Bob crushed out his smoke. “Three years ago, before I met you and the boys, I walked out with a girl from Cultra.” His voice softened. “It wasn’t until she’d married an army captain, Lord John MacNeill, next in line to be the Marquis of Ballybucklebo, that I realised I’d let a gem go. Your Kitty’s a jewel. She cares for you and it shows. Don’t make my mistake if you feel for her. Don’t lose her.”
Fingal sat back. “Thanks, Bob,” he said quietly. “I appreciate the advice. I didn’t know about the girl from Cultra. I’m sorry for your troubles. Thank you for telling me.”
Bob shrugged. “Water under the bridge.”
Look in your heart, Fingal told himself. Bob’s giving you good advice. You are in love with Kitty O’Hallorhan. “I’ll tell her—after the exam.”
Bob inclined his head. “Good man. I don’t think you’ll regret it.”
“You’re right.” Fingal took out his fountain pen. “Now. Read the bloody book.”
Bob began, “The leukaemias are a family of blood cancers—” Fingal’s fingers tightened on the pen, “first described by Rudolph Virchow in 1885 who reported a large number of white blood cells in a smear of a sample taken from a recently deceased patient. He coined the term from the Greek leukos, white and aima, blood. Ten years later Franz Neuman noted that instead of being red the bone marrow of a leukaemia patient was ‘dirty-green-yellow—’”
“So medicine’s only recognised the disease for fifty years,” Fingal said.
“Looks like it.” Bob read on—and on until he closed the book and announced, “Here endeth the lesson.”
“Right,” Fingal said. “Let’s see what you’ve learnt.”
Bob sighed. “I love the way you can switch from slave driver to grand inquisitor, O’Reilly. You’re sure you’re not Torquemada reincarnated? Haven’t we done enough for one day?”
“Divil the bit,” Fingal said. He’d remember every word. He had a pressing reason to, but if Bob was faced with an exam question on these disorders, it was important he remember what he’d been reading. “Classify the leukaemias.”
Bob lit a cigarette, pushed back his chair, and said, “Leukaemia is an abnormal increase in white blood cells which are produced in the bone marrow, but appear in the bloodstream—”
“I didn’t ask for a definition. I asked—”
“For a classification. I know. Steady on, old man. The leukaemias are classified by the type of cell involved and the speed of onset and progression of the clinical course. Two types of cells may be involved: Lymphocytes, which are infection fighters, and myelogenous cells, which are immature forerunners of many blood components, including red cells, white cells, and platelets.”
“So there are only two types of leukaemia?” Fingal asked.
Bob shook his head. “I said the rate of progression was important. Disease of both cell types can be acute or chronic. The chronic ones have a slow onset and can go on for many years with many patients succumbing to some other unrelated cause of death.”
Fingal could hear Doctor Micks. “If it is—we must pray it is one of the chronic varieties.”
“Acute leukaemias, lymphocytic and myelogenous, are swift in onset and rapidly fatal,” Bob said, and grinned. “There, how did I do?”
“Top of the class,” Fingal said quietly. “Absolutely right.” He pulled in a deep breath and sighed.
Bob leant forward. “You all right, Fingal? I thought you were just your usual no-nonsense about work self, but now you sound, I don’t know, you sound a bit low.”
“I’m sorry, Bob,” Fingal said. Like his love life, he didn’t want to discuss family matters, not even with closest friends. Certainly not now when the tests had yet to be done and Father’s diagnosis was speculative. “Just a bit tired, and worried about Part One.” He slipped from his chair and pulled out his pipe. “Tell you what. Let’s have that drink, a smoke, then you take the notes and grill me on the signs, symptoms, investigations, and treatment.”
Fingal lit his pipe while Bob poured two Jamesons.
“Here.” He handed a glass to Fingal. “Fingal,” Bob said. “I’ve already stuck my nose into your business about Kitty. You can tell me to shut up if you like, but you’re not yourself today. What’s up?”
Fingal swallowed and felt the smoothness of the Irish whiskey. He rolled the glass between his palms, and looked at Bob. “At eleven o’clock this morning my father had blood samples taken. We’ll have the results on Monday. We hope it’s glandular fever.” He didn’t need to go on. Bob’s whispered “Oh Christ” was enough for Fingal to know his friend had understood what else might be turned up.
29
The Sensation of a Short, Sharp, Shock
Describe the macroscopic and microscopic postmortem findings in a patient who had been suffering from sarcoidosis of the lungs and liver. Fingal reread the question. It didn’t help. He still knew virtually nothing about the subject. Two hours ago, the invigilator had announced, “It is two o’clock. You may turn over the examination paper and begin.” Moments later, Fingal had recognised his nemesis. The mine lurking in calm waters. Now, having written the other two required essays, he was glaring at the question and realising he was not going to find divine inspiration.
He sat in the back row of the hushed Examination Hall of Trinity College Dublin. Six months earlier he’d squired Kitty here to the New Year’s Ball. Since Monday he’d written two three-hour exam papers each day. One before lunch. One after. The subjects were twinned. Materia medica and therapeutics, medical jurisprudence and hygeine, and pathology and microbiology. They were passed or failed in pairs, a good mark in one could compensate for a poor mark in the other. Two sets of poor marks and the student would be repeating the exam in those two subjects in December.
And the papers weren’t all. Starting tomorrow would be a series of oral and practical exams. Now, on Wednesday afternoon, June 26, 1935, he was staring at the last paper of Finals Part I. Pathology. And he wasn’t happy.
He’d had no trouble with two of the questions, rheumatic fever and cirrhosis of the liver. He’d learnt about the former when he’d looked after Kevin Doherty. Cirrhosis had been one of the subjects he’d missed for rugby practice, but they’d seen a patient of Hilda’s on the women’s ward. The poor woman had died three weeks after admission. He and Bob had spent an evening together reading the pathology. But this? This? He knew sweet Fanny Adams about sarcoidosis. He’d missed the Thursday lecture two weeks ago when Doctor Micks had come to Lansdowne Road. Fingal had never seen a case and had been too preoccupied with the blood disorders since his old chief’s visit to read up on this disease. He wished to the bottom of his soul that he’d spent an hour or two on the rare inflammatory condition.
And he’d not been satisfied with his answers on this morning’s microbiology paper either. A first-class answer to all three questions now should compensate for a poor showing in one question this morning. But to mess up two linked subjects? He’d be joining the chronics in December, would have to reread two vast subjects in detail to be sure of a pass, and that would mean less time to study for the all-important Finals Part II exam next June.
Damn it. He shook his head. Damn it, if he had to go down, he’d go down fighting.
On the principle that a blank sheet would garner nothing, but putting down what little he knew might collect a few critical marks, Fingal wrote, Sarcoidosis is a rare disease of unknown causation. Collections of inflammatory cells, but he hadn’t a clue about which specific ones, can be identified in any organ system and would be particularly numerous in the lungs and liver of the patient in this question. There is no known cure. Just, he thought, as there is no known cure for not having prepared enough for this exam. He looked down the hall where his entire class bent over their desks scribbling. Several students from more senior years were re-sitting.
He looked up. The clock said there were fifty minutes left before time was up, but what was the point of sitting here? He held up his hand. The invigilator
left his desk and walked past the ranks of desks. “Yes, Mister O’Reilly?” he said sotto voce.
“I have finished, sir.” He handed his answer booklet to the lecturer. Perhaps Fingal should have said, “I am finished, sir,” to convey his certainty that he had failed, but he felt an even more appropriate expression would have been, “I am bollixed.”
“Once you leave the hall you will not be readmitted.”
“Yes, sir.”
“Very well. Good luck.” He smiled.
* * *
Fingal found a bench under a sycamore tree in the courtyard. The sounds of traffic from nearby College Green were muted. The sky was overcast and he heard a distant rumble of thunder. A grey day to suit his mood. He lit his pipe feeling like a newborn taking comfort from a dummy tit. Lord knows, Fingal O’Reilly needed solace, and being certain he’d failed two subjects was the least of his troubles since Monday nine days ago. He puffed a mighty cloud and remembered.
“O’Reilly,” Doctor Micks had said, “you are on time. Good.” The consultant turned to his entourage. “I shall see you all back here on Saint Patrick’s Ward on Wednesday.”
There was a chorus of, “Thank you, sir,” from the current group of clinical clerks.
He took Fingal by the elbow. “Come with me,” and led him into a small room to the side of the ward. “Please sit down.” He picked up a report and handed it to Fingal. “I imagine you’ve become quite knowledgable about leukaemia. Under the circumstances, I certainly would have read up on the subject.”
“I did, sir.” Fingal looked at the report. “There’s no rise in the lymphocyte count so it’s not glandular fever.” Damn. “The platelet count is low, the red cells are low, and that explains why my father has bruises and is tired and short of breath—” Fingal looked up at his teacher and back down to the form, “but the white count isn’t increased. I don’t understand.” He grinned. “He doesn’t have leukaemia. That’s wonderful.”
Doctor Micks steepled his fingers and looked straight at Fingal. “That’s what I thought, but blood diseases aren’t my field. I asked Doctor Fullerton. He has a special interest in haematology.”
Fingal’s grin faded; his palms were sweating.
“I’m sorry,” Doctor Micks said, “but there is a rare variant called aleukaemic leukaemia.”
“It wasn’t in the book I read, sir.” Aleukaemic meant “without white blood.” “How can anyone be suffering from an excess of white cells without having too many of them? It doesn’t make sense.”
“My thought exactly, but contrary to popular belief, consultants are not omniscient. My colleague explained that in this situation the abnormal cells are produced but never leave the bone marrow so they don’t show up on a blood test. They do, however, interfere with the production of other blood components.”
“Father’s red cells and platelets are low.”
“I’m afraid so.” Doctor Micks leant closer. “Fingal,” he said, surprising him with the familiarity, “Fingal, I very much fear it is what ails your father.” He paused.
He’s giving me time to digest that, Fingal thought, and it’s a tough mouthful to swallow. “Will Father need a bone marrow biopsy?” he asked.
“Yes, he will. It will deny or confirm that there is leukaemia, but more importantly if there is, what cell type and whether it is chronic or acute.” He touched Fingal’s arm, surprising him for the second time in as many minutes. “My boy, things might yet turn out well. The condition may be chronic.”
“How soon can you arrange the biopsy, sir?”
“Doctor Fullerton will do the procedure himself as a courtesy to you and to a fellow Trinity professor.”
“That’s very decent.” It was. Even in skilled hands, driving a wide-bore instrument into the breast or hip bone to get into the marrow cavity was tricky and painful.
“Unfortunately Doctor Fullerton is leaving this afternoon for an extended visit to Saint Bartholomew’s Hospital in London. He can be back on the thirtieth, do the biopsy, and read the slides first thing on Monday, July first.”
That was two weeks away. Fingal was going to ask could the test not be done sooner, but his senior asked, “Where will you be at ten o’clock that day?”
“Here, sir. July first is the start of our surgical dressership at Sir Patrick’s.”
“I’ll explain to Mister Kinnear, the senior surgeon, why you will be absent that morning. I’ll talk to you here, and take you with me to your parents’ house.”
“Thank you very much, Doctor Micks.” Fingal hesitated. If a physician of Doctor Micks’s stature was comfortable with having to wait, a student should be too. But this was Father’s test.
“Can we afford to wait two weeks, sir?” Fingal had been taught that in cases of cancer, speed of diagnosis and treatment were critical. To say nothing of leaving patients in a limbo of worry. Two weeks could seem like a lifetime.
“Yes.”
“Two weeks?” Fingal heard his voice rise in pitch.
“I appreciate it sounds like an eternity, but if we think about it dispassionately—”
“It’s not easy, sir, being dispassionate about family. This is my father.”
“It’s difficult for you under the circumstances, Fingal, I know.” Doctor Micks inhaled deeply. “I do know.”
“Thank you.”
“But the harsh facts are there is no cure for leukaemia. We can try to help his anaemia with iron supplements, proper diet while we wait for the results. We’ll be giving it to him regardless of the final diagnosis anyway. If he becomes very anaemic, a blood transfusion will help and for the long term—”
Fingal nodded and swallowed. “I understand, sir.”
“I’m sorry, but as things stand, I think waiting so the best man in the country can do the tests makes sense. Doing them isn’t going to change anything, it will only give us answers and a prognosis, and they’ll be the same in two weeks as they are today. They’ll not change any treatment.”
“I agree.” Fingal realised he was crushing the report, relaxed his grip, and smoothed out the creases in the paper. “I do understand, but the waiting’s not going to be easy.” He gave Doctor Micks the report.
Doctor Micks accepted the form. “Can you be free this afternoon?”
“Yes, sir.”
“I promised your parents I’d call by to give them the blood results. I imagine you’d like to be there.”
“Will you be able to soften the blow, sir?”
Fingal was surprised when Doctor Micks shook his head and said, “They’ll need time to digest everything I’ll have to tell them. I must be absolutely honest.”
And he had been at Lansdowne Road that afternoon. The coming biopsy, the possible results, and the different prognoses depending upon the results had been presented factually and calmly. Father and Ma had taken the news stoically. It wasn’t until Doctor Micks had left that Ma had permitted herself to cry. “It’s so unfair, Connan,” she said.
“Yes, it is,” Father said, handing her his hanky, “but then life’s not fair, and if I’ve understood the consultant there is a good chance I might have the fairly benign disorder.”
She blew her nose.
Fingal hesitated. He didn’t want to intrude. It was a time his parents needed to be together without him. “If you’ll excuse me, I’ll go and give Lars a ring,” he said. “Let him know what’s happening.”
“I’d rather you didn’t,” Ma said. “I know you’ll worry, but I think we shouldn’t concern your brother until we know exactly what the future holds. You agree, Connan?”
“Completely. I’m sure I’ll have the chronic sort so why upset Lars? Am I right, Fingal?” Father asked.
Fingal hesitated. For the first time ever Father, Father with a capital F, had asked Fingal’s advice, his reassurance. “You are indeed, Dad.” Dad. It seemed somehow right to call his father Dad, and by the way the man smiled, he must have thought so too. “But I’ll give Lars a call anyway. I’ll not worry him, just t
ell him you need one more test in a couple of weeks, to bide content with that and not worry.” I can worry enough for all of us, Fingal thought, and Doctor Micks is right. A doctor’s job is to alleviate suffering.
“Thank you,” Father said. “I am relieved.”
“Be a good boy, Fingal,” Ma said. “I’m sure you need to get back to your hospital, but on your way out ask Bridgit to have Cook send up some tea and biscuits.”
His mother had deftly protected her eldest boy for two more weeks. And now, sensing Fingal’s discomfort, she had given Fingal an excuse to leave and allow her and her husband the privacy she must know Father would prefer. She could perfectly well have rung for Bridgit.
Fingal kissed her cheek. “I’ll be in touch,” he said, “try not to worry too much.”
The flash of a lightning bolt and nearly simultaneous thunder brought Fingal back to the present. The first drops rattled on the sycamore leaves. He scurried back to the Examination Hall, shoulders hunched against the downpour, as a second jagged strike rent the heavens and the celestial cannons roared.
Back in the shelter of the anteroom Fingal found a seat. Time for the remaining candidates would be up in twenty minutes. He’d wait for the lads. The plan had been to go for a pint after the last paper. Even if he was not enthusiastic, he’d go. Being with his friends would take his mind off his troubles.
The hall doors opened. Bob Beresford strode out, lighting a cigarette. He waved. “Fingal.”
“Have a pew, Bob.” Fingal nodded at the seat beside him. “You’re out early.”
“Huh,” Bob said. “I just hope I put down enough. All that nose to the grindstone stuff with you, O’Reilly. I know I backslid for a while, but recently I’ve started to hope I’d make it.”
“So you bloody well should. We’ve been telling you we’d make a doctor of you in spite of yourself, Beresford. And remember that conversation we had about making a difference—perhaps in research.”
A Dublin Student Doctor Page 25
