“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 Massachusetts Avenue. As I came down the steps of Mallory, an ambulance drove past me toward the Boston City EW. As it passed 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 attitudes 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 passenger 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, I did forget. Then I was all right.
APPENDIX I:
Delicatessen Pathologists
PART 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 as unpleasant as cancer may be described as food, as in the case of oat-cell carcinoma of the lung.
APPENDIX II:
Cops and Doctors
DOCTORS ARE GENERALLY MISTRUSTFUL of the police and 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, pronounced 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
THROUGHOUT 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; until 1890, 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 attitude, 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 bloody 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
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 document 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 ass out of here.” And in pediatrics is perhaps the most unusual abbreviation of all, FLK, which means “Funny-looking kid.”
APPENDIX V:
Whites
EVERYBODY KNOWS DOCTORS WEAR WHITE UNIFORMS, and nobody, 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, im
posing 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 surgeons 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 analogy 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
THERE ARE GENERALLY CONSIDERED to be six arguments for abortion, and six counterarguments. The first argument considers the law and anthropology. 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 Japan, 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 Japanese, 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.
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 Japan, 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, and therefore, 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 circumstances, 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 sex.
Those who disagree with this argument usually point out that a modern, emancipated 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 substitute 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 is a person human in terms of what is a human being? Returning to the analogy 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 assumes DNA is a “non-unique” copy of inf
ormation, 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 classes should be stemmed. There is no point in considering these viewpoints. They are advanced, for the most part, by thoughtless and irritable little men.