The Vasectomy Doctor

by Dr. Andrew Rynne

  A strange thing about going through the six-year course of medicine is that the longer you go on the easier it becomes. For example human anatomy is a horrible subject that requires you to submit reams upon reams of largely useless information into your brain and to regurgitate it at exam time. The next year or two are not much better. But when you come to the two final clinical years during which you study medicine, surgery, paediatrics, obstetrics and gynaecology, ophthalmology, some psychiatry, radiology and dermatology, all of these subjects are rational, practical, interesting, and easy to remember and to understand.

  Practical medicine is taught at the bedside and we all flock around the poor patient up on Richmond One. The women are allowed up front because in the main they are not as tall as the fellows. Some of the fellows, but one in particular, seems to always get himself up right beside the patient. This guy pisses the rest of us off a bit. Professor Alan Thompson is giving the tutorial. The patient, an elderly man, is suffering from chronic bronchitis and emphysema or, as we would say nowadays, chronic obstructive airways disease or COAD for short. In hospital, as a kind of a code, they were often just referred to as ‘blue puffers’. At that time hospital wards in Dublin were full of blue puffers whose conditions were exacerbated by the higher levels of air pollution that we had in those days. Blue puffers were considered good teaching material because they had a lot of signs and symptoms – a lot of things to ‘demonstrate’ as we used to say.

  Even though we had two more years to go we were often, a bit sarcastically I suspect, addressed as doctor.

  ‘Tell me, doctor,’ says Professor Thompson, looking straight at me, ‘What do you think is the matter with this poor man?’ This is the first real live ‘patient’ that I have ever seen in my life and the professor wants an opinion from me! But to be fair about it Professor Thompson, who always wore a dickey bow and was the first radio doctor to ever broadcast on Radio Éireann, was a gentleman and a kind teacher. He saw my discomfort and offered me a way forward.

  ‘Does the man look well or does he look ill?’ he wanted to know.

  And there was my very first lesson in clinical medicine and one that all doctors instinctively use throughout their professional lives. Simple commonsense, intelligent and straightforward observation can still tell you more about a person than even the most sophisticated blood test or scans. Does the person look well or ill? Always look your patient straight in the face and ask yourself that question.

  ‘He looks very ill, sir,’ I proffered. The professor concurred.

  Someone suffering end stage ‘cor pulmonale’, as this condition is also sometimes referred to, looks dreadfully unwell. Their functioning lungs, which should look like a large bunch of tiny grapes, are now more like a bunch of tennis balls. Thus the surface area of the lungs used to oxygenate the blood and carry away carbon dioxide is massively reduced. The patient’s lips are constantly blue, or cyanosed as we say in the trade, due to a chronic lack of oxygen and excess CO2. In an effort to get as much air into their lungs as possible the patient holds his chest wall in the full inspiration or expanded position and this is referred to as ‘barrel chested’. While breathing out the patient purses his lips in an effort to push back the escaping air so as to leech out of it the maximum possible amount of oxygen. When you look at their fingernails, blue puffers will often exhibit ‘clubbing’ a sure sign of long-term oxygen starvation. This man is slowly dying in front of us.

  All of these things are carefully pointed out to us and their significance explained. This is part one of the steps to be taken in order to reach a diagnosis. It is referred to as ‘inspection’ and it is what you can see with your eyes before laying a hand on the patient. Auscultation comes next.

  One of the greatest inventions ever made in medicine has to be the stethoscope. Simple and all as it may be, it has to remain up there with anaesthesia, x-rays, insulin, vaccines and penicillin. It was first devised by a French chest physician, Dr Rene Laennec, in 1816 as a simple cardboard, and later a wooden, tube. Indeed it was not until nearly the end of that century that the stethoscope began to take on its present form of two earpieces connected by tubing to a diaphragm.

  Just as all anglers are said never to forget catching their first salmon, so too it can be said that all doctors remember purchasing their first stethoscope. This is a ritual before entering your second last year of medicine. Mine was proudly bought in Fannin’s of Grafton Street. The trick then was to carry it around in your pocket with part of it sticking out for all to see. A stethoscope is as iconic to a doctor as a whistle is to a referee or a crozier to a bishop; the only difference being that the former two may be of some practical use while the latter is of none.

  When growing up as a child I always thought that there was something terribly clever about the way a doctor could place the bell of a stethoscope on your back, ask you to breathe in and out and that this actually told the doctor something about what was going on inside you. But actually there really is not all that much to it once you have a bit of practice. We line up to listen to this poor man’s lungs. Professor Thompson tells us where to place the stethoscope and then asks us to describe what we are hearing. We already know what a normal lung should sound like because earlier several of us had taken our shirts off and allowed our colleagues to listen to our healthy young lungs. Listening to a normal healthy lung through a stethoscope you hear a sound like a gentle breeze through the trees. But when you listen to this poor man’s lungs there is no breeze at all, there is at first a hideous silence. And then, like a cry in the night, you hear something that just sounds all wrong, something foreign and strange to nature. We call these ‘rals’ in the trade. They are a kind of a musical liquid clicking sound, the sound of air travelling through disease. The sound of approaching death.

  On another ward a young woman has pneumonia. These days you would not routinely hospitalise someone with this condition but forty years ago doctors were more conservative. The professor asks the lady if she would mind if all ten of us took turns to listen to her lungs. She seems quite happy to oblige. People, God bless them all, seem to understand that medical students have got to learn somewhere and are generally happy to lend a hand.

  When you listen with a stethoscope to the lungs of someone with lobar pneumonia you hear the sound of a gentle breeze through the trees throughout the lungs until you come to the part that is infected. At this precise point you hear something totally different and strange. In the trade we call these sounds ‘crepitations’, classically likened to the sound of snow being crushed under foot as you walk along of a winter’s evening. But this group of students has a problem with that description, accurate and all as it may be. They all come from countries where it never snows so they have no idea what we are talking about. Someone produces a balloon and blows it up. If you rub the surface of an inflated balloon you can produce a sound exactly like the crepitations of pneumonia. We are all learning fast.

  In the afternoon it is surgery with Professor William McGowan upstairs on Richmond Four. A fifteen-year-old girl has been admitted with abdominal pain and vomiting. Again it is inspection first. Just look at the abdomen and see if you notice anything strange. Usually you won’t but in rare circumstances like bowel obstruction you may see what’s called ‘visible peristalsis’ or forceful movements in the bowel against the obstruction. One or two of us only then are asked to palpate her abdomen. The other students will have to wait for another day but all of this stuff is vitally important and critical to the making of a competent doctor.

  First you ask the patient to point with one finger to where the pain is. Later when the students have turned into doctors and have gained experience they will learn that in practice, in the case of very small children, when you ask them to point to the pain, the mother often steps in and tries to do it for the child. I know the mother means well but this is a big mistake. The child knows exactly where the pain is. And besides children are honest and have no hidden agenda like trying to justify their conce
rns or justify their presence in your surgery.

  You palpate an abdomen gently but firmly using the tips of your fingers with the palm of your hand spread out and laid on the skin. Watch the patient’s face, not your hand and start at the point furthest away from the pain. You do not prod or poke and you are ever mindful of the structures underneath where you are feeling. When you come to the point where the patient indicated the pain to be at its worst, you may or may not elicit tenderness and cause the patient to grimace or the child to cry. At this point too there may be muscle guarding or tightening of the abdominal muscles protecting the source of the pain. If you do all this correctly then you may never miss the diagnosis of appendicitis. But there isn’t a doctor that I know, including myself, who could honestly claim any such record.

  * * *

  It was during these final two clinical years at the College of Surgeons in Dublin that I developed a love for game shooting – a hobby that would eventually surpass, though never replace, my interests in Irish music and singing. Shooting is an interest that I carried through all of my life. In these parts the sport can be divided roughly into three divisions – rough shooting, driven shooting and wildfowling or duck shooting. Rough shooting in turn can be divided into two groups – snipe and woodcock shooting or rough shooting pheasants. At this stage, when I was in my final medical school years, I really only knew about rough shooting pheasants. Woodcock and snipe, wildfowling, driven shooting and clay pigeon were all to come later.

  There are two ways of rough shooting pheasants. You can use springer spaniels and run them along the hedges and ditches and through the stubble and root crops, all the time hoping that they will come on pheasant and flush them within range for you. The problem with this approach is that spaniels, other than the exceptional field trial specialists, tend to go like hell and there is always the danger that when they do put up birds that these will be out of range of the guns. Birds were too scarce to be flushing wild when I did my early shooting.

  The other way to rough shoot pheasants is to use pointers or setters or, as our ghillie down in Kerry, Eugene Hayes, calls them, ‘stopping dogs’. My friend Joe Ward outside Prosperous kept short-haired liver and white English pointers and these were perfect for the kind of terrain that we were shooting over – a mixture of cut-away bog and agricultural land. The great thing about shooting over pointers is the comfort that’s in it. When a pointer gets a whiff of a pheasant he freezes immediately like a piece of sculpture. You know that there is a bird around somewhere. But you do not know exactly where it is or when it will burst onto wing and take off rocketing across the ditch.

  In the two seasons that I shot with Joe Ward and his pointers I do not believe that I shot one single pheasant. I did not know how to shoot in those days and it was not until I got lessons in clay shooting in Canada a few years later that I began to understand what was involved. But Joe was a generous man and would always give me a bird or two to take home and no one was any the wiser and everyone thought that I could shoot.

  But the point of shooting, strangely, is not about killing birds. It is mainly the working and watching of the dogs, not the actual shooting itself, that makes this sport so enjoyable. When I think back on those wintry Sundays and Joe Ward and I out under clear blue skies very early on a frosty morning, in and around the Cot bog or Ballinafagh or Kilmurray where the rushes might be frozen solid and the gorse still showing an occasional golden bloom, or where the hawthorns had not even yet dropped the last of its dark red berries and blackbirds cry in alarm in front of our stopping dogs, when I recall all of this, as I often do, I am again filled with a warm and good feeling and I know that life for the most part is wonderful.

  * * *

  Now my mother is writing her biography of Francis Ledwidge, the pastoral poet who lived just outside Slane in county Meath. This is a fairly massive undertaking involving all new research and interviewing no fewer than thirty of the poet’s own contemporaries still alive at the time. The entire work takes her eight years to complete – from 1964 to 1972 – during which time her health was to deteriorate quite markedly. The reasons why my mother undertook such a labour of love were, I think, threefold:

  Firstly Cardinal Wright of Boston, with whom she enjoyed a warm friendship over her many years lecturing in the United States, suggested the idea for this biography to her.

  Secondly there was the question of her own brother Richard who was a private in the Irish Guards and killed in the Battle of the Somme on 15 September 1916. Ten months later on 31 July 1917 Francis Ledwidge was blown to pieces and died instantly when a stray shell exploded beside him as he worked at road building behind the battle lines of Ypres in Belgium near the French border.

  And thirdly, and perhaps most compelling of all, it was there to be done. Nobody had thought to capture this gentle poet’s short life in a biography until my mother saw fit to do so. She most certainly did not do it for the money. She worked on the book over a period of eight years and received total royalties of only £200.

  As a literal artist of the Irish Renaissance of the early part of the twentieth century, Ledwidge did, or certainly was destined to had his life not been cut so short, rank with the best of them; with Yeats, Kavanagh, Russell and Colum. The wonder then is not that my mother should have taken up the challenge when she did; the real wonder is that nobody seems to have done so many years earlier.

  Thomas MacDonagh, executed at Arbour Hill following the 1916 Easter Rising, was one of Francis Ledwidge’s best friends and his mentor. They were, after all, fellow poets and nationalists. One of MacDonagh’s main interests and talents was the translating of early bardic poems from Irish into English in a manner that preserved the rhythm and internal rhyming system unique to this period. Cathal Buí Mac Giolla Ghunna was such a bardic poet and coming upon a dead bittern on his journeys wrote his well-known poem ‘An Bonnan Buí’ or in English ‘The Yellow Bittern’. MacDonagh translated the first verse thus:

  Oh yellow bittern who never broke out

  On a drinking bout may as well have drunk.

  For his bones are now thrown on a naked stone

  Where he lived alone like a hermit monk.

  And had I known you were so near your death

  Or had my breath held out I’d have run to you

  Till a splash from the lake of the sons of all birds

  Would have stirred your heart to life anew.

  When Francis Ledwidge heard of the execution of his great friend Thomas MacDonagh he must have felt torn with bitter sadness, great anger, resentment and confusion. Crown forces, the same crown forces for whom Ledwidge was then fighting, had executed his best friend. The Meath poet was on leave back home in Ireland in the weeks following the rising and MacDonagh’s execution. Returning to the front lines to fight on the side of those who had executed his great friend must have been nigh on impossible. Echoing the resonances in his friend’s poem ‘The Yellow Bittern’ Ledwidge wrote of his executed friend:

  He shall not hear the bittern cry

  In the wide sky, where he is lain,

  Nor voices of the sweeter birds

  Above the wailing of the rain.

  Nor shall he know when loud March blows,

  Through slanting snows her fanfare shrill,

  Blowing to flame the golden cup

  Of many an upset daffodil.

  But when the dark cow leaves the moor,

  And pastures poor with greedy weeds,

  Perhaps he’ll hear her low at morn

  Lifting her horn in pleasant meads.

  During the Irish folk revival of the mid-1960s, and completely independent of the fact that my mother was at the time researching Ledwidge and MacDonagh, I had actually learned the English or MacDonagh version of ‘An Bonnan Buí’ and had been singing it at the various gigs around Dublin at the time. When my mother discovered this she was absolutely bowled over by the serendipity of it all. To her dying day this song remained her favourite and she would ask me to sing it
for her on any old pretext or occasion.

  * * *

  It was in the winter of 1966 that Christy Moore did me a good turn. I never actually asked him to do it but of his own volition he got me a series of gigs over a two-week period in and around the folk clubs of Manchester and Birmingham where he was well got at the time. At this stage Christy’s own career had not yet taken off nor could either of us at that time have anticipated just how enormously successful he would become some ten or fifteen years later. We were staying with a relation of Christy’s who ran a vegetable shop and she kind of mothered us and kept an eye on us, for mothering we badly needed. I remember I had a woeful hangover one day and I got into a box of grapefruits from the shop below and ate them one after another. Grapefruits are a great cure for a hangover.

  While thus recovering on a bed upstairs Christy thought that I could be better engaged and set me up in front of a tape recorder and asked that I sing some of my better songs into it because he wanted to learn some of them, not indeed that he was in any way stuck for material himself. I sang ‘The Cliffs of Duneen’, ‘Who are you my Pretty Fair Maid?’, ‘My Dark-Eyed Sailor’ and ‘The Banks of the Lee’. The last song there has nothing to do with the other ‘The Banks’ as usually sung around Cork but goes:

  When two lovers meet down beneath the green bower

  When two lovers meet down beneath the green tree

  Where Mary, fond Mary, she declared unto her lover