A Case of Need

by Michael Crichton

Listen,” he said. “Morality must keep up with technology, because if a person is faced with the choice of being moral and dead or immoral and alive, they’ll choose life every time.

Keep the gun in sight, but keep it in your holster. Period.” In effect we were ordered to bluff our way through everything. We learned to do it. All cops learn to do it.

The differential diagnosis of amenorrhea, particularly in young girls, must consider nervousness as a strong etiologic possibility. Women often delay or miss their menstrual periods for psychological reasons.

Cops, like soldiers, can be proud of their infirmities. You knew Peterson hadn’t received his in an auto accident.

The smile began to fall, probably from fatigue and unused muscles.

WHEN I GOT OUTSIDE into the October drizzle, I decided this was a hell of a time to quit smoking.

DHJ: doing his job.

I often think of Cameron Jackson and the dozen people I know like him. Usually, I think of him late at night, when I’ve been held up at the lab or when I’ve been so busy I haven’t had time to call home and say I’ll be late.

“I’m beginning to understand,” he said, “why priests don’t marry.”

Within the Boston medical establishment, the City is known as the Boston Shitty because of its clientele.

As I cut through the corridors and buildings, I remembered my rotation through the hospital as a resident. Small details came back. The soap: a strange, cheap, peculiar-smelling soap that was used everywhere.

The standard autopsy incision is a Y-shaped cut running down from each shoulder, meeting at the midline of the body at the bottom of the ribs, and then continuing as a single incision to the pubic bone. The skin and muscle is then peeled away in three flaps; the ribs are cut open, exposing the lungs and heart; the abdomen is widely incised. Then the carotid arteries are tied and cut, the colon is tied and cut, the trachea and pharynx are cut—and the entire viscera, heart, lungs, stomach, liver, spleen, kidneys, and intestine are removed in a single motion.

THE LAST TIME ANYONE COUNTED, there were 25,000 named diseases of man, and cures for 5,000 of them. Yet it remains the dream

Practically speaking, it is much better to discover a new disease than to find a cure for an old one; your cure will be tested, disputed, and argued over for years, while a new disease is readily and rapidly accepted.

It takes a certain kind of man to assume this burden, to set his sights on such a distant goal. By the time he is ready to begin surgery on his own, he has become another person, almost a new breed, estranged by his experience and his dedication from other men. In a sense, that is part of the training: surgeons are lonely men.

You couldn’t be sure about a man like Conway: he was one of the few doctors who become so famous so fast that they take on some aspects of politicians and movie stars; they acquire blindly loyal fans and blindly antagonistic critics; one either loves them or loathes them.

They say J. D. Randall likes cutting hearts because he never had one of his own.”

Fortunately, history judges men by their actions, not their motivations.

It is also strongly narcissistic—a trait it shares with another city of questionable origin, San Francisco.

We are all tied to the past, individually and collectively. The past shows through in the very structure of our bones, the distribution of our hair, and the coloring of our skin, as well as the way we walk, stand, eat, dress—and think.

Many things in life are difficult to live down, but nothing is more difficult than a name.

“Probably, but I don’t remember. She could be maddening about names, talking about people casually as if you knew them intimately.

A doctor cannot change his name after receiving his M.D. degree without invalidating that degree. This means that there is a great rush in the final weeks of med school among doctors flocking into court to change their names before they receive their diplomas.

I was reminded that surgeons were the last autocrats in society, the last class of men who were given total control over a situation.

The Passing of the Buck is a time-honored ceremony, to be observed in silence.

“In the technicalities lies the strength of the law.” “And the weaknesses.”

Nobody else seemed to care whether Art was guilty or not. The issue that was crucial to me was irrelevant to them. Now why was that?

She shrugged. Somehow, she had learned to make every bodily gesture a wiggle.

All this means is that illegal abortions are about twenty-five times as deadly as they have to be. Most people are horrified by this. But Art, who thought clearly and carefully about such things, was impressed by the statistic. And he said something very interesting: that one reason abortion remained illegal was because it was so safe.

There they are,” Art said, “dying on the highways at the rate of about eighty a day. Everybody accepts it as a fact of life. So who’s going to care about the fourteen women who die every day of abortions?”

The trouble with this country,” he said, “is that the women have no guts. They’d rather slink off and have a dangerous, illegal operation performed than change the laws. The legislators are all men, and men don’t bear the babies; they can afford to be moralistic. So can the priests: if you had women priests, you’d see a hell of a quick change in religion. But politics and religion are dominated by the men, and the women are reluctant to push too hard. Which is bad, because abortion is their business—their infants, their bodies, their risk. If a million women a year wrote letters to their congressmen, you might see a little action. Probably not, but you might. Only the women won’t do it.”

She was drinking her Scotch quickly—she’s a gulper—and obviously preparing to plunge into the group of wives.

I smiled, remembering Art’s line about doctors being illpolitical. He meant it the way you used words like illiterate.

Telser because he is surrounded in dermatology by patients whom he considers neurotic, not sick.

Because I know Art better than most people, I attach a great importance to his being Chinese. I think his origin and his physical appearance have been a great influence on him. There are a lot of Chinese and Japanese men in medicine, and there are a lot of jokes about them—half-nervous jokes about their energy and their cleverness, their drive to success. It is precisely the kind of jokes one hears about Jews. I think Art, as a Chinese-American, has fought this tradition, and he has also fought his upbringing, which was essentially conservative. He swung the other way, became radical and leftist. One proof of this is his willingness to accept all things new. He has the most modern office equipment of any OB man in Boston. Whenever a new product comes out, he buys it. There are jokes about this, too—the gadget-oriented Orientals—but the motivation is different. Art is fighting tradition, routine, the accepted way.

When you first hear these ideas and theories, you are impressed. Only later do you realize that he is compulsively attacking tradition, finding fault whenever and wherever he can.

because I feel that a man’s reasons for doing something are less important than the ultimate value of what he does. It is a historical truth that a man may do the wrong thing for the right reasons. In that case he loses. Or he may do the right thing for the wrong reasons. In that case, he is a hero.

In retrospect, all of Blake’s arguments seem no more useful or important than watching an athlete exercise in a gym, but at the time they can be fascinating. Blake has a keen sense of the arbitrary, and it stands him in good stead when working with members of the most arbitrary profession on earth.

My years in the courtroom have taught me one thing, at least.” “What’s that?” “Never take a position unless you are certain it can be defended against any onslaught. That may sound like good advice to a general,” he said, smiling, “but then, a courtroom is nothing more than a very civilized war.”

He ran his hands over his shirt. It was something you always noticed about Fritz: he was continually touching his body, as if to assure himself that he had not disappeared.

snifters

I AWOKE FEELING MEAN. Like a caged animal, trapped, enclosed.

Once he asked me what an ecdysiast was, pronouncing the word perfectly but carefully, as if it were fragile.

AROUND THE CORNER at the end of the block was a stand-up, self-service greasy spoon. Hamburgers twenty cents.

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.

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.

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.

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.

dx is diagnosis; px, prognosis; Rx, therapy; sx, symptoms; hx, history; mx, metastases; fx, fractures.

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.”