I was the intern on call for neurosurgery when an ambulance delivered Larry’s motionless body to the ER. His clothes smelled of vomit. His curly brown hair was matted with blood, but he had a good pulse, fair color, and moaned when I twisted the flat handle of a reflex hammer between two tightly squeezed toes. If I twisted until the toes cracked, he opened his eyes and weakly flailed both arms and legs, but then, the instant the pain ceased, he lapsed back into coma. I rated him eight out of fifteen on the Glasgow coma scale – halfway between normal and dead.  

Larry’s history trickled in bit by bit. His California driver’s license declared him a twenty-nine-year-old Caucasian male. When the ambulance driver told an ER clerk that Larry had been picked up off the floor at Melanie’s Grill, a San Mateo night spot famous for its drunken brawls, the clerk called Melanie’s and handed me the phone. For several minutes I listened to a running debate on the other end of the line between a bartender and a drunken patron: Larry’s assailants – there were two; no, three, maybe four – had come after him with their fists. And there was a chair, plus a bottle or two, slammed upside his head. The fight had begun when Larry spat in someone’s beer. 

This story was confirmed by the physical evidence. The ER intern who sewed up Larry’s three scalp lacerations found bits of broken glass embedded in the wounds, while tense black bruises on the occiput and left cheek suggested blunt trauma. The skull X-ray showed no acute fracture, though hypertrophic lines suggested one or two healed fractures. In any case, Larry’s contused brain was taking a rest. Judging by the hypertrophic lines – plus seven scars on his scalp and face, one of which ran from the corner of his right eye to the angle of his jaw – I suspected his brain had taken several such rests in the past. 

Ron G., the senior resident who dispatched me to look after Larry, was an arrogant, difficult man. Years later, when he became chairman of neurosurgery at a preeminent medical school, his tenure was marred by an infamous locking of horns with America’s most celebrated female neurosurgeon. During several well-publicized interviews, she declared Ron the quintessential male chauvinist pig. In fact, Ron gave everyone a hard time – men and women, young and old, doctors and nurses, even the occasional patient – but I loved him. Yes, he could be a jerk. His sense of humor was caustic, merciless, riotously brilliant. A brilliant man altogether, almost as skilled a surgeon and diagnostician as he claimed to be. 

When Stanford’s ophthalmology department accepted me as a resident, Ron clapped me on the shoulder. “Congratulations, Gamel,” he said in a loud voice. “If you can’t be a real doctor, you might as well fit eyeglasses for the rest of your life.” He often spoke in a loud voice. When a medical student announced that he wanted to become an internist rather than a surgeon, Ron harangued him: “You lazy bastard, that’ll break your mother’s heart. A good Jewish boy like you should get off his ass and do something useful.” In the cafeteria one day, apropos of nothing in particular, Ron all but shouted, “Pediatricians are the biggest wimps on earth. Not a one of them has a peter any bigger than a cigarette.” The pediatricians sitting at the next table fell silent and turned red in the face. 

But Ron was a fine doctor. If my brain harbored a meningioma, I would place myself in his care without a moment’s hesitation. Beneath the anger and raucous humor there dwelt an abiding integrity; an integrity at times conflicted, to be sure, yet fierce and unrelenting. In all likelihood, it was this integrity, not Ron’s swollen ego, that cost two innocent victims their lives. 

Where did it come from – Ron’s anger, his arrogance and smoldering hostility? His gray eyes were piercing, defiant, as though daring anyone to look askance at his limping stride. That he was handsome, with broad shoulders and a strong, classic jaw, only added to the response his frown and his peculiar gait aroused in strangers; stares followed him whenever we walked the corridors of San Mateo County Hospital. Ron seemed to sense these stares, scowling while his deformed legs struggled to leave them behind as quickly as possible. His limp, as I soon discovered, had much to do with his hatred of drunks.

Yes, Ron hated drunks. This never affected the quality of his care – he gave excellent care to all his patients, pouring over their charts and X-rays into the early morning hours – but at the bedside of a lush, he uttered not one word more than was needed. These were dark little sessions, with a stuporous, slack-jawed patient struggling to tell his story while Ron glowered and clenched his teeth. In the ER, amid the reek of vomit and infected wounds, or in the ICU, sonorous with the hiss . . . clunk . . . hiss . . . clunk of half a dozen respirators, I often thought, If the world agreed to look the other way for ten seconds, Ron would kill that man with his bare hands. But Ron restrained himself. 

“Sit up, dammit – I’m talking to you!” 

Those were the harshest words I ever heard him say to the drunkards that filled so many of the beds in our hospital. At rounds one evening, when Ron interrupted a gentle old alcoholic in the midst of a rambling confabulation by scowling at the poor man and telling him to shut up, I asked Ron where this anger came from. He led me to an empty room and sat down on a chair. 

“Look,” he said, snatching up the legs of his blue scrub trousers. “Lean down, get closer.” 

I leaned down. His shins were lumpy, misshapen, covered with curly hair. Flecks of black pigment lay scattered beneath a lacework of scars. 

“That asshole,” Ron said. “A drunk Asian. He sold fortune cookies. It was Christmas, my first year of medical school. I was going to marry this beautiful girl. We were walking home from a movie, and the asshole ran over us. She was gone, killed on the spot, the murdering son of a bitch. He killed her and broke my legs. The black stuff is asphalt.” 

Since that day, every whiff of alcohol on a patient’s breath inflamed the memory of his murdered bride-to-be, while every stride on those twisted legs was charged against the drunks of the world. But Ron’s integrity always held sway, even against a resentment that tainted almost every aspect of his life. If he denied his intoxicated patients respect or a cheerful smile, he never – never – denied them the best care a doctor could give. 

Pig Shit Collins – a well-earned nickname. At least once a month, our ER admitted a free spirit who had sailed through the windshield of his pickup truck, but Mr. Collins distinguished himself from the typical Saturday-night acrobat by landing in a pigsty. He arrived combative and blind drunk, covered with muddy feces. Two orderlies wheeled him to the cast room, where they stripped off his clothes, hosed him down, then strapped him to a gurney and left him alone to scream himself to sleep. 

Collins probably would have died there if Ron G. hadn’t stopped to chat with one of the patrolman who had worked the crash site. Ron got on well with cops, perhaps because they hated drunks as much as he did. He had seen Pig Shit cursing and swinging at the orderlies and gave no thought to serious injury until the patrolman mentioned an alarming fact: the pigsty Mr. Collins had landed in was over a hundred feet from the wrecked pickup. 

“Oh, Christ,” Ron said, then rushed to the cast room with me on his heels. By that time Collins had quieted down. He lay naked, shivering and whimpering under the wet sheet. “You ok?” Ron shouted in his ear. 

“No,” Collins moaned. He burst into choking sobs. His teeth chattered. “My neck hurts.” 

Ron’s response amazed me. That pathetic moan – “my neck hurts” – transformed Ron’s face, his posture, his tone of voice. One moment he seemed ready to squash Collins like a bug, the next he was tender and anxious as though caring for an injured child.

“Hurry up,” Ron said to me. He kicked off the gurney’s brakes and grabbed a side rail. “Let’s get him to X-ray.” 

The PA and lateral films showed an undisplaced fracture of the odontoid process, the pivotal point of the upper cervical spine. Pig Shit Collins had broken his neck. If the fragment slipped, it would cut the spinal cord just below its exit from the skull. Collins, hovering a millimeter from instant death, had begun to sober up. 

For the next hour, while Collins’s gurney was trundled to radiology and then to the OR, Ron stayed by his side every instant. He kept a hand on the patient’s brow to steady his head until the anesthetic took effect. When Collins awoke, his head was shaved smooth as an egg, and a plaster cast covered his upper torso. Four long vertical rods were embedded in the cast. These rose up to join a steel circle held in place by six pins driven into Collins’ skull. This crown of thorns – seeming, to the unlearned eye, nothing more than a splendid instrument of torture – would stabilize the spine while the fractured odontoid healed. 

In the recovery room, Ron held Collins’ hand as he regained consciousness. 

“Yeah, I know it hurts,” he said in a gentle voice, “but trust me, things will get better. You must not move. Just hang on, another shot of morphine will do the trick.” 

Our efforts on Mr. Collins’s behalf were handsomely rewarded. The morning after his surgery, bathed and shaved with special care – lest an untoward movement snap his spine – he showed himself a comely fellow. His naked scalp glowed like a china doorknob. His pale blue eyes, framed by dark lashes, seemed innocent as a child’s, painfully sweet and precious, while the crown of thorns gave him the heart-rending aura of a pieta. No doubt such beauty had a moving effect on the two young women who rushed into his room the moment visiting hours began, each carrying a brown paper bag tucked her arm. One was Collins’s girlfriend, the other his wife. Within seconds, the bags were torn, their contents scattered across the floor: toothbrushes, flannel pajamas, a purple robe, various foodstuffs broken into crumbs or mashed into greasy lumps. 

Ron and I had just finished morning rounds at the other end of the hall when the two women tumbled out of Collins’s room in a heap, both pounding away and shouting “Bitch! Bitch! Bitch!” at the top of their lungs. I had thought women only bit and scratched and pulled hair, but the thin, honey-gold blonde – I never found out whether she was the wife or the girlfriend – was admitted to ENT with a fractured mandible. Her opponent, a sturdy Hispanic woman, had scratches on her face and neck and a tooth-hole punched through her lower lip. After an ER intern stitched her lip, she sat by Collins’s bed until visiting hours were over. 

That evening, as Collins whimpered with pain from the six pins screwed into his skull, Larry Beaten took a turn for the worse. A nurse paged me around midnight to report that his coma had deepened. I checked him out. Bad news: a reflex hammer twisted between his toes until they cracked elicited only faint movements of his left arm and leg, while his right arm and leg lay motionless. He no longer moaned, and his eyes remained closed. These findings dropped his Glasgow Coma Scale to four out of fifteen points – near death. When I woke Ron, he ordered a stat skull film and a cerebral arteriogram, and by two a. m. the data were in: Larry had a subdural hematoma overlying his left frontal lobe. Ron sent me off to talk to the family while he prepared Larry for surgery. 

“Hang some crepe,” he said. “The poor schmuck might lose his frontal lobe, so be sure to give ‘em that routine about a change in personality.” 

A lobotomy – caused by trauma, by an unintended operative complication, or by a deliberate surgical procedure – tends to soothe the savage beast. It was used to treat a variety of mental ailments in the 1930s, then reached its apogee a decade later when Doctor Walter Freeman pioneered the “ice-pick lobotomy.” During this five-minute procedure, he hammered a slender rod into the brain through the bony wall of each eye socket, then waved the tip around to sever all neural connections with the frontal lobes. The patient remained wide awake. Eye drops served as the only anesthetic. For years Doctor Freeman toured America in what he called his “lobotomobile,” performing a total of 3,439 operations, but this surgical travesty was all but abandoned by the 1970s because many of his victims, including John F. Kennedy’s sister, became slovenly automatons. Ron feared that Larry’s subdural hematoma, or the surgery to remove it, might lobotomize the patient. My job was to prepare his family for this complication.

I looked forward to seeing Larry’s family again. During my first meeting with them, on the night of Larry’s admission, I had developed a bit of a crush on his sister Virginia, a young woman with a narrow face and dark hair that shimmered under the fluorescent lights of the ICU waiting room. I had a soft spot for thin, literate, strong-willed women, and the intellectual mien imparted by the wire frame of her myopic glasses finished me off. Of course I showed no hint of my erotic tumult as I spoke to this lovely houri, but when she strode to the front of Larry’s clan to serve as their spokesman, my pulse quickened. 

A dozen of them showed up for our first meeting – aunts, uncles, parents, Virginia, two other sisters. The gray-haired parents wept quietly, blotting their red-rimmed eyes with a handkerchief they passed back and forth between them. I was aching with fatigue after a night on call. Given Larry’s combat record, I had expected a disreputable mob, yet here was a clean and orderly gathering. They all rose when I entered the waiting room, looking at me with steady, intelligent eyes. I explained Larry’s guarded prognosis. Virginia sighed, wiped her eyes, asked three or four questions, then thanked me for taking care of her brother. As I was about to leave, she pressed my hand for a few delightful moments between her warm, soft palms.  

Three days later, when I called to report that Larry was on his way to an emergency craniotomy, only Virginia, the parents, and one other sister showed up. They looked tired and somber as I went through my routine. 

“To get at the blood clot,” I explained, “we’ll have to remove a piece of his skull . . . We can’t be sure how much of his brain has been damaged, how much function he’ll recover . . . There’s a risk of paralysis, and after surgery you might notice a change in personality . . . ” 

The moment they heard “change in personality,” the whole group started. Their eyes, half-closed with fatigue an instant before, shot wide open. I paused. They all stared at me. I cleared my throat and was about to continue when Virginia grabbed both of my arms. 

“Doctor, doctor – a change in personality? What do you mean?” She stood close, looking up at me, her eyes bright with desperation behind those square lenses. 

“Well,” I said, “it’s like when we used to lobotomize schizophrenics and manic depressives. They changed, they calmed down, it seemed to work, but some had a bad outcome. Some became passive, detached, unkempt . . . ” 

“Doctor,” Virginia said, squeezing my arms. “Doctor, how bad could it be? If you only knew . . . ” Tears streamed down her face. Her voice quavered. “You can’t imagine what we’ve been through. Larry, my god, from the day he was born . . . it’s been a nightmare. No one knows all the jails, the hospitals, the rehab wards. Can’t you help us? ‘Passive,’ ‘detached’ – god, what a blessing! Anything would be better than . . . ” Her voice trailed off. Her dark eyes remained fixed on mine. She stood so close I felt her warm breath on my face. 

My moment had come – a perfect moment. Here, in front of this desperate princess, I would show the poise and professional élan acquired during my years of medical training. In the lavatory a few minutes before, I had straightened my tie, combed my hair, trimmed my bushy red beard with the scissors I carried in the pocket of my white coat. An opportunity like this couldn’t be missed. 

I missed it. How long did I stand there gaping, speechless, without a single useful thought in my brain? At last I stammered, “Gee . . . well, I don’t know . . . I’ll have to talk to Doctor G. . . . ” Then I left, running up the nearest flight of stairs so fast I tripped and almost cracked my head. 

Larry Beaten lay supine on the OR table, covered head to toe by powder-blue surgical drapes. A beam of bright light shone down from an overhead fixture. In the center of the beam, beneath a hole in the drape, Larry’s vermillion scalp lay naked to the world. Ron had shaved and scrubbed that scalp, then painted it with Betadine, and now he was tracing the black curve of the impending incision with a sterile felt-tip pen. The room reeked of Betadine and isopropyl alcohol. Only a few hours remained before dawn. When I stepped up to the OR table, the scrub nurse at Ron’s side pulled off her gloves and slung them into a trash bucket. 

“I’ve got to go,” she said. “They need me on a case in room five.” 

As she disappeared through the whooshing pneumatic doors, the anesthesiologist looked up from the magazine in his lap. He yawned, grunted, cracked his knuckles, then lifted a clipboard from its hook on the side of the respirator and scribbled a note on the progress sheet to mark the time of the nurse’s departure. 

For the next hour, I handed instruments to Ron while he worked his way into Larry’s brain. The flap of scalp, its thick, dark edges glistening with blood, curled back as the chrome spatula lifted it from the bone. The spatula made a soft scraping sound. The Bovie knife sparked and buzzed each time Ron cauterized the bleeding wound, giving off a wisp of smoke that smelled like charred meat, until at last the flap lay coiled upon itself. Beneath the coil lay the clean white arc of the skull. 

I slapped the handle of a drill into Ron’s palm, then picked up a vacuum cannula to suck away the fragments that piled up around the hole in Larry’s skull. As I listened to the steady crunch of the bit grinding its way through the bone, it struck me that a layman off the street might think he had wandered into a carpenter’s shop. When the drill broke into the cranial cavity, the underlying dura matter bulged out through the hole, forming a dark, vein-laced blister that pulsed in sync with the hiss . . . clunk . . . hiss . . . clunk of the respirator. 

“Hey,” Ron shouted to the anesthesiologist, who started and almost fell off his stool. “You’d better hyperventilate this guy right now. If we don’t get his pressure down, his brain’ll come squirting out like toothpaste.” 

The anesthesiologist cleared his throat, muttered, “Ok, ok,” then leaned forward and turned a dial on the respirator. The bellows in the respirator jumped to forty cycles a minute. This lowered the carbon dioxide level in Larry’s blood, leading to a physiologic cascade that reduced his intracranial pressure. After a few minutes Ron said, “That’s better, you can turn it down,” but I wasn’t convinced. The dark blister that bulged through the hole in Larry’s skull still seemed dangerously tense. Ron picked up the drill. Soon four thumb-sized blisters formed the points of a square, all four pulsing in sync with the respirator, and all four – in my fearful, inexperienced mind – ready to erupt like volcanoes, squirting brain paste all over the surgical drapes. 

Next came the saw wire, a toothed metal strand that Ron threaded beneath the skull from one hole to another. Using O-rings on the ends of the wire, he pulled back and forth until it sawed out through the bone. Ron repeated this maneuver three more times, until at last the square flap of skull cracked loose and fell to the side. A fist-sized lump bulged through the hole. 

“There it is,” Ron said. 

Beneath the vein-laced surface of the lump lay a dark blotch. When he touched the blotch with his gloved finger, it squirmed and slithered about like an octopus. My knees wobbled. This was my first subdural hematoma, a blood clot trapped between the brain and the overlying dura matter, and the texture of that glutinous slime made me gag, but I held my own until Ron thrust the vacuum cannula into the clot. Black tentacles oozed into the cannula, then surged in quivering jerks down the transparent vacuum tube. I gasped for breath. With each revolting quiver came an even more revolting sound: slurp slurp slurp . . . sluurrp . . . sluuuuurrrrp . . . slurp slurp . . . sluuuuuuurrrrrrp . . . 

“Ron,” I said, “I’m going to vomit.”

“No, you’re not,” he said. “Gimme that retractor.” 

I gave him the retractor, swallowed the bile that surged up the back of my throat, blinked away the eye-stinging sweat that dripped down my forehead. In the end I didn’t vomit, but by the time I remembered Virginia’s plea, Ron had finished cleaning up the mess. There before us, framed by the square hole in Larry’s skull, lay what remained of his left frontal lobe – a tangle of fat gray worms laced with arteries and veins. Every trace of the clot was gone, its site marked by a shallow concavity. 

“Ok,” Ron said, “time to close up.” 

“Uh, Ron,” I said, “before you do that, we need to talk.” 

“About what?”

“Well, how much of this guy’s frontal lobe did he lose? Did we give him a lobotomy?” 

“Oh, no,” Ron said, a note of pride in his voice. “He’ll be right as rain. That clot just knocked off a bit of the left lobe, maybe thirty percent. And the right lobe, it’s been shoved around a little, but it’ll be fine. Tell his family everything’s going to ok.” 

It was time to unload. I told Ron about Virginia’s bizarre plea, the eager murmur of approval from Larry’s other relatives when she urged me to do everything I could – and she meant everything – to change his personality. 

“Ron,” I said, “that family’s great. The father’s a professor at San Jose State, the sister’s a peach and bright as hell. They’ve suffered the tortures of the damned since the day this S. O. B. was born. Did you see the scars on his face?”

“Yea, yea, yea,” Ron said. “I didn’t count ‘em, but I know his type.” 

“Well, do lobotomies work? All I know is what I read in books.” 

“Oh, yea,” Ron said, “lobotomies work, work just fine. I’ve lifted the hood on a few bikers – you know, chains, leather jackets, scars and tattoos everywhere – and when they lose enough frontal cortex, they wake up pretty nice guys. Sometimes they forget to bathe or brush their teeth, but they stop bashing people around.”  

“Well . . . ,” I said.  

Ron and I looked at each other. A cap and mask covered everything except the eyes, but his eyes said it all. They gazed at me across the OR table, across the gaping skull of our unconscious patient. For a long time, we looked at each other in silence, sharing a dark and terrifying thought – a moral dilemma beyond anything I would encounter during the remainder of my medical career. Then Ron’s gaze shifted to the anesthesiologist, who sat slumped in his chair, his cheek resting on an arm draped across the top of the respirator. His magazine lay on the floor. His breathing was noisy, slow and rhythmic. 

I knew what it would take. Not much. Years before I had watched my uncle sauté a cow’s brain. It was soft and squishy, oozing around the skillet like undercooked scrambled eggs. Just a few quick sucks – slurp slurp slurp – and the job would be finished. 

Ron didn’t finish the job. Later, he said it was the worst mistake of his life. We paid for that mistake when Larry Beaten woke from anesthesia with a hostile sneer on his lips, as though we had inflicted his injury rather than saved his life. We paid again during rounds every morning, when Larry – lying flat in bed, his head swathed in gauze – snarled and insulted without saying a word. With every encounter, hot blood rushed into Ron’s face. And into mine. I loathed that jerk from the moment he opened his eyes.  

“Sit up, dammit!” Ron said. “I’m talking to you!” 

But for me, the most terrible price came when Virginia stormed out of her brother’s room and caught me in the hallway. She grabbed the sleeve of my coat. Her face was twisted with pain and anger. 

“My god, he’s the same! Just the same!”

Her dark eyes flashed behind those wire-frame glasses. What incomprehensible ethic had left her family in torment? 

Three months after his discharge, Larry paid the price himself when an ambulance once again delivered his motionless body to the San Mateo County ER. This time he was dead. His blood alcohol measured near the lethal range. He had run his car into a bridge abutment on the Junipero Serra Freeway, a hit so solid it froze the speedometer needle in place at sixty-seven miles an hour. But Larry didn’t die alone. The two teenage hitchhikers he had picked up a few minutes before the wreck were huddled in the back seat. Admitted in coma to the neurosurgery ward, they both died within a few days. 

Who killed those teenagers? Larry Beaten? Ron G? 

Doctors are not meant to play God. Surely, they are not meant to commit crimes upon their patients. Unauthorized surgery is an assault, a felony of the highest order, but I wish – and I suspect Ron G. wishes, even more fervently than I – that on this one occasion, in the dark of night, we had done the wrong thing.