldn"t have it in a smiling, difficult-patient way and I suggested she go to h.e.l.l. She didn"t much like that but I didn"t much like her. I reached up and felt the bandages on the side of my skull and made a few comments. She didn"t like those any better so she left. Pretty soon Norton Hammond came in.
"You"re a h.e.l.l of a barber," I said, touching my head."I thought we did pretty well.""How many holes?""Three. Right parietal. We took out quite a bit of blood. You remember any of that?""No," I said."You were sleepy, vomiting, and one pupil was di-388lated. We didn"t wait for the X rays; we put the bun-holes right in.""Oh," I said. " When do I get out of here?""Three or four days, at most.""Are you kidding? Three or four days?""An epidural," he said, "is a rugged thing. We want to be sure you rest.""Do I have any choice?""They always say," he said, "that doctors make the worst patients.""More morphine," I said."No," he said."Darvon.""No.""Aspirin?""All right," he said. "You can have some aspirin.""Real aspirin? Not sugar pills?""Watch it," he said, "or we"ll call a psychiatric consult.""You wouldn"t dare."He just laughed and left the room.I slept for a while, and then Judith came in to see me. She acted annoyed with me for a while, but not too long. I explained to her that it wasn"t my fault and she said I was a d.a.m.ned fool and kissed me.Then the police came, and I pretended to be asleep until they left.
In the evening, the nurse got me some newspapers and I searched for news about Art. There wasn"t any. Some lurid stories about Angela Hard- ing and Roman Jones, but nothing else. Judith came again during evening visiting hours and told me that Betty and the kids were fine and that Art would be released the next day.
I said that was great news and she just smiled.
THERE IS NO SENSE OF TIME IN A HOSPITAL. One day blends into the next; the routine-temperatures, meals, doctors" rounds, more temperatures, more meals-was everything. Sanderson came to see me, and Fritz, and some other people. And the police, only this time I couldn"t fake sleep. I told them everything I knew and they listened and made notes. Toward the end of the second day I felt better. I was stronger, my head was clearer, and I was sleeping less. blends into the next; the routine-temperatures, meals, doctors" rounds, more temperatures, more meals-was everything. Sanderson came to see me, and Fritz, and some other people. And the police, only this time I couldn"t fake sleep. I told them everything I knew and they listened and made notes. Toward the end of the second day I felt better. I was stronger, my head was clearer, and I was sleeping less.
I told Hammond and he just grunted and said to wait another day.Art Lee came to see me in the afternoon. He had the old, wry grin on his face but he looked tired. And older."Hi," I said. "How"s it feel to be out?""Good," he said.He looked at me from the foot of the bed and shook his head. "Hurt much?""Not anymore.""Sorry it happened," he said."It"s all right. It was interesting, in a way. My first epidural hematoma."I paused. There was a question I wanted to ask him. I had been thinking about a lot of things andkicking myself for my foolish mistakes. The worst had been calling that reporter into the Lees" house that night. That had been very bad. But there were other bad things. So I wanted to ask him.Instead, I said, "The police have things wrapped up now, I imagine."He nodded. "Roman Jones was supplying Angela. He made her do the abortion. When it failed-and you got curious-he went over to Angela"s house, probably to kill her. He decided he was being followed and caught you. Then he went to her place and went after her with a razor. That was what happened to your forehead.""Nice.""Angela fought him with a kitchen knife. Slashed him up a little. It must have been a pleasant scene, him with the razor and her with the knife. Finally she managed to hit him with a chair and knock him out the window.""She said that?""Yes, apparently."I nodded.We looked at each other for a while."I appreciate your help," he said, "in all this.""Any time. You sure it was help?"He smiled. "I"m a free man.""That"s not what I mean," I said.
He shrugged and sat down on the edge of the bed.
"The publicity wasn"t your fault," he said. "Be- sides, I was getting tired of this town. Ready for a change."
"Where will you go?"
"Back to California, I guess. I"d like to live in Los Angeles. Maybe I"ll deliver babies for movie stars."
"Movie stars don"t have babies. They have agents."He laughed. For a moment, it was the old laugh, the rnomentary self-pleasure that came when he had just heard something that amused him and had hit upon an amusing response. He was about to speak, then closed his mouth and stared at the floor. He stopped laughing.I said, "Have you been back to the office?""Just to close it up. I"m making arrangements for the movers.""When will you go?""Next week.""So soon?"He shrugged. "I"m not eager to stay.""No," I said, "I imagine you"re not."I SUPPOSE EVERYTHING THAT HAPPENED afterward was the result of my anger. It was already a rotten business, stinking rotten, and I should have left it alone. There was no need to continue anything. I could let it go and forget about it. Judith wanted to have a farewell party for Art; I told her no, that he wouldn"t like it, not really. was the result of my anger. It was already a rotten business, stinking rotten, and I should have left it alone. There was no need to continue anything. I could let it go and forget about it. Judith wanted to have a farewell party for Art; I told her no, that he wouldn"t like it, not really.That made me angry, too.On the third hospital day I b.i.t.c.hed to Hammond until he finally agreed to discharge me. I guess thenurses had been complaining to him as well. So they let me go at 3:10 in the afternoon, and Judith brought me clothes and drove me home. On the way, I said, "Turn right at the next corner.""Why?""I have to make a stop.""John-""Come on, Judith. A quick stop."She frowned, but turned right at the corner. I directed her across Beacon Hill, to Angela Harding"s street. A police car was parked in front of her apartment. I got out and went up to the second floor. A cop stood outside the door."Dr. Berry, Mallory Lab," I said in an official tone. "Have the blood samples been taken yet?"The cop looked confused. "Blood samples?""Yes. The sc.r.a.pings from the room. Dried samples. For twenty-six factor determinations. You know."He shook his head. He didn"t know."Dr. Lazare is worried about them," I said. "Wanted me to check."
"I don"t know anything about it," the cop said. "There were some medical guys here yesterday. Those the ones?"
"No," I said, "they were the dermatology people."
"Uh. Oh. Well, you better check for yourself." He opened the door for me. "Just don"t touch anything. They"re dusting."
I entered the apartment. It was a shambles, furniture overturned, blood spattered on couches andtables. Three men were working on a gla.s.s, dusting powder onto it and blowing it off, then photographing the fingerprints. One looked up, "Helpyou?""Yes," I said. "The chair-""Over there," he said, jerking his thumb toward the chair in the corner. "But don"t touch it."
I went over and stared at the chair. It was not very heavy, a cheap wood kitchen chair, rather nondescript. But it was st.u.r.dily made. There was some blood on one leg.
I looked back at the three men. "You dusted this one yet?""Yeah. Funny thing. There"s hundreds of prints in this room. Dozens of people. It"s going to take us years to unravel it all. But there were two things we couldn"t get prints from. That chair and the doork.n.o.b to the outside door.""How"s that?"The man shrugged. "Been wiped.""Wiped?""Yeah. Somebody cleaned up the chair and the doork.n.o.b. Anyhow, that"s the way it looks. d.a.m.ned funny. Nothing else was wiped, not even the knife she used on her wrists."I nodded. "The blood boys been here yet?""Yeah. Came and went.""O.K.," I said. "Can I make a call? I want to check back with the lab."He shrugged. "Sure."I went to the phone, picked it up, and dialed theweather bureau. When the voice came on, I said, "Give me Dr. Lazare.""-sunny and cool, with a high in the mid-fifties. Partly cloudly in late afternoon-""Fred? John Berry. I"m over at the room now.""-with fifty-percent chance of showers-"
"Yeah, they say the samples were taken. You sure you haven"t gotten them yet?"
"-tomorrow, fair and colder with a high in the forties-""Oh. I see. O.K. Good. Right. See you."-"wind from the east at fifteen miles per hour-"
I hung up and turned to the three men. "Thanks," I said.
"Sure."n.o.body paid any attention to me as I left. No-body really cared. The men who were there were doing routine duty. They"d done things like this be-fore, dozens of times. It was just routine.
POSTSCRIPT: MONDAYOCTOBER 17I WAS IN A BAD MOOD MONDAY. I sat around for most of the morning drinking coffee and smoking cigarettes and tasting a lousy sour taste in my mouth. I kept telling myself that I could drop it and n.o.body would care. It was over. I couldn"t help Art and I couldn"t undo anything. I could only make things worse.
Besides, none of this was Weston"s fault, not really. Even though I wanted to blame somebody, I couldn"t blame him. And he was an old man.
It as a waste of time. I drank coffee and told myself that, over and over. A waste of time.I did it anyway.
Shortly before noon I drove over to the Mallory and walked into Weston"s office. He was going over some microscopic slides and dictating his findings into a small desk recorder. He stopped when I came in.
"h.e.l.lo, John. What brings you over here?"I said, "How do you feel?" 396"Me?" He laughed. "I feel fine. How do you feel?" He nodded to the bandages on my head. "I heard what happened.""I"m okay," I said.I looked at his hands. They were under the table, in his lap. He had dropped them down as soon as I had come into the room.I said, "Hurt much?""What?""Your hands."He gave me a puzzled look or tried to. It didn"t work. I nodded to his hands and he brought them out. Two fingers of his left hand were bandaged."Accident?"
"Yes. Clumsy of me. I was chopping an onion at home-helping out in the kitchen-and I cut myself. Just a superficial wound, but embarra.s.sing. You"d think after all these years I"d know how to handle a knife."
"You bandaged it yourself?""Yes. It was just a small cut."I sat down in the chair opposite his desk and lit a cigarette, aware that he was watching me carefully. I blew a stream of smoke out, toward the ceiling. He kept his face calm and blank; he was making it hard for me. But that was his right, I guess. I"d probably do the same."Was there something you wanted to see me about?" he asked."Yes," I said.We stared at each other for a moment, and thenWeston pushed his microscope to one side and turned off the recorder."Was it about the path diagnosis on Karen Randall? I"d heard you were concerned.""I was," I said."Would you feel better if someone else looked them over? Sanderson?""Not now," I said. "It doesn"t really matter now. Not legally, anyway.""I suppose you"re right," he said.We stared at each other again, a long silence falling. I didn"t know how to bring it up, but the silence was killing me."The chair," I said, "was wiped. Did you know that?"
For a moment, he frowned, and I thought he was going to play dumb. But he didn"t; instead, he nodded.
"Yes," he said. "She told me she"d wipe it.""And the doork.n.o.b.""Yes. And the doork.n.o.b.""When did you show up?"
He sighed. "It was late," he said. "I had worked late at the labs and was on my way home. I stopped by Angela"s apartment to see how she was. I often did. Just stopped in. Looked in on her."
"Were you treating her addiction?""You mean, was I supplying her?""I mean, were you treating her?""No," he said. "I knew it was beyond me. I considered it, of course, but I knew that I couldn"thandle it, and I might make things worse. I urged her to go for treatment, but . . ."He shrugged."So instead, you visited her frequently.""Just to try and help her over the rough time. It was the least I could do.""And Thursday night?"
"He was already there when I arrived. I heard scuffling and shouts, so I opened the door, and found him chasing her with a razor. She had a kitchen knife-a long one, the kind you use for bread-and she was fighting back. He was trying to kill her because she was a witness. He said that, over and over. You"re a witness, baby," in a low voice. I don"t remember exactly what happened next. I had always been fond of Angela. He said something to me, some words, and started at me with the razor. He looked terrible; Angela had already cut him with the knife, or at least, his clothes . . ."
"So you picked up the chair."
"No. I backed off. He went after Angela. He was facing her, away from me. That was when ... I picked up the chair."
I pointed to his fingers. "And your cuts?""I don"t remember. I guess he did it. There was a little slash on the sleeve of my coat, too, when I got home. But I don"t remember.""After the chair-""He fell down. Unconscious. Just fell.""What did you do then?""Angela was afraid for me. She told me to leaveimmediately, that she could take care of everything. She was terrified that I would be involved. And I ...""You left," I said.He looked at his hands. "Yes.""Was Roman dead when you left?""I don"t really know. He had fallen near the window. I guess she just pushed him out and then wiped up. But I don"t know for sure. I don"t know for sure."
I looked at his face, at the lines in the skin and the white of the hair, and remembered how he had been as a teacher, how he had prodded and pushed and cajoled, how I had respected him, how he had taken the residents every Thursday afternoon to a nearby bar for drinks and talk, how he used to bring a big birthday cake in every year on his birthday and share it with everyone on the floor. It all came back, the jokes, the good times, the bad times, the questions and explanations, the long hours in the dissecting room, the points of fact and the matters of uncertainty.
"Well," he said with a sad smile, "there it is."I lit another cigarette, cupping my hands around it and ducking my head, though there was no breeze in the room. It was stifling and hot and airless, like a greenhouse for delicate plants.Weston didn"t ask the question. He didn"t have to."You might get off," I said, "with self-defense.""Yes," he said, very slowly. "I might."OUTSIDE, cold autumnal sun splashed over the bare branches of the skeletal trees along Ma.s.sachusettsAvenue. As I came down the steps of Mallory, an ambulance drove past me toward the Boston City EW. As it pa.s.sed I glimpsed a face propped up on a bed in the back, with an oxygen mask being held in place by an attendant. I could see no features to the face; I could not even tell if it was a man or a woman.Several other people on the street had paused to watch the ambulance go by. Their expressions were fixed into att.i.tudes of concern, or curiosity, or pity. But they all stopped for a moment, to look, and to think their private thoughts.You could tell they were wondering who the person was, and what the disease was, and whether the person would ever leave the hospital again. They had no way of knowing the answers to those questions, but I did.This particular ambulance had its light flashing, but the siren was off, and it moved with almost casual slowness. That meant the pa.s.senger was not very sick.Or else he was already dead. It was impossible to tell which.For a moment, I felt a strange, compelling curiosity, almost an obligation to go to the EW and find out who the patient was and what the prognosis was.
But I didn"t. Instead I walked down the street, got into my car, and drove home. I tried to forget about the ambulance, because there were millions of ambulances, and millions of people, every day, at every hospital. Eventually, 1 did forget. Then I was all right.
As unpleasant as cancer may be described as food, as in the case of oat-cell carcinoma of the lung.
APPENDIX I: Delicatessen Pathologists Delicatessen PathologistsPART OF ANY PATHOLOGIST"S JOB is to describe what he sees quickly and precisely; a good path report will allow the reader to see in his mind exactly what the pathologist saw. In order to do this, many pathologists have taken to describing diseased organs as if they were food, earning themselves the name, delicatessen pathologists.
Other pathologists are revolted by the practice; they deplore path reports that read like restaurant menus. But the device is so convenient and useful that nearly all pathologists use it, at one time or another.
Thus there are currant jelly clots and postmortem chicken-fat clots. There is ripe raspberry mucosa or strawberry gallbladder mucosa, which indicates the presence of cholesterol. There are nutmeg livers of congestive heart failure and Swiss-cheese endometria of hyperplasia. Even something APPENDIX II: Cops and Doctors Cops and DoctorsDOCTORS ARE GENERALLY MISTRUSTFUL of the policeand try to avoid police business. One reason:A brilliant resident at the General was called out of bed one night to examine a drunk brought in by the police. The police may know that certain medical disorders-such as diabetic coma-may closely imitate inebriation, even including an "alcoholic" breath. So this was routine. The man was examined, p.r.o.nounced medically sound, and carted off to jail.He died during the night. At autopsy, he was found to have a ruptured spleen. The family sued the resident for negligence, and the police were extraordinarily helpful to the family in attempting to put the blame on the doctor. At the trial, it was decided that the doctor had indeed been negligent, but no damages were awarded.
This doctor later tried to obtain certification from the Virginia State Board to practice in that state, and succeeded only with the greatest difficulty. This incident will follow him for the rest of his life.
While it is possible that he missed the enlarged or ruptured spleen in his examination, it is highly unlikely considering the nature of the injury and extremely high caliber of doctor. The conclusion of the hospital staff was that probably the man had received a good kick in the stomach by the police, after he had been examined.There is, of course, no proof either way. But enough incidents such as this have occurred that doctors mistrust police almost as a matter of general policy.APPENDIX III: Battlefields and Barberpoles Battlefields and BarberpolesTHROUGHOUT HISTORY, surgery and war have been intimately related. Even today, of all doctors, young surgeons are the ones who least object to being sent to the battlefield. For it is there that surgeons and surgery have traditionally developed, innovated, and matured.The earliest surgeons were not doctors at all; they were barbers. Their surgery was primitive, consisting largely of amputations, blood-letting, and wound-dressing. Barbers accompanied the troops during major campaigns and gradually came to learn more of their restorative art. They were hampered, however, by a lack of anesthesia; until1890, the only anesthetics available were a bullet clenched between the victim"s teeth and a shot of whiskey in his stomach. The surgeons were always looked down on by the medical doctors, men who did not deign to treat patients with their hands, but took a more lofty and intellectual approach. The att.i.tude, to some extent, persists to the present day.Now, of course, surgeons are not barbers, or vice versa. But the barbers retain the symbol of their old trade-the red-and-white-striped pole which represents the b.l.o.o.d.y white dressings of the battlefield.But if surgeons no longer give haircuts, they still accompany armies. Wars gives them vast experience in treating trauma, wounds, crush injuries, and burns. War also allows innovation; most of the techniques now common to plastic or reconstructive surgery were developed during World War II.All this does not necessarily make surgeons either prowar or antipeace. But the historical background of their craft does give them a somewhat different outlook from other doctors.APPENDIX IV: Abbreviations Abbreviations DOCTORS LOVE ABBREVIATIONS, and probably no other major profession has so many. Abbreviations serve an important time-saving function, but there seems to be an additional purpose. Abbreviations are a code, a secret and impenetrable language, the cabalistic symbols of medical society.For instance: "The PMI, corresponding to the LBCD, was located in the 5th ICS two centimeters lateral to the MCL." Nothing could be more mysterious to an outsider than that sentence.
X is the most important letter of the alphabet in medicine, because of its common use in abbreviations. Use ranges from the straightforward "Polio x3" for three polio vaccinations, to "Discharged to Ward X," a common euphemism for the morgue. But there are many others: dx is diagnosis; px, prognosis; Rx, therapy; sx, symptoms; hx, history; mx, metastases; fx, fractures.
Letter abbreviations are particularly favored in cardiology, with its endless usage of LVH, RVF, AS, MR to describe heart conditions, but other specialties have their own.On occasion, abbreviations are used to make comments which one would not want to write out in full. This is because any patient"s hospital record is a legal doc.u.ment which may be called into court; doctors must therefore be careful what they say, and a whole vocabulary and series of abbreviations have sprung up. For instance, a patient is not demented, but "disoriented" or "severely confused"; a patient does not lie, but "confabulates"; a patient is not stupid, but "obtunded." Among surgeons, a favorite expression to discharge a patient who is malingering is SHA, meaning "Ship his a.s.s out ofhere." And in pediatrics is perhaps the most unusual abbreviation of all, FLK, which means "Funny-looking kid."APPENDIX V: Whites WhitesEVERYBODY KNOWS DOCTORS WEAR WHITE UNIFORMS, and n.o.body, not even the doctors, knows why. Certainly the "whites," as they are called, are distinctive, but they serve no real purpose. They are not even traditional. and n.o.body, not even the doctors, knows why. Certainly the "whites," as they are called, are distinctive, but they serve no real purpose. They are not even traditional.In the court of Louis XIV, for example, all physicians wore black: long, black, imposing robes which were as striking and awe-inspiring in their day as shining whites are now.
Modern arguments for whites usually invoke sterility and cleanliness. Doctors wear white because it is a "clean" color. Hospitals are painted white for the same reason. This sounds quite reasonable until one sees a grubby intern who has been on duty for thirty-six consecutive hours, has slept twice in his clothes, and has ministered to dozens of patients. His whites are creased, wrinkled, dirty, and no doubt covered with bacteria.
Surgeons give it all away. The epitome of aseptic conditions, of germ-free living, is found in the operating room. Yet few OR"s are white, and the sur- geons themselves do not wear white clothing. They wear green, or blue, or sometimes gray.
So one must consider the medical "whites" as a uniform, with no more logic to the color than the designation of blue for a navy uniform or green for an army uniform. The a.n.a.logy is closer than the casual observer might expect, for the medical uniform designates rank as well as service. A doctor can walk into a ward and can tell you the rank of everyone on the ward team. He can tell you who is the resident, who the intern, who the medical student, who the male orderly. He does this by reading small cues, just as a military man reads stripes and shoulder insignias. It comes down to questions like: Is the man carrying a stethoscope? Does he have one notebook in his pocket or two? File cards held by a metal clip? Is he carrying a black bag?The process may even be extended to indicate the specialty of a doctor. Neurologists, for example, are readily identified by the three or four straight pins stuck through their left jacket lapels.APPENDIX VI: Arguments on Abortion Arguments on AbortionTHERE ARE GENERALLY CONSIDERED to be six arguments for abortion, and six counterarguments. The first argument considers the law and anthro-pology. It can be shown that many societies routinely practice abortion and infanticide without parental guilt or destruction of the moral fiber of the society. Usually examples are drawn from marginal societies, living in a harsh environment, such as the African Pygmies or Bushmen of the Kalahari. Or from societies which place a great premium on sons and kill off excess female infants. But the same argument has used the example of j.a.pan, now the sixth-largest nation in the world and one of the most highly industrialized.The reverse argument states that Western society has little in common with either Pygmies or the j.a.panese, and that what is right and acceptable for them is not necessarily so for us.Legal arguments are related to this. It can be shown that modern abortion laws did not always exist; they evolved over many centuries, in response to a variety of factors. Proponents of abortion claim that modern laws are arbitrary, foolish, and irrelevant. They argue for a legal system which accurately reflects the mores and the technology of the present, not of the past.
The reverse argument points out that old laws are not necessarily bad laws and that to change them thoughtlessly invites uncertainty and flux in an already uncertain world. A less sophisticated form of the argument opposes abortion simply because it is illegal. Until recently, many otherwise thoughtful doctors felt comfortable taking this position. Now, however, abortion is being debated in many circles, and such a simplistic view is untenable. many circles, and such a simplistic view is untenable.
The second argument concerns abortion as a form of birth control. Proponents regard abortion on demand as a highly effective form of birth control and point to its success in j.a.pan, Hungary, Czechoslovakia, and elsewhere. Proponents see no essential difference between preventing a conception and halting a process which has not yet resulted in a fully viable infant. (These same people see no difference between the rhythm method and the pill, since the intention of both practices is identical.) In essence, the argument claims that "it"s the thought that counts."Those who disagree draw a line between prevention and correction. They believe that once conception has occurred, the fetus has rights and cannot be killed. This viewpoint is held by many who favor conventional birth-control measures, and for these people, the problem of what to do if birth control fails-as it does in a certain percentage of cases- is troublesome.The third argument considers social and psychiatric factors. It has variants.The first states that the physical and mental health of the mother always takes precedence over that of the unborn child. The mother, and her already existing family, may suffer emotionally and financially by the birth of another infant, andtherefore, in such cases the birth should be prevented.The second states that it is immoral and criminal to bring into the world an unwanted child. It states that, in our increasingly complex society, the proper rearing of a child is a time-consuming and expensive process demanding maternal attention and paternal financial support for education. If a family cannot provide this, they do a grave disservice to the child. The obvious extreme case is that of the unwed mother, who is frequently unprepared to rear an infant, either emotionally or financially.The counterargument is vague here. There is talk of mothers who unconsciously wish to conceive; talk of the maternal urge to procreate; flat statements that "there never was a child born who wasn"t wanted." Or an ex-post-facto approach: once the child is born, the family will adjust and love him.The fourth argument states that a woman should never, under any circ.u.mstances, be required to bear a child if she does not wish to do so. Abortion on demand should be a right of every woman, like the right to vote. This is an interesting argument, but its usefulness has been diluted by many of its proponents, who often express a rather paranoid feeling that the world is dominated by men who cannot be expected to show any sympathy for the opposite s.e.x.
Those who disagree with this argument usually point out that a modern, emanc.i.p.ated woman need not become pregnant if she does not wish it. A wide variety of birth-control methods and devices is available to her, and they believe that abortion is not a subst.i.tute for birth control. The case of birth-control failure and inadvertent pregnancy-such as rape-are difficult to handle within this framework, however.The fifth argument states that abortion is safe, easy, simple, and cheap; thus there can be no practical objection to legalizing termination of pregnancy.The counterargument states that abortion carries a finite risk of mortality, which, though small, nonetheless exists. Unfortunately for this viewpoint, it is now perfectly clear that a hospital abortion is one-sixth to one-tenth as dangerous as a hospital delivery. This means it is safer to abort a child than to carry it to term.The sixth argument is the newest and the most ingenious. It was first proposed by Garrett Hardin, and it attacks the problem at a crucial question: Is abortion murder? Hardin says no. He argues that the embryo does not become human until after birth and a long period of training. He states that the embryo is nothing but a template, ultimately derived from DNA, the information-carrying genetic substance. Information in itself, he says, is of no value. It is like a blueprint. The blueprint of a building, he says, is worthless; only the building has value and significance. The blueprint may be destroyed with impunity, for another can easily be made, but a building cannot be destroyed without careful deliberation.This is a swift and oversimplified summary of his argument. Hardin was trained both as an anthropologist and as a biologist, and his viewpoint is unique. It is interesting because it considers the question of when when is a person human in terms of is a person human in terms of what what is a human being? Returning to the a.n.a.logy of blueprint and building, the blueprint specifies size, shape, and general structure, but it does not state whether the building will be erected in New York or Tokyo, whether in a slum or an affluent area, whether it will be used effectively or fall into disrepair. By implication, Hardin is defining a human being not only as an animal that walks on its hind legs, has a large brain, and an opposable thumb; he includes in the definition enough maternal care and education to make a person a well-adjusted and functioning unit of a social grouping. is a human being? Returning to the a.n.a.logy of blueprint and building, the blueprint specifies size, shape, and general structure, but it does not state whether the building will be erected in New York or Tokyo, whether in a slum or an affluent area, whether it will be used effectively or fall into disrepair. By implication, Hardin is defining a human being not only as an animal that walks on its hind legs, has a large brain, and an opposable thumb; he includes in the definition enough maternal care and education to make a person a well-adjusted and functioning unit of a social grouping.The counterargument says that Hardin a.s.sumes DNA is a "non-unique" copy of information, when in fact it is quite unique. All children of a given mother and father are not identical; therefore the DNA cannot be "non-unique."
To this Hardin replies that we already, quite by chance, select only some of the potential DNA combinations of sperm and egg and allow these to reach maturation. He notes that an average woman has 30,000 eggs in her ovaries, yet will bring only a few to term. The others are destroyed just as surely as if they had been aborted. And, as he says, one of them might have been "a super Beethoven."
Hardin"s argument is still new and strikes many as abstruse. But undoubtedly his is just the first of many new arguments, for and against abortion, which will be proposed on an increasingly subtle scientific basis. It is a commentary on modern man that he must justify his morality on the basis of the molecular mechanisms at work within a single cell of his body.
There are other arguments, but they are mostly evasive and petty. There are economic arguments concerning the cost of turning hospitals into abortion mills; there are vague and wild-eyed arguments of unleashed libertinism, similar to the arguments heard before the introduction of birth-control pills. There are also reflex liberal arguments that anything freer is by definition good and meritocratic arguments that the outpouring of children from the lower cla.s.ses should be stemmed. There is no point in considering these viewpoints. They are advanced, for the most part, by thoughtless and irritable little men.APPENDIX VII: Medical Morals Medical MoralsIN MEDICINE TODAY, there are four great moral questions involving the conduct of medical practice. One is abortion. Another is euthanasia, the killing of a patient with a terminal and incurable illness. A third concerns the social responsibility of the doc-tors to administer care to as many people as possible. A fourth concerns the definition of death.The interesting thing is that all these problems are new. They are products of our technology, moral and legal problems which have sprung up within the last decade or so.Hospital abortion, for example, must now be regarded as a relatively inexpensive and safe procedure, carrying a mortality rate roughly similar to a tooth extraction. This was not always true, but in the modern context it is, and we must therefore deal with it.
Euthanasia was once much less serious a problem. When doctors had fewer "supportive" aids, artificial respirators, and knowledge of electrolyte balances, patients with terminal illnesses tended to die quickly. Now, medicine faces the fact that a person can be kept technically alive for an indefinite period, though he can never be cured. Thus the doctor must decide whether supportive therapy should be inst.i.tuted and for how long. This is a problem because doctors have traditionally felt that they should keep their patients alive as long as possible, using every available technique. Now, the morality-and even the humanity-of such an approach must be questioned.
There is a corollary: whether the patient facing an incurable disease has the right to refuse supportive therapy; whether a patient facing weeks or months of terminal pain has a right to demand an easy and painless death; whether a patient who has put himself in a doctor"s hands still retains ultimate life-and-death control over his own existence.Social responsibility in its modern terms- responsibility to a community, not an individual-is something rather new to medicine. Formerly patients who were indigent were treated by kind doctors, or not at all; now, there is a growing feeling that medical care is a right, not a privilege. There is also a growing number of patients who were once charity cases but are now covered by health insurance or Medicare. The physician is today being forced to reconsider his role, not in terms of those patients who can afford to seek his help, but in terms of all the people in the community. Related to this is the increased medical emphasis on preventive care.The definition of death is a problem with a single cause: organ transplants. As surgeons become more skilled in transplanting parts from the dead to the living, the question of when a man is dead becomes crucial, because transplantable organs should be removed as rapidly as possible from a dead man. The old, crude indicators-no pulse, no breathing- have been replaced by no EKG activity, or a flat EEG, but the question is still unresolved, and may not be for many years to come.
There is another problem involving medical ethics, and that concerns the doctor and the drug companies. This is currently being fought over in a four-way tug-of-war involving patient, doctor, government, and drug manufacturer. The issues, and the eventual outcome, are still unclear.
MICHAEL CRICHTON graduated from Harvard Medical School and served his internship before deciding to devote himself full-time to writing.
A CASE OF NEED was first published when he wastwenty-six years old. His more recent novels include DISCLOSURE and JURa.s.sIC PARK