'Don't be cheeky!' she snapped.
She turned quickly to her desk and came back with some foolscap sheets of typewritten notes.
'Take these,' she commanded.
We selected a sheet each. They were headed 'Instructions on Case-Taking for Students.'
'You may look at patients number five, eight, twelve, and twenty,' Sister Virtue went on sternly. 'You will replace the bedclothes neatly. You will always ask the staff nurse for a chaperon before examining any female patient below the head and neck. Kindly remember that I do not like students in my ward at all, but we are forced to put up with you.'
Her welcome finished, she spun round and sailed off to give a probationer hell for not dusting the window-ledges the correct way.
We silently crept through the doors and leant against the wall of the corridor outside to read the instruction papers. Grimsdyke was the only one to speak.
'I wonder if she goes to lunch on a broomstick?' he said.
I turned my thoughts to the typewritten paper. 'A careful history must be taken before the patient is examined,' I read. There followed a list of things to ask. It started off easily enough-'Name. Address. Age. Marital state. Occupation. For how long? Does he like it?' It continued with a detailed interrogation on the efficiency with which the patient performed every noticeable physiological function from coughing to coitus.
I turned the page over. The other side was headed 'Examination.' I read half-way down, but I was burning to try my luck on a real patient. I stuffed the paper in my pocket, like a child tossing aside the instructions for working a new complicated toy. I carefully put my nose inside the door and was relieved to find Sister had returned to her lair. I thought she was probably digesting someone.
Timidly I walked down the rows of beds to patient number twelve.
'Look where you're going!' a female voice said angrily in my ear.
I spun round. Behind me was a cross-looking nurse. She was young and not bad-looking, and she wore the bows and blue belt of a qualified staff nurse.
'Can't you see that floor has just been polished?' she demanded.
'I'm sorry,' I mumbled. She tossed her head and stalked off with a swish of starched apron.
Number twelve was a stout young blonde browning at the roots-a frequent condition in female wards. She was sitting up in bed in a green woollen jacket reading a book by Peter Cheyney.
'Good morning,' I said humbly, expecting she as well would attack me.
She immediately slipped a piece of paper in her book, set it down on her bedside locker, threw off her bedjacket, and dropped the top of her nightdress off her shoulders to reveal a large and not unpleasant bosom. Then she smiled.
'Good morning,' she said. She was obviously used to the routine.
I felt a little at a loss. I had never been in such circumstances before, anywhere.
'Er-do you mind if I examine you?' I asked diffidently.
'Go ahead,' she said invitingly, giving me a bigger smile.
'Thanks awfully.'
The experience was so unusual I couldn't think of anything to say. I groped for remembrance of the instructions, but the sheets in my mind's eye were as blank as the patient's counterpane. I felt like an after-dinner speaker who had risen to his feet and found he'd forgotten his notes. Then an idea rescued me unexpectedly-I would take her pulse. Seizing one wrist, I felt for the throbbing radial artery while I gazed with unseeing concentration at the face of my wrist-watch. I felt I had held her arm for five minutes or more, wondering what to do next. And all the time her gently heaving breasts kept tugging at my eyes. They fascinated me, not with any sexual appeal but alarmingly, as if they were a couple of dangerous snakes. I noticed they had fine drops of sweat on them near the nipples.
A thought exploded in my mind.
'I must fetch a nurse!' I exclaimed. I dropped her wrist as if she had smallpox. 'A chaperone, you know.'
She giggled.
'Oh, go on with you!' she said playfully.
I backed away quickly. A nurse undecorated with belts or bows was dusting a locker on the other side of the ward. She looked hearteningly junior.
'I wonder if you would kindly chaperone me with a patient for a few minutes?' I asked urgently.
'No!' she said. She paused in her dusting to glance at me. I must have looked so miserable a little pity glowed in her heart. 'Ask the junior probationer,' she suggested brusquely. 'It's her job. She's in the sluice-room cleaning the bedpans.'
I thanked her humbly and went to look for my help-meet. She was a worried-looking girl of about eighteen who was busy polishing a pile of metal bedpans as if they were the family silver.
'Will you please be my chaperone?' I asked meekly. She pushed a lock of straw-coloured hair out of her eyes wearily.
'I suppose so,' she said. 'If I have to.'
We went back into the ward together and gathered some screens round the stout blonde's bed. The probationer stood opposite me with a look of contempt on her face for my inexpert manipulations while I examined the blonde's tongue, her eyes, and her teeth. I stuck my stethoscope warily here and there on her chest, though the noises were as uninformative to my ears as the sound of sea on a distant shore.
Taking the earpieces out I said 'Good!' as if I had completed my diagnosis.
'Aren't you going to examine my tummy?' asked the blonde with disappointment. 'All the doctors examine my tummy. It's my tummy what's wrong.'
'To-morrow,' I said firmly. 'I have to go and operate.'
How could I tell her in front of the nurse I had not yet learned as far as the tummy?
****
Inspection, palpation, percussion, auscultation-the unalterable, ever-applicable tetrad. They were drummed into us like drill to recruits. Whatever part of the patient you examine, whatever disease you suspect, the four motions must be gone through in that order. You look first, then feel; when you have felt, you may tap, but not before; and last of all comes the stethoscope.
I began to learn how to look at a patient so that even the fingernails might shine with a dozen diagnoses. They taught us to feel lumps, livers, and spleens; how to percuss correctly and to understand the evasive murmurs transmitted through a stethoscope. Diagnosis is simple observation and applied logic-detection, in fact. A matter of searching for clues, igniting a suspicion and knowing where to look for proof. Conan Doyle modelled Sherlock Holmes on a physician, and the reverse holds perfectly well.
Dr. Maxworth took his firm round the ward every Wednesday morning. He was a thin, desiccated little man who had never been known to appear in public dressed in anything but black coat and striped trousers. He was not really interested in students at all. For most of the round he forgot we were crowding in his footsteps, and would suddenly recall our presence by throwing a few half-audible scraps of instruction over his shoulder, He was a specialist in neurology, the diseases of the nervous system. This is the purest and most academic branch of medicine and requires for its practice a mind capable of playing three games of chess simultaneously while filling in a couple of stiff crossword puzzles between the moves. As almost all the nervous diseases we saw in the ward appeared to be fatal, it seemed to me a pretty barren speciality. But Maxworth drew exquisite pleasure from it. He was not primarily concerned with treating his patients and making them better, but if he scored a diagnosis before the proof of the post-mortem he was delighted. He was, his houseman said, a fairly typical physician.
I began to see how the ward was managed by Sister, whom I avoided like a pile of radium. Every bodily occurrence that could be measured-the pulse, the amount of urine, the quantity of vomit, the number of baths-was carefully entered against the patient's name in the treatment book, which reduced the twenty or so humans in the ward to a daily row of figures in her aggressive handwriting.
There were two functions of the physiology which Sister thought proceeded wholly in her interest. One was temperature. The temperature charts shone neatly from the foot of the beds, and each show
ed a precise horizontal zigzag of different amplitude.' Sister wrote the dots and dashes on them herself every morning and evening. The temperatures were taken by the junior nurses, who used four or five thermometers. In spite of inaccuracies due to a different instrument being used daily on each patient and the varying impatience of the nurse to whip the glass spicule away, the figures were looked upon as indispensable. Any errors occurring through mercurial or human failings were not of great importance, however, because Sister always substituted figures of her own if the ones returned by the patient did not fit with her notion of what the temperature in the case ought to be.
The other particular concern of the Sister was the patient's bowels. A nurse was sent round the ward every evening with a special book to ask how many times each inmate had performed during the past twenty-four hours. 'How many for the book?' she would enquire with charming coyness. The patients caught the spirit of the thing, and those returning fair scores to the nurse did so with a proud ring in their voices but anyone making a duck confessed with shame and cowered under the bedclothes.
The number of occasions was written in a separate square at the foot of the temperature chart. A nought was regarded by Sister as unpleasant, and more than two blank days she took as a personal insult. Treatment was simple. One nought was allowed to pass without punishment, but two automatically meant cascara, three castor oil, and four the supreme penalty of an enema.
We rapidly became accustomed to our position of inferiority to everyone on the ward staff. Like all apprentices, the students were used as cheap labour by their superiors. We did all the medical chores-urine-testing, gruel meals in patients with duodenal ulcers, blood samples, and a few simple investigations. For the first few weeks everything seemed easy. It was only at the end of the three-month appointment that there crept up on me an uneasy certainty that I did not yet even know enough to realize how ignorant I was.
6
The impact of surgery on the student is likely to be more dramatic than the first gentle touch of medicine. Although surgeons have now abandoned such playful habits as hurling a freshly amputated leg at a newcomer in the theatre, the warm, humid atmosphere, the sight of blood spilt with apparent carelessness, and the first view of human intestines laid out like a string of new sausages sometimes induces in a student a fit of the vapours-a misfortune which draws from his unaffected companions the meagre sympathy afforded a seasick midshipman.
Nevertheless, I started the surgical course with a feeling of superiority over my predecessors of ten or fifteen years ago. As I went to the pictures fairly regularly I was already as familiar with the inside of an operating theatre as with my father's consulting room.
From a seat in the local cinema not only myself but most other people in the country had achieved a thorough and painless knowledge of what went on behind the doors marked 'Sterile.' I was ready for it all: the crisp white gowns; the cool, unhurried efficiency; the tense concentrated silence broken only by the click of instruments, a curt word of command from the surgeon, or a snapped-out demand for a fresh ligature by the theatre sister. I prepared myself to face the solemnity of an operation, with the attention of everyone in the room focused on the unconscious patient like the strong beam of the operating spotlight.
I was attached to Sir Lancelot Spratt for my surgical teaching. My official title was Sir Lancelot's dresser, which meant not that I had to help him into his white operating trousers in the surgeons' changing-room, but that I was supposed to be responsible for the daily dressings of three or four patients in the ward. The name had a pleasing dignity about it and suggested the student really did something useful in the hospital instead, as it was always impressed on him by the nurses and houseman, of getting in everyone's way like a playful kitten.
The appointment of Sir Lancelot's firm was something of an honour, as he was the Senior Surgeon of the hospital and one of its best-known figures. He was a tall, bony, red-faced man with a bald head round which a ring of white fluffy hair hung like clouds at a mountain top. He was always perfectly shaved and manicured and wore suits cut with considerably more skill than many of his own incisions. He was on the point of retiring from the surgical battlefield on which he had won and lost (with equal profit) so many spectacular actions, and he was always referred to by his colleagues in after-dinner speeches and the like as 'a surgeon of the grand old school.' In private they gave him the less charming but equivalent epithet of 'that bloody old butcher.' His students were fortunate in witnessing operations in his theatre of an extent and originality never seen elsewhere. Nothing was too big for him to cut out, and no viscus, once he had formed an impression it was exercising some indefinite malign influence on the patient, would remain for longer than a week _in situ._
Sir Lancelot represented a generation of colourful, energetic surgeons that, like fulminating cases of scarlet fever, are rarely seen in hospital wards to-day. He inherited the professional aggression of Liston, Paget, Percival Pott, and Moynihan, for he was trained in the days when the surgeon's slickness was the only hope of the patient's recovery, the days before complicated anaesthetics, penicillin, blood-transfusion, and the other paraphernalia of modern surgery had watered down the operator's skill and threatened to submerge him completely.
Sir Lancelot had made a fortune, chiefly from the distressing complaints of old gentlemen, and was charging two hundred guineas for an appendicectomy while Aneurin Bevan was still thumping a local tub in Ebbw Vale. His real success started in the 'twenties, when he earned his knighthood by performing a small but essential operation on a cabinet minister that allowed him to take his seat in the House with greater ease. The minister was delighted, and recommended him in every drawing-room of importance in London. Just at that time Sir Lancelot got it into his head that rheumatism could be cured by the removal from the body of all organs not strictly necessary for the continuance of life. As most people over the age of fifty have rheumatism and it is impossible to make it much better or much worse with any form of treatment his practice increased tenfold overnight.
The rheumatism rage lasted long enough for him to buy a house in Harley Street, a country home on the Thames, a cottage in Sussex, a small sailing yacht, and a new Rolls, in which he was still wafted round between the four of them and the hospital. By then he was ready to operate on anything-he was, he told his dressers with pride, one of the last of the general surgeons. He claimed to be capable of removing a stomach or a pair of tonsils with equal success, or to be able to cut off a leg or a lung.
Every Tuesday and Thursday afternoon he operated in his own theatre on the top floor. The list for the session was pinned up outside like a music-hall bill-the best cases were always at the top for Sir Lancelot to operate on himself, and the programme degenerated into a string of such minor surgical chores as the repair of hernias and the removal of varicose veins, to be done by his assistants when he had gone off to his club for a glass of sherry before dinner.
On the first Tuesday after my appointment to the firm I walked up the stairs to the theatre-students were not allowed to use the hospital lift-and went into the dressers' changing-room. A row of jackets and ties hung under a notice in letters three inches high: DO NOT LEAVE ANYTHING IN YOUR POCKETS. Everyone entering the theatre had to wear sterile clothing, which was packed away in three metal bins opened by foot pedals. Using a pair of long sterile forceps I took an oblong cap from one, a mask from another, and a rolled white gown from the third. Unfortunately there was no indication of the size of these coverings, and the gown fell round my feet like a bridal dress while the cap perched on my head like a cherry on a dish of ice-cream. I pushed open the theatre door and stepped inside reverently, like a tourist entering a cathedral. Standing by the door, my hands clasped tightly behind me, all I wanted was completely to escape notice. I felt that even my breathing, which sounded in my ears like the bellows of a church organ, would disturb the sterile, noiseless efficiency of the place. I was also a little uncertain of my reactions to cut flesh and wa
nted to keep as far away from the scene of activity as possible.
'You, boy!'
Sir Lancelot's head popped above the caps of his attendants. All I could see of him was a single brown, bushy strip that separated the top of his mask and the edge of his cap, through which there glared two unfriendly eyes like a hungry tiger inspecting a native through the undergrowth.
'Come over here,' he shouted. 'How often have I got to tell you young fellers you can't learn surgery from the door-post?'
The operating table was in the centre of the bare, tiled room, directly under the wide lamp that hung like a huge inverted saucer from the ceiling. It was completely invisible, as about twenty figures in white gowns were packed round it like tube passengers in the rush-hour. These were mostly students. The operating team was made up of Sir Lancelot himself, who was a head higher than anyone else in the room; his theatre Sister, masked and with all her hair carefully tucked into a sterile white turban, standing on a little platform beside him; his senior houseman, Mr. Stubbins, and his registrar, Mr. Crate, assisting him from the opposite side; and his anaesthetist, sitting on a small metal piano stool beside a chromium-plated barrow of apparatus at the head of the table, reading the _Daily Telegraph._ On the outskirts of this scrum two nurses in sterile clothes dashed round anxiously, dishing out hot sterilized instruments from small metal bowls like waiters serving spaghetti. A theatre porter, also gowned and masked, leant reflectively on a sort of towel rail used for counting the swabs, and another strode in with a fresh cylinder of oxygen on his shoulder. The only indication that there was a patient present at all was a pair of feet in thick, coarse-knitted bed-socks that stuck pathetically from one end of the audience.
As soon as Sir Lancelot spoke, the group round the table opened as if he were Aladdin at the mouth of his cave. I walked unhappily into the centre. My companions closed tightly behind me, and I found myself wedged against the table opposite Sir Lancelot with a man who played in the second row of the hospital forwards immediately behind me. Escape was therefore out of the question, on physical as well as moral grounds.
DOCTOR IN THE HOUSE Page 5
