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Opinion: A matter of  Life & Death
Opinion: A matter of Life & Death Exclusive
May 7, 2012 | By Leigh Alexander

May 7, 2012 | By Leigh Alexander
More: Console/PC, Business/Marketing, Exclusive

When I was a kid, there was a brief period of time during which I felt quite sure I was going to be a surgeon. I was basically an expert, I reasoned, in operating room practices and in the workings of human innards.

I was such a good self-taught physician that I could diagnose myself, even. When in third grade it was time to do long division, I would regularly report an acute pain on my lower right side -- recurring bouts of appendicitis, naturally, that meant I couldn't possibly sit through my math studies.

My teacher often had to point out that I often confused my left and right sides, but still. I knew about appendices, I felt! I learned it from a computer game.

This game was The Software Toolworks' Life & Death, a 1988 point-and-click medical simulation, complex and distinct enough that it maintains a kernel of cult fandom to this day. The player takes the role of a surgeon who diagnoses patients through touch, X-ray and ultrasound machinery, and prescribes them through a variety of ailments ranging from kidney stones to aortic aneurysms.

The major challenge of Life & Death lies within the operations portion, though. Say your patient has some tenderness specific to one region, and an X-Ray reveals no kidney stones -- you as the doctor determine appendicitis and head to the operating room.

What follows is actually a deceptively complex series of tasks; the player controls a scalpel and its associated insicions with a steady hand on the mouse, and manages every aspect of the operation. Delicate tissues require different techniques than sturdy muscle, for example; heart conditions that can arise mid-operation require injections, and the procedures to graft a damaged aorta or remove a virulent appendix are incredibly detailed, involving sutures, clamps, vials and anything else you might guess at when you think about surgery.

Life & Death is so detail-intensive that anyone playing it is liable to wonder if it's based, at least in part, on real medical procedures. It's not uncommon to come through a successful playthrough privately entertaining the idea that, if any of your friends suddenly needed emergency surgery, you could probably figure it out.

From a game design standpoint, the fun comes from that required attention to detail. With just a mouse, the game manages to create an impressive variety of challenges. Some are precision-oriented; click the wrong part and you might puncture something. Your incisions must be tidy and just long enough.

Others are speed-oriented: Address the unstable EKG or clamp the bleeding wound before it gets out of hand. Still others are process-oriented: You must inject the right anti-clotting agent before opening the aorta, or you must very carefully observe the right series of tasks for managing peritoneal layers, and remember them each time. A missed step or mishandled task bumps you back to medical school for a visual correction, and then you're back on the ward to try again.

There are some subtle touches, too: You can pick your two attendant staffers for surgery -- they act as the feedback system -- and each of them has a dossier that lets you know who they do and don't work well with. Pick a pair with the right area of expertise that are compatible and they'll be more helpful to you in surgery than others.

The amazing thing about this old gem, though, is how it manages to create just the state of mind that one imagines a surgeon might have: Breath bated, absolute concentration, every fingertip tremor a potential threat.

Players need to learn their way through the proper surgical procedures for appendectomies and aneurysms in part by intuition, but mostly through trial and error. Each time you put a new patient under the knife, you might feel like this is the time you've really got it; eager to be correct, you proceed with proud learned behavior through virtual vital organs -- until you reach a brand-new moment of unfamiliarity.

One wrong move could kill your patient and force you to start again. It's incredibly tense and thrilling, and it's the source of the immersion and challenge in the game.

I'm frequently fascinated when I revisit old games that flout what we now know today to be among the best practices of game design: Don't frustrate players, don't make them repeat themselves. Don't create failure states for the purpose of providing information -- give players a chance to arm themselves for the challenges to come rather than correcting by punishment.

Life & Death is incredibly frustrating. It's also incredibly repetitive. It's probably not fair that once I splay my patient's viscera I won't know where to clamp the meso-whatever artery until I've done it wrong and have to start again. Today's games would at least have given me some virtual books to read and practice before they made me try to work all that arterial stuff out.

But would I still have the same drive toward triumph, the motivation of a space that's nearly-learned, whose conquering is just around the next bend? The sense of mastery, when repetition eventually makes of me a confident surgeon who can breeze through the first few minutes of skin and subcutaneous fat with expert detachment? How would I get the thrill of finally realizing you must pull aside the small intestine like a curtain to be swaddled in a sterile towel, there to find a whole new layer of body to navigate?

Life & Death succeeds through its stubbornness. It is unfair and it's not easy, and it taxes players' memories as much as their motor skills. And that's why it captured my imagination so much as a child, and why it created the wrist-quivering hyperfocus, the deep investment in getting it right this time that made me believe, as an eight or nine year-old, that I had it in me to be a doctor. That I might love it.

Playing older, smaller games is always interesting. Nearly all the time as I point-and-click, or wrestle with text parsers, or stealthily Google obscure FAQs, I think, "No one would ever make a game like this today."

And usually that's a good thing. Most shareware adventure game designers who cobbled together clumsy stories in WorldBuilder (complete with alternately humble and snarky requests for $5 by snail mail!) were half creative, half curious, but even the pros were shooting in the dark when I was a kid.

Now we know much better what makes good video games, but sometimes I stumble across these counter-intuitive little miracles that make me wonder if we now know too much.

There are a lot of childhood favorites I revisit only to realize that I was just especially forgiving and imaginitive, and that those 'favorites' were not in fact of mentionable quality. Life & Death still gets its hooks way under my skin, though, and I think that's because it's complex and inventive using only a simple interface -- and because it's willing to make me upset with it.

My teacher let me know that becoming a surgeon would require strong math skills and a patience for long years of school. Yeah, I'll just stick to Life & Death, thanks. I wish people made more games like it today.

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Jeremy Reaban
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We know how to make better video games now in the same way Hollywood knows how to make better movies than it did...

(which I guess is the point of the article, except I never realized people seriously thought games were better now, not worse, in anything except graphics/sound)

David Holmin
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I remember playing this game as a kid at a friend's place. Even though I didn't play it much and never really got anywhere, my memory of it is strong and fond.

I agree with the implied point of the article, too. The modern idea of herding players through the game is missing the point of what makes a great game.

Theo van den Bogaart
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Jeremy has a point when he says that games are better in the sense that Hollywood movies are better than non-Hollywood moves. The definition of better here, is commercial succes.

When judging a game especially on its design, as Leigh seems to do here, I think it should be judged on properties that make the game design better. This is not better in a commercial standpoint per se. Take niche genres for instance.

Jason Withrow
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Now here's a game I'd like to see pop up on GOG.

Although I admit, I would have wanted some virtual books, though I'm not sure I would have read them at that age...

Michael Jungbluth
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The medical theme certainly helps to embrace the difficulty in this game. Failure in the realm of surgery has about as harsh an outcome as you can have in life, and to not mirror those to some degree when the rest of the game is mirroring so many other details, it wouldn't be nearly as successful. Were the same sort of penalties placed on a plumbing simulator, even with many of the same mechanics, I doubt it would be as rewarding, based largely on the perception of a plumber's work vs a doctor's work.

Jorge Gonzalez Sanchez
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As I kid, I loved taking patients who clearly had aneurisms and sending them home with aspirin. The head doctor would then chew me because he/she had died.

Another awesome thing was that if you didn't let go of your mouse button once you started cutting, the game wouldn't object to what you were doing.

So I would get any random patient, send him to the operation room, and slash at his/her face for 5 minutes until all you had left was a gory red mess. Without anesthetics of course.

I remember that if you did this, the head doctor would say something about you being Freddy Krueger.

Great games.

Kenan Alpay
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I've never heard of this game, but I always thought that "medical simulations" started with Trauma Center and such games on the Nintendo DS. Amazing that they were archetypes on PC way before the DS ever was released!

Still, I think Trauma Center has a lot more aliens and super-viruses than Life & Death. :)

Johan Wendin
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The difference between now and then is that back then, gamers were curious. Thought-provoking stuff (which today is considered hard and frustrating) was captivating. Why? Because those who had computers were families in which at least someone was technically aligned.

Today, gamers are media consumers. Spoon-fed cheap thrills is where it's at (commercially). Less thinking, more railroad experiences. "Everyone" have some sort of media machine/computer today - even the non-techie families.

I for one, think that we really, really need to find a golden middle-road here where the zombie-like state of media consumption is gradually taught that effort and pondering in the end leads to a more fulfilling experience. This can happen both game-wise, mostly in the indie scene since it will meet limited commercial success early on - or tech-wise with stuff like the Raspberry-pi getting children of today more cerebral than their older siblings.

Jake Smith
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It's not so much a shift in game development/design as it is a result of the natural desire to expand the marketplace.

As Jonah states, the audience then was smaller and technologically-curious; a select few. Building the guts (pardon the pun) of L&D was mostly a one-man show (code, graphics, sound and testing). While some of the high-concept ideas (hospital environment, the beeper copy protection and packaging) came from skilled outside support; the core development and production-values were not overwhelming.

Modern Game development today is comparatively monstrous endeavor. It is so not because the developers or designers have changed (many of my old crew are still deep in game development) but because the publishers demand that games appeal to broader audiences, beyond the technologically-engaged. But, as Jonah thoughtfully pointed out, there are indie-game options just like there are indie-film (music, art, etc.) options. Just don't expect those to appeal to the average 14 year old boy looking for shambling zombies to slaughter.

Sometimes we forget that our audience back then (that's you Leigh, David, Jorge, et. al.) were themselves a special breed.