Masters and Green Series Box Set

by Douglas Clark

  It took them several minutes to find their way from here. Narrow streets, backing the main shops; smaller alleys leading off. A serpentine way, past a public lavatory and a makeshift car park. At last they came to it. A double-fronted house with wooden bays painted a dingy green. Four steps up to the door. The small area in front paved over, with grass and weeds growing in the cracks. A cube biscuit tin in the porch with a stick-on label: ‘Please place urine-specimen bottles in tin’. A bronze plaque with white lettering: ‘Dr N. B. Sisson M.B. B.Ch. Physician and Surgeon’. The original surgery times had been changed. Little stuck-on squares of newer bronze gave the alterations. Under the bell it said: ‘Please Ring’. Masters, after a glance at his watch, did so.

  Neville Sisson was a big man. Nowhere near as big as Masters, but a useful scrum-size. He appeared to be loosely built, slumping into his pelvis, which gave him heavy haunches and a sloppy appearance. His black hair had been crew-cut half an inch long all over, and his side whiskers came down to his ear lobes. His eyes, like his skin, were brown, and his teeth stood out brilliant white. His tie was little more than a thin rag under a crumpled collar, and as he stood at the door he tucked the ends in behind the button of his jacket. His trousers hung low on his hips and wrinkled above fawn shoes that needed polish. Masters said, ‘I’ve brought Inspector Green with me. Do you mind?’

  ‘Not in the least. Come in.’

  There was a waiting-room notice to the right, and a surgery notice to the left. Sisson ignored them and led the way up stairs covered in linoleum. Their feet tapped out a rhythm as they went up. The first floor landing, square and spacious, was carpeted in drab haircord. Through half-open doors Masters could see a bathroom and kitchen. Sisson headed for a door leading into the front room on the right of the house.

  Here there was more comfort than had appeared elsewhere. Four armchairs, all different, but comfortable looking. A coffee-table radiogram. Bookcases and drinks cabinet. An old-fashioned white marble fireplace with a stone jar of yellow Spanish iris on the hearth. An electric clock and two silver candlesticks on the mantelpiece. Two small oils in gilt frames, almost obliterated but apparently views of Edinburgh Castle from widely separated points on Princes Street. Two others in black frames—obviously old—of little girls in long frilly frocks and wide-brimmed hats standing in daisy fields. The carpet was a handsome, self-figured green: the curtains a browny-fawn velvet that went well with it. Scattered about were newspapers and journals, giving the room a lived-in appearance.

  ‘Where would you like to sit?’ Sisson asked.

  They chose their seats. Masters inquired: ‘Are you a married man, doctor?’

  ‘Not me. Haven’t had time to think about it yet.’

  ‘Not even to think about it?’

  ‘Well … you know how it is.’

  Masters took out his pipe and asked permission to smoke it. Sisson got up and poured three whiskies. When they were all settled again, Masters said, ‘I know nothing about diabetes and comas. Chief Superintendent Hook told me you are an expert. Could you enlighten me as simply as possible?’

  Sisson balanced his glass on his chair arm. ‘It’s not a disease, you know,’ he said.

  ‘What is it, then?’ asked Green.

  ‘You could call it a disorder. But strictly it’s what’s known as a metabolic defect.’

  ‘Could you explain that?’ Masters requested.

  ‘You don’t know what metabolism means?’

  Green said, ‘He will. I don’t.’

  ‘It’s the physical and chemical processes within the body by which food is converted into living substance.’

  ‘You mean it turns boiled beef and carrots into living flesh?’ Green asked.

  ‘Not quite. It organizes food into a state where it can be reconverted into simpler compounds like starch and sugar, which in turn change to fat or release energy for the use of the body. That’s a very simple and not wholly accurate picture, but it will do.’

  ‘Got it,’ Green said.

  ‘Good. Now, to complete the metabolism, sugar needs insulin to oxidize it for use as energy in the muscles. O.K. so far?’

  Masters nodded.

  ‘If the body can’t produce enough insulin of its own to use up all the sugar, you get spare sugar being discarded by the body—in the urine. Hence the name of the defect—diabetes mellitus, which means honeyed urine.’

  ‘How does this defect occur?’ Masters wanted to know.

  ‘Like any other defect, such as poor eyesight. You can be born with it, have it caused by accident, or as you get older you can gradually come to it.’

  ‘But Sally Bowker was only about twenty-two …’ Green said.

  ‘I know. That’s one of the tragedies. Kids as young as eleven can develop it—and up to about the age of thirty their type of defect is still known as juvenile diabetes, which is, incidentally, the worst form, because of all the demands made upon the body by young, active life.’

  ‘How does it start?’ Masters asked.

  ‘By developing a defect in the pancreas. Or to give it the butchers’ name, the sweetbread.’

  ‘Seriously? You mean we eat …’ Green said.

  Sisson nodded. ‘Now you know where it gets its name.’

  ‘I’ll never touch it again.’ Green looked at Masters as though the latter doubted him. ‘I won’t, I promise you.’

  Sisson went on: ‘The pancreas has lots of little glands which produce insulin. Now, if those glands aren’t working, or if only some of them are, we have to inject insulin to make up the body’s requirements. Fortunately, most diabetics are not of this type. Most are what is known as maturity-onset patients. This means that in later life, together with most other parts of the body, the insulin glands are beginning to get a bit tired, and so don’t do their stuff properly. If that’s all that’s happened, we very often don’t have to inject insulin. In lots of cases we can give pills that ginger up the glands to make them start working a bit harder. That produces enough insulin for older people, because they are less active and so have smaller appetites. But when we can’t ginger up the tired glands, then we have to resort to insulin again.’

  Masters said, ‘Let me see if I’ve got this right. A girl like Sally Bowker, still in the flush of youth, hasn’t lived long enough for her glands to begin to wear out. They’ve just packed it in for some reason or another, and so there’s no alternative to injected insulin. Correct?’

  ‘Absolutely. All young diabetics have to be given insulin.’

  Masters relit his pipe. As he put the match in the tray he said, ‘Many thanks. That’s cleared that up. But I’m puzzled about diabetic comas. Shouldn’t she have taken a sugar lump or something?’

  Sisson stretched his legs and rested the heel of one shoe on the other toe. ‘Let’s put it this way—just for simplicity’s sake. There are two types of coma a diabetic can fall into. One’s what we’ll call a sugar-coma, meaning they need sugar; and one we’ll call an insulin-coma, meaning they need insulin. Those aren’t the correct names, but they’ll make it easier for you if you’ll remember that the substance mentioned in the name is the substance they are short of. Better still, call them sugar-hunger and insulin-hunger, then we shan’t get confused. Are you with me?’

  ‘I’m on your heels, doc,’ Green replied. ‘If I keep this up I’ll be applying for medical school next.’

  ‘The more the merrier. But to get back to the Chief Inspector’s remark about the sugar lump. Most people regard sugar as poison for diabetics. It isn’t. It’s the staff of life. They should all carry it with them to suck at any time, because it’s true that by far the most common type of coma is sugar-hunger. And the coma can come on fast. But it goes even faster if you can get some sugar into them. They’ll literally recover in the middle of being given a glucose drink. They should be able to dose themselves as soon as they start to perspire and feel woozled. Most of them do. But insulin-hunger is a different—and far more serious—thing. Fortunately it’s not nearly so
common. And the answer is to inject insulin. But because it’s a more serious condition, diabetics who suffer from it at any time usually need medical attention and nursing.’

  ‘How quickly does it come on, and go?’ Masters asked.

  ‘Much more slowly than sugar-hunger, both coming and going. It takes anything up to forty-eight hours each way, unless …’

  ‘Unless what?’

  ‘Unless there’s something to aggravate it and bring it on much more quickly.’

  ‘Meaning?’

  ‘When diabetics get other illnesses, like ’flu or a bilious attack, etcetera, they need more insulin to combat them. Not less, as some think. You see, they believe that because an illness means they lose their appetites, they don’t need insulin. This is wrong. In fact they need more to help them fight the ailment. And if they omit to take the insulin—or don’t increase it if necessary—they start to suffer from insulin-hunger, and the symptoms of a coma start coming on.’

  ‘What symptoms?’

  ‘Thirst. Desire to urinate. Tiredness. Drowsiness. Nausea. Probably abdominal pain. Shortness of breath.’

  ‘Are they the people whose breath starts smelling of peardrops?’

  ‘That’s it.’

  ‘How does that come about?’

  ‘Well, with no insulin to oxidize the sugar, the body starts to utilize the fat for energy. It burns it up, but there’s not complete combustion. Just like when you make a coal fire you produce warmth—which is your object—but you also produce smoke, soot and ash. The body gets rid of some of this through the urine—the ash, as it were—while the soot remains as a sort of poison to make them ill, and the smoke comes out as acetate on the breath. These people lose weight very rapidly.’

  ‘I can see they would if they burn up their fat. Now, Miss Bowker. She died in a diabetic coma, brought on by insulin-hunger?’

  ‘Yes.’

  ‘Because she injected herself with useless insulin?’

  ‘That is my belief.’

  ‘Even though these comas are slow to start?’

  ‘That’s the only thing that puzzles me. Why she didn’t get help while she was still capable of doing so.’

  ‘Even though she was sick? She vomited, you know.’

  ‘She would. That’s one of the symptoms. It’s caused by the accumulated poisons of excessive fat metabolism. They urinate a lot and they vomit. This dehydrates them. The body loses all its fluid. As much as ten or fifteen pints. With the fluid go the basic minerals. As a result, their circulation collapses, their pulse becomes feeble and god knows what else. They look like Belsen inmates and they are in immediate danger of death. Insulin alone won’t save them then. They’ve got to have the fluid they’ve lost put back straight away. And even when that’s done they can die from shock and heart failure. If there’s nobody to help them …’ He didn’t complete his sentence. The thought of Sally Bowker, ill and helpless, seemed to affect him more than Masters expected a doctor to be affected by the death of a patient. Without regarding doctors as in any way callous—any more than he was himself—he was of the opinion that they encountered death so often it inevitably began to have less effect on them as time went by—again, just like himself.

  ‘When did you last see her—before her death?’ he asked.

  ‘On Saturday morning. I like to reserve that surgery for permanent patients. Patients who have to come and see me at intervals for long periods or, as in the case of diabetics, for the rest of their lives.’

  ‘You examined her?’

  ‘Thoroughly. They bring charts of their urine tests, you know. I looked at Sally’s record pretty carefully, and tested the sample she brought. I do that. Just to make sure they’re not backsliding or making mistakes with their own tests. And I gave her an overhaul. Examined her feet pretty carefully …’

  ‘Why her feet?’

  ‘Because the extremities are a diabetic’s most vulnerable spot. Any cut or abrasion on the feet is liable to go wrong. I’ll not go into the medical reasons, but take my word for it, gangrene can set in very easily because their feet are poor healers.’

  ‘Are you in a position—ethically—to tell us the result of your examination?’ Masters asked.

  Sisson turned towards him. He said gruffly, ‘To hell with ethics in this case. Sally Bowker was one hundred per cent fit. Not a snuffle in her nose or chest. Not a flutter of her heart. One hundred per cent fit. That’s why, when she died in a coma shortly afterwards, I was suspicious. Insulin comas take time to come on—maybe up to forty-eight hours—as I’ve told you. If she’d been starting one that would render her helpless by Saturday night, I’d have spotted some of the symptoms twelve hours before.’

  ‘You’re sure?’

  Sisson glowered. ‘Of course I’m sure.’

  ‘Please don’t misunderstand me. I’m not doubting the thoroughness and skill of your examination. I’m wanting to establish without doubt that a coma which could knock a girl out by midnight would be showing some signs during the morning before. The first signs couldn’t have appeared, say, in the middle of the afternoon?’

  ‘Not a chance.’

  ‘Alternatively, could the coma have come on later than Saturday night?’

  ‘It could. But I’ll take my oath it didn’t.’

  ‘What makes you so sure?’

  ‘Lots of reasons. First of all, the body takes a long time to die, and Sally had been dead at least twenty-four hours when I saw her on Monday evening. That means she’d died no later than Sunday evening. A coma such as this doesn’t kill even the old and decrepit in a flash. If she became comatose by midnight on Saturday, it means that she was lying there less than twenty hours. A girl as fit and well as Sally would take at least that time to die.’

  ‘That sounds convincing.’

  ‘But there’s something else which makes me sure this coma came on fast. Sally was a very sensible, practical girl. She knew what the symptoms of coma were and how to combat them.’

  ‘Had you taught her?’

  ‘Thoroughly. She knew that at the first signs she was to take more insulin. This she had done. The dose taken from the bottle shows that.’

  ‘Does it? How?’

  Sisson accepted a cigarette from Green and sat back thinking for a moment. Masters watched him carefully. At last the doctor said, ‘Let’s go through my reasons from the beginning. Sally was on long-acting insulin. That means she only had to inject twice a day.’

  ‘At twelve-hour intervals?’

  ‘Not necessarily. Actually the times of injections are governed by the times of main meals. To get ready to counteract the food that the body is about to get, you need to inject about half an hour before the meal. So I’d given Sally a programme which meant an injection half an hour before breakfast and half an hour before supper.’

  ‘She ate breakfast?’ asked Green. ‘Not just a glass of orange juice?’

  ‘She ate hearty.’

  ‘Was she allowed to?’

  Sisson grinned. ‘These juvenile diabetics are put on a diet like everybody else. But because they’re so active they need more food, so as long as they don’t go too far over the score, they’re not restricted nearly as much as most people think. Certainly the first rule for diabetics is “Never go hungry”.’

  ‘I see. The little weighing-scales are completely out of fashion.’

  ‘Gone years ago. You can adjust insulin intake these days fairly easily to make up for minor indiscretions. It’s a good thing to take great care, of course, but the thought that they’re not in an absolute strait-jacket helps them mentally.’

  ‘I can understand that. But now to get back to Sally Bowker …’

  ‘Oh, yes. When she came to me on Saturday she’d already had her morning injection, and she told me she’d got just enough left for her before-supper dose. That was how it should be. I prescribed just enough to carry her through to the day of our next appointment.’

  ‘Isn’t that a bit risky?’

  ‘N
ot at all. She could always call at any time if the need arose. But I like to give them just what they need each time. Then they can get a nice, fresh supply for the next four weeks.’

  Masters tapped out his pipe on the palm of one hand and dropped the ash into the tray. ‘So you gave her a new prescription which we know she took to the chemist that morning. At seven in the evening—or just before supper time—she’d have taken the last dose of the old stock. The new should have been started at breakfast time on Sunday. Right?’

  ‘Quite right. But I’m positive that having died on Sunday evening, she could not possibly have been in a fit state to inject herself on Sunday morning. I’m positive that the latest time she would have been able to do this would have been midnight Saturday.’

  ‘I’ll accept that for the moment. Now can you explain why she didn’t get help.’

  Sisson leaned forward. ‘I’m certain she was taken by surprise. She must have suddenly become aware that the coma was on her. She acted quite properly in giving herself another dose of insulin. Thinking that would work she probably didn’t call anybody and then, by the time she realized the injection wasn’t going to reverse the symptoms, she was probably too ill to phone. State of collapse, I’d have thought. Flaked out on the bed and never came round.’

  ‘Then how do you account for her going to the lavatory to vomit, and clearing up afterwards?’

  ‘That was probably the first symptom. And you know yourself that if you have a good clear-out, you feel better, if only momentarily. At least until the next wave comes. You probably feel so much better you can pull the chain, clean your teeth … all sorts of things. Then you’re sick again. And so on. Until, as I see it in Sally’s case, you lie down virtually exhausted, waiting for recovery. Instead you become comatose.’

  Masters got to his feet. ‘Thank you, doctor. If nothing else you’ve given us a basis for working on.’

  Sisson stood up and said, in a rather embarrassed tone, ‘I’m glad. I want to help.’