by Tom Smith
She staggered out and I was glad to see on her notes that she lived a few yards away, on the same side of the road as the surgery, so she wouldn’t be facing the danger of crossing it. I doubted whether she could have managed to cope with the kerb without falling over it. I walked to the greenhouse and called in the next patient…
By the end of the morning, I had seen around a dozen patients, nine of whom were on Tuinal, and all of whom were taking a combination of at least two of the three bottles. I never worked out the basis on which Dr Rose had chosen which combination for which patient. I suppose the reasons were lost in the mists of time: certainly the patients were of no help. They thought that as the good doctor had prescribed them, they must be doing them good. None of them, apparently, was ill. They all assumed that their good health was in no small measure due to Dr Rose’s marvellous medicines.
Mrs Rose offered me a cup of tea after the surgery ended, then asked when she should order the next lot of medicines. It was a dispensing practice, which meant that the doctor not only prescribed the medicines but gave them out, too. The stores of medicines were replenished each week by an old pharmacist friend of Dr Rose, who saved him from having to worry about the details of ordering and maintaining his stocks. Dr Rose’s main aim in life had been to keep his families as happy as possible with the minimum of grief. Perhaps he had gone a little far by turning many of them into walking zombies, but it gave them, and him, particularly, a good night’s sleep.
Mrs Rose was a decent lady, who took little interest in the running of the practice. She was looking forward to a quiet retirement with her sister, who was coming to stay. She wasn’t sure that the friendly pharmacist would continue to supply the drugs, because he now wanted to retire, too, but she mentioned that Dr Renton, who had been the last doctor in the Braehill practice, had given her his dispensing records to give to me. I gathered later that he had not left them with Jeanie in Braehill because she had a sharp brain and a keen interest in the doings of the doctors. Mrs Rose, he had known, was safe on two counts: she was a doctor’s widow and knew when to be discreet, and she wasn’t in the slightest interested in the running of the practice or his finances.
Mrs Rose suggested that I might like to take a leaf out of Dr Renton’s book, as he seemed to have been very efficient at dispensing. She didn’t know much about modern drugs, she said, but her one brief glance at Dr Renton’s prescription profits suggested that he was more adept at organising things than her husband. He certainly seemed to have earned more than her husband had.
I opened Dr Renton’s ledger. He had made quite a profit from dispensing – in fact more than his salary. In a dispensing practice, the doctor would write out a prescription for each item dispensed. At the end of the month, all the prescriptions were sent to the Pricing Bureau, and the doctor received for each prescription a dispensing fee, the usual cost of the materials and a proportion of extra money added on as profit. The cheaper he could buy the pills and potions, the bigger would be the difference between his actual cost and the one estimated for the relevant drug by the Pricing Bureau. I looked at the dispensing records from the last few months and the totals from the Pricing Bureau. Dr Renton had worked hard, but within the law, to enhance his income. He had bought in ‘generics’ at low prices and claimed for them under their generic names. He had received the ‘mark-up’ that the Pricing Bureau thought was appropriate, based on the Bureau’s estimate of cost. That was much higher than had actually been paid for the drugs, so his profit was a healthy one and still strictly according to the rules.
Dr Renton may have managed this within the rules, but the whole area of prescribing and dispensing drugs offered less scrupulous doctors considerable room for fraud. In my former practice in Birmingham, it had been rumoured that Dr Dai had his special prescription list. He would allegedly write ‘tabs ADT, one daily’ on the prescription and instruct the patient to go to his friendly pharmacist for it. The pharmacist would dispense something harmless and very cheap, such as a small dose of folic acid, or one of the B vitamins. At the end of each month, Dr Dai and the pharmacist would get together. The doctor would review all the ADT prescriptions, and re-write them for something more expensive, such as an antibiotic or an anti-arthritis preparation. That prescription would be sent to the Pricing Bureau, and the pharmacist would glean a healthy profit, which would be split down the middle with Dr Dai.
Dr Dai’s partner, Dr Owen, who declined to be ‘on the take’, did warn me about the ADT scam. I couldn’t find tabs ADT in my National Formulary, which wasn’t surprising. It stood for ‘any damn thing’.
If writing prescriptions offered some chance of colluding with a bent pharmacist to defraud the NHS, it was nothing compared to the opportunities that arose when the doctor both wrote the prescriptions and dispensed the drugs.
As I drove back to the cottage from Collintrae that day, I realised that I had some hard decisions to make. The dispensing for Collintrae and Braehill had to be organised properly and we had to find, very urgently, a new place to consult in the village. Mairi and I also had to find a new home. As for the medication dished out ad lib from the surgery, I had to start to plan how to get most of the village population off Tuinal, and to discover what exactly was in those white, green and brown bottles.
The last was the easiest to achieve. Just after lunch I had a phone call from Girvan. It was a social call: the town pharmacist, David Weir, a young man in his early thirties, was calling to welcome me to the district, and to offer any help I might need to get stocked with emergency and routine drugs. I jumped at the chance. I had no commitments that afternoon, so drove the fourteen miles into town to meet him. David told me that the mixtures were prepared by Dr Rose himself according to that old 1933 Formulary. We looked at the ingredients together. The white mixture was a simple antacid, a mixture of magnesium, aluminium and calcium carbonates, silicates and hydroxides. It would settle any stomach, but might well develop a concrete-like consistency in the bowel. I made a mental note to ask anyone who needed a repeat in the future about his or her toilet habits.
The green ‘tonic’ contained a large dose of nux vomica. The good people of Collintrae must have had strong stomachs, as even a smidgeon of nux vomica would make a newcomer to the medicine spew, and very quickly. Presumably the good doctor relied on the principle expounded by doctors from Hippocrates onwards that a ‘medicine that can make you sick will stop you being sick’. The second part of that dictum is that ‘once you get used to it, it will keep protecting you’. I didn’t subscribe to either idea. All the notorious poisoners in history, from Lucrezia Borgia to Palmer the Poisoner (a Victorian serial-killer GP), have relied on them for their success. Nux vomica isn’t exactly arsenic or strychnine, but the principle isn’t too different.
So the nux vomica repeats would have to go. So would the brown medicine. It turned out to be a liquid version of ‘Livingstone’s rousers’. Every young man proceeding to Africa as a missionary, a diplomat or soldier, in the nineteenth century was strongly advised to take several Livingstone’s rousers every day. A mixture of rhubarb, jalap, calomel and quinine, it was designed to destroy any intestinal parasite known to the Victorian explorer and, in the passing, to take care of malaria, too. If the mixture didn’t actually kill off the parasites, it made sure that food passed so quickly and in such a torrent from mouth to anus that the poor microbes had no time to gain a foothold inside their host’s gut. We were short of malaria cases, as far as I knew, in South Ayrshire, but I could see that the brown mixture would be a perfect, and perhaps the only, antidote to the white one. My only doubt was that the dose needed to dissolve the antacid concretion might be very close to that needed to dissolve the patient.
David and I liked each other and have been firm friends ever since. He volunteered to help me organise my dispensing, and it went smoothly from that day on. I would add my small weekly order on to his much larger one, and I managed to dispense my prescr
iptions honestly and ethically, with no worries. I remain grateful to him for that to this day.
But what about the chloroform? As I drove home that afternoon, that remained a puzzle. It was solved that evening. I got a call from the Collintrae district nurse. There was a baby on the way to a Mrs Watson, in a farmhouse near the village. Could I join her?
I’ve always loved obstetrics, and I was excited to be doing my first delivery on the district. This was Mrs Watson’s third baby, the first two having been delivered at home by Dr Rose. The nurse, Flora Malcolm, was easing her into the third stage of labour, coaxing her and comforting her. I had the instant impression of an efficient, very professional, excellent colleague who could have delivered the baby standing on her head without my help. But in those days, it was the doctor’s job, and she moved aside for me. Mrs Watson watched me wash my hands in the basin and put on the gloves, and frowned a little.
‘You won’t put me out, doctor? I’d like to be awake this time,’ she said. Flora must have seen the surprise in my face. She explained: ‘Dr Rose used to use chloroform just at the last, to help the baby out and ease the mother’s pain. I presume we’re going to do it differently now?’
‘Sure,’ I smiled at both of them. I spoke as reassuringly as I could to Mrs Watson, ‘Maybe a little gas and air if you really need it, but we’d be glad to have you with us the whole way through it. Don’t worry.’
It was a straightforward birth, a baby girl, and Mrs Watson said she would call her Flora after nurse, which brought a big beaming smile from the new namesake. Afterwards, Flora and I sat in my car outside the house, talking about the practice. Over the next few months I found that she was as good as having another doctor on hand. She was as relieved as I was to lose the chloroform, and I reassured her she would never have to smell it again in the district.
How wrong I was. Two days later, Flora was at our home, in the kitchen, helping Mairi with Catriona. It was a Saturday morning, and the surgery was not to start until ten o’clock, so we had about an hour to have a leisurely coffee together and talk over baby things and practice problems. We were interrupted by the phone ringing. On the other end was a very agitated lady, crying that her husband had collapsed in the byre. Not only that, all the cows had collapsed, and there was a funny smell. Could I come at once?
Flora came with me. The farm was four miles away from our cottage, and we took five minutes to get there, whizzing past tractors and milk tankers on the way. We pulled up in the farmyard to an amazing sight. Alec Campbell, the farmer, a big man in his late fifties, was lying prostrate just inside the entrance to the cowshed. Inside the shed were eighty cows, all of them lying on their sides, fast asleep. The air was thick with the pungent smell of chloroform.
Flora and I bent over Alec. He was gently snoring. More than that, he was anaesthetised, but as far as we could see, otherwise well. We pulled him over to the house door, and let him lie there in the fresher air. The byre atmosphere was still permeated by the chloroform which, weirdly, appeared to be emanating from the cows. In danger of being chloroformed ourselves, we left the cows to themselves and started to tend to Alec. He came round quite quickly now he was breathing fresh air.
It took us about ten minutes to understand what had happened. Alec was what might be called ‘careful’ with his money. He had a thousand sheep on his hill, and his eighty milking cows. During the winter, the vet had found liver fluke in some of his sheep, and had advised Alec to dose them against the disease. Liver flukes are parasites that sheep pick up while grazing grass in which there are infected snails. The snails pass the parasite on to the grass, the sheep eat the grass, and the parasites find a cosy home inside the sheep’s liver. An affected sheep fails to thrive, and that’s a big loss in a herd of a thousand.
So Alec had ordered thousands of doses of the liver fluke antidote, carbon tetrachloride. Most people know of carbon tetrachloride from its use in the past as a dry-cleaning fluid – it’s what gave dry-cleaning shops their smell. It is a very efficient fluke killer, and for sheep it comes in handy little red oily capsules. The trick is to open the sheep’s mouth and blow the capsule down its throat with an instrument like a peashooter.
Alec and his son Chris were adept at doing this. They dosed their thousand sheep over two or three days, and felt it was a job well done. But they were left with a thousand doses to spare, and didn’t want to waste their money. The natural thing was to dose the cows, too. The cows shared the same pasture, and although they didn’t show any signs of fluke, it was better to be safer than sorrier, wasn’t it?
Unfortunately, Alec and Chris made two mistakes in coming to this decision. The first was that they didn’t know the dose to give the cows, and assumed that it went by the weight of the animal. As a cow weighed about six times as much as a sheep, they decided to give each cow around six times the sheep’s dose. All it needed was to put six capsules in the peashooter and blow them in: dairy cows are surprisingly compliant about such interference, provided they are familiar with the man who does it.
The second mistake was not to read the instructions on the packets of capsules. It’s easier when you are dosing hundreds of animals, to pour out all the capsules into a big container and take them from that when needed. So it was natural for them to throw the packet leaflets away with the old packaging.
It was a big error. The label (which luckily Flora had retrieved from the farm bin) stated in large letters DO NOT GIVE TO ANIMALS FEEDING ON CONCENTRATES. Sheep graze on hillside grass. Concentrates are not within their rather narrow life horizon. On the other hand, cows find concentrates delicious: they help them produce more milk and keep them fat and happy. Each of Alec’s cows had been happily munching on concentrated feeds for the whole of their relatively contented lives. Of course, they liked variety, too, so the grass in the meadow was just as delicious, infected snails or not.
So why should a simple combination of dry cleaning fluid and concentrates have such a surprising result? Here is a little chemistry lesson. When cows digest concentrated foods in their stomach, one of the by-products is hydrogen gas. Forty years on, the greenhouse gases, particularly methane and carbon dioxide, produced by belching cows would worry the whole world. At that time, Flora and I and Mrs Campbell had another gas to worry about, however.
The chemical structure of carbon tetrachloride is simple: its name shows that a molecule of it contains one atom of carbon and four of chlorine. What happens when it meets up with hydrogen gas, released from the digestion of concentrates? One of the chlorine atoms is replaced by a hydrogen atom. That creates the compound carbon hydrogen trichloride. Its other name is chloroform.
Within minutes of swallowing such a whacking dose of carbon tetrachloride, each cow had started to manufacture chloroform in her stomach. It’s not very far from the stomach to the lungs, and from there into the brain. Just as Alec was dosing his last cow, the first one to be dosed keeled over, with a loud clatter. As he rushed up to the unconscious animal, he was faced with cows going down like a stack of dominoes. One by one his precious cows fell over in their stalls. As they did so, they breathed out their chloroform into the air of the byre. Standing in the middle, Alec was getting the full benefit of the exhalations of eighty cows, all sound asleep. He joined them very soon afterwards.
Alec and his cows all recovered, although he wasn’t allowed to send his milk to market until there was no more detected chloroform in it. Flora and I never found out who spilled the beans to the rest of the community. It certainly wasn’t either of us, but forever afterwards his friends called him ‘Chloroform Campbell’.
Chapter Six
Keepers and Poachers
As the first few weeks passed, Mairi and I settled in. We heard the rumours that the doctor ‘was ower young’ for the practice, and ‘that wee wifie o’ his is only eighteen (she was all of twenty three) - they winna last.’ But we bore them in good stead. Frankly the work was far le
ss arduous than it had been in Birmingham and it was quality, rather than quantity that mattered. I could spend a lot more time with each patient, and had time to smell the roses.
Roses there were in plenty, in fact, as the cottage was surrounded by them. They had been planted by the nuns years before, and made the cottage an ideal place to bring up a baby in the spring and early summer. I also had time to get to know our next door neighbours, the lurching Archie and his long-suffering Agnes extremely well. Too well in fact, because we heard almost every word of their frequent rows across the open courtyard between us. Archie, being an outdoor type, tended to leave all the doors of their cottage open. We knew when things were brewing up badly when we heard the strains of ‘The Star of Rabbie Burns’ drifting across to us. Archie fancied himself as a singer, and the more he drank, the more he fancied his own voice, and the more amorous he would become. Not unnaturally Agnes’s own index of amorousness was in exact inverse proportion to Archie’s. If there was one thing that turned her off him, it was that tune.
Archie was not the world’s most attractive man – he was unshaven, a stranger to the bathroom or shower, and tended to wear, all the time, the clothes in which he had killed various vermin. ‘Vermin’ for Archie extended well beyond the usual rats, foxes and birds of prey that were the legitimate target of his fellow gamekeepers. They included the neighbourhood’s pet cats and small dogs, and Archie was adept not only at catching and dispatching them, but at hiding their bodies so that his mass murder would not be detected by the rest of the villagers, who were mystified by the regular disappearance of their pets. Rumour had it that there was a large predator in the woods around the village, perhaps one of those big black cats, like a panther, that had been seen from time to time in a forest further north.
