DOCTOR IN THE HOUSE

by Richard Gordon

  The operation was on the point of starting. The patient was still invisible, as the body was covered with sterile towels except for a clean-shaved strip of lower abdomen on the right-hand side of which the operating light was focused diagnostically. I couldn't even see if it was a young man or a woman.

  Having forced me into a ringside seat, Sir Lancelot then appeared to dismiss me from his mind. He paused to adjust the cuff of the rubber glove that stretched over his bony hand. Stubbins and Crate were waiting with gauze dabs, and the theatre sister was threading needles with catgut as unconcernedly as if she was going to darn her stockings.

  'Stubbins,' said Sir Lancelot chattily, making a three-inch incision over the appendix, 'remind me to look into Fortnum's on my way home, there's a good lad. My missus'll give me hell if I forget her dried ginger again. I suppose it was all right for me to start?' he asked the anaesthetist.

  The Daily Telegraph rustled slightly in assent.

  I was surprised. Dried ginger in an operating theatre?

  Shopping lists disturbing the sanctity of surgery? And the _Daily Telegraph?_

  'I've got a damn funny story to tell you lads,' went on Sir Lancelot affably, deepening his incision. 'Make you all laugh. Happened to me last week. An old lady turned up in my rooms in Harley Street…Sister!' he exclaimed in a tone of sudden annoyance, 'do you expect me to operate with a jam-spreader? This knife's a disgrace.'

  He threw it on the floor. Without looking at him she handed him another.

  'That's better,' Sir Lancelot growled. Then, in his previous tone, as though he were two people making conversation, he went on: 'Where was I? Oh yes, the old lady. Well, she said she'd come to see me on the advice of Lord-Lord Someoneorother, I can't remember these damn titles-whom I'd operated on last year. She said she was convinced she'd got gallstones.

  'Now look here, Stubbins, can't you and Crate keep out of each other's way? Your job is to use that gauze swab sensibly, not wave it around like a Salvation Army banner. How the devil do you think I can operate properly if everything's wallowing in blood? Why am I always cursed with assistants who have a couple of left hands? And I want a clip, Sister. Hurry up, woman, I can't wait all night!'

  Sir Lancelot had cut through the abdominal wall while he was talking, like a child impatient to see inside a Christmas parcel.

  'Well,' he went on, all affability again, seemingly conducting the operation with the concentration of a gossipy woman knitting a pair of socks, 'I said to this old lady, "Gallstones, eh? Now, my dear, what makes you think you've got gallstones?" And I've never seen anyone look so embarrassed in my life!'

  He returned to the operation.

  'What's this structure, gentlemen?'

  A reply came from under a student's mask on the edge of the crowd.

  'Quite correct, whoever you are,' said Sir Lancelot, but without any congratulation in his voice. 'Glad to see you fellers remember a little fundamental anatomy from your two years in the rooms…so I wondered what was up. After all, patients don't get embarrassed over gallstones. It's only piles and things like that, and even then it's never the old ladies who are coy but the tough young men. Remember that bit of advice, gentlemen…Come on, Stubbins, wake up! You're as useless as an udder on a bull.'

  He produced the appendix from the wound like a bird pulling a worm from the ground, and laid it and the attached intestine on a little square of gauze.

  'Then the old lady said to me, "As a matter of fact, Sir Lancelot, I've been passing them all month…", Don't lean on the patient, Stubbins! If I'm not tired you shouldn't be, and I can give you forty or fifty years, my lad.

  'So now we come to the interesting part of the story. She showed me a little box, like those things you send out pieces of wedding cake in…Sister! What in the name of God are you threading your needles with? This isn't catgut, it's rope. What's that, woman?' He leant the red ear that stuck out below his cap towards her. 'Speak up, don't mutter to yourself. I'm not being rude, damn you! I'm never rude in the theatre. All right, tell your Matron, but give us a decent ligature. That's more like it. Swab, man, swab. Stubbins, did I ever tell you about the Matron when, she was a junior theatre nurse? She had a terrible crush on a fellow house-surgeon of mine-chap called Bungo Ross, used to drink like a fish and a devil for the women. Became a respected G.P. in Bognor or somewhere. Died last year. I wrote a damn good obituary for him in the _British Medical Journal._ I'm tying off the appendicular artery, gentlemen. See? What's that, Stubbins? Oh, the old lady. Cherry stones.'

  He tossed the appendix into a small enamel bowl held for him by Stubbins.

  'Looks a bit blue this end, George,' he said in the direction of the anaesthetist. 'All right, I suppose?' The anaesthetist was at the time in the corner of the theatre talking earnestly to one of the nurses who had been serving out the instruments. Theatre kit is unfair to nurses; it makes them look like white bundles. But one could tell from the rough shape of this one, from the little black-stockinged ankles below her gown and the two wide eyes above her mask, that the parcel would be worth the unwrapping. The anaesthetist jumped back to his trolley and began to twiddle the knobs on it. Sister, who was already in a wild temper, injected the nurse with a glance like a syringeful of strychnine.

  'Forceps, Sister!' bellowed Sir Lancelot. She handed him a pair which he looked at closely, snapping them together in front of his mask. For some reason they displeased him, so he threw them over the heads of the crowd at the opposite wall. This caused no surprise to anyone, and seemed to be one of his usual habits. She calmly handed him another pair.

  'Swabs correct, Sister, before I close? Good. Terribly important that, gentlemen. Once you've left a swab inside a patient you're finished for life. Courts, damages, newspapers, and all that sort of thing. It's the only disaster in surgery the blasted public thinks it knows anything about. Cut their throats when they're under the anaesthetic, yes, but leave anything inside and you're in the _News of the World_ in no time. Shove in the skin stitches, Stubbins. What's the next case? Tea? Excellent. Operating always makes me thirsty.'

  7

  During the following three months I learnt a little about surgery and a lot about surgeons. I learnt more than I wanted about Sir Lancelot. In the theatre he was God. Everything in the routine for operating sessions was arranged to suit his convenience. A white linen suit, freshly starched, was carefully warmed by the junior nurse before being laid out in his changing-room in the morning. A Thermos pitcher of iced water labelled 'Sir Lancelot Spratt ONLY' was set on a silver tray nearby. He had his own masks, his own scrubbing brush, and his own soap. When he crossed the theatre floor from the scrub-up basins to the table the onlookers scattered before him like unarmed infantry in front of a tank. If anyone got in his way he simply kicked them out of it. He rarely asked for an instrument but expected the Sister to guess which one to place in his waiting hand. If she made a mistake, he calmly dropped the wrong instrument on to the floor. Should she do no better at her second attempt he repeated his little trick. Once he silently reduced a whole trayful of instruments to an unsterile heap at his feet, and the Sister had hysterics.

  Sir Lancelot had a personality like an avalanche and a downright bedside manner that suited equally well a duchess's bedroom or the hospital out-patient department. He radiated confidence like a lighthouse through a storm. His suggestions on the removal of his patients' organs never met with their objection. The more he did to them, the greater the complications that resulted from his interference, the larger the number of supplementary operations he had to perform to retrieve his errors, the more they thanked him: there was never one but died grateful.

  His teaching in the ward, like his surgery in the theatre, was full-blooded. He had a long string of aphorisms and surgical anecdotes, none of which was original or strictly accurate, but they stuck in the minds of his students long after the watery lectures of his colleagues had evaporated.

  His round was held every Tuesday morning at ten o'clock, and had the s
ame effect on the ward as an admiral's inspection of a small warship.

  The preparations for his visit began about five in the morning. The night nurses started the long business of sprucing up the ward to its best pitch of speckless sterility, and when Sister and her day staff arrived at seven the energy given to preparing the long room so that nothing in the slightest way offensive should fall on the great man's eye was increased tenfold. Every article in it was scrubbed and polished thoroughly-the floor, the medicine cupboards, the windows, the instruments, the patients' faces. The bedside lockers, which usually carried a friendly jumble of newspapers, soap, jam, football coupons, and barley-water, were stripped clean and their contents buried out of sight. Even the flowers looked sterile.

  The tension and activity in the ward rose together, like the temperature and pulse in a fever. At nine the senior house-surgeon, in a fresh white jacket, looked in for a worried, whispered conversation with, Sister too be certain everything commanded on the Chief's last visit had been done. He didn't glance at the patients. That morning they were part ward furniture, or at most instruments by which the medical staff could demonstrate their abilities to Sir Lancelot.

  There was one point, however, on which the patients could not be argued away from their humanity. At nine-fifteen bedpans were issued all round. The acquisition of one of these at such an hour (seven and five were the official times for their use) was usually a business comparable with catching the eye of a waiter in a busy restaurant. At nine-fifteen on Tuesdays, however, they were forced upon the patients. The nurses tripped briskly out of the sluice-room, each carrying a couple under a cloth. This was because Sister thought a request for one of these articles while Sir Lancelot was in the ward unreasonable to the highest degree-indeed, almost indecent.

  The bedpans were whipped away a quarter of an hour before the Chief was due. There followed an energetic final ten minutes occupied by a process known as 'tidying' the patients. They could obviously not be allowed to disturb the general symmetry of the scene by lolling about in bed anyhow, like a squad of soldiers falling in with their hands in their pockets. They had to be fitted in to the ward neatly and unobtrusively. The technique was simple. A pair of nurses descended on the patient. First he was shot into the sitting position, and retained there by one nurse while the other smoothed and squared up his pillows (the open ends of the pillowcases always to face away from the door). He was then dropped gently on his back, so as not to ruffle the smooth surface unnecessarily with his head. The bedclothes were seized at the top by the two young women and pulled taut between them like a tug-of-war; they next applied the tension upwards from the patient's feet, which brought the top edge of the bedclothes level with the patient's nostrils. In one quick motion, without releasing the tension to which the blankets were submitted, they tucked them in firmly all round. This made it impossible for the occupant of the bed to perform any muscular movement whatever, except very shallow breathing.

  The ward by ten was silent, orderly, and odourless. Sister and the nurses had changed into fresh white aprons and each of them felt like Moses immediately on his arrival at the top of the mountain. Meanwhile, another focus of consternation had formed not far away.

  It was the tradition of St. Swithin's that the Chief should be greeted in the courtyard and lead his firm to the ward. Surgeons were met in front of the statue of Sir Benjamin Bone and physicians before that of Lord Larrymore. This form of reception resulted in everyone becoming cold in winter, hot in summer, and wet all the year round, and as it had apparently been going on for three or four hundred years this seemed an excellent reason for refusing to alter, it.

  We gathered for our first ward-round under the cold eye of Sir Benjamin. The differences that divided the firm, which were emphasised on Tuesday mornings, had already become obvious. The students stood in a little subdued group behind the statue. We wore our suits, with stethoscopes coiling out of our pockets and foolscap notebooks under our arms. We chatted quietly between ourselves, but would not have contemplated exchanging words with the two house-surgeons, who stood apart murmuring to each other with expressions of intense seriousness on their faces.

  The third section of the party consisted only of Crate, the registrar. He was allowed to wear a long white coat like the Chief, but as he had no companion to talk to and was unable to converse with his housemen or students at such a solemn moment he had to content himself with looking at the sky in a reflective and earnest way, as if he were turning over in his mind the niceties of surgery or trying to forecast the weather.

  At ten the Rolls drew into the courtyard and stopped opposite our group. Crate opened the door and wished Sir Lancelot good morning. The car was driven to its parking-place by the chauffeur and the Chief disappeared with his registrar towards the staff common room to leave his hat and put on his white coat. When they reappeared the rest of the party followed them to the wards.

  Once Sir Lancelot burst through the ward door more people arranged themselves in his wake. Indeed, it was impossible for a man of his importance to walk about St. Swithin's at all without a procession immediately forming up behind him.

  First, of course, was Sir Lancelot, the therapeutic thunderbolt. A pace behind came the registrar, and behind him the two house-surgeons, the senior one leading. After the two housemen was Sister, her long cap trailing behind her like a wind-stocking on an aerodrome. She was followed by her senior staff nurse, who carried a trayful of highly-polished instruments with which the patients could be tapped, scratched, and tickled in the aid of making a diagnosis. Sir Lancelot never used any of them and probably did not know how to, but they were produced every Tuesday nevertheless, like a ceremonial mace. Behind the staff nurse was a junior nurse bearing a thick board covered with a pad of paper, to which a pencil was attached with a piece of string. The board was marked sternly 'SIR LANCELOT SPRATT'S DRAWING PAPER.' On this he would sometimes sketch points of anatomy-not often, about once every six months, but the board had to be flashed to his hand if he asked for it. In the rear of the junior nurse, in the winter months a probationer carried a hot-water bottle in a small red blanket for Sir Lancelot to warm his hands before applying them to exposed flesh.

  At the end of the party, behind even the hot-water battle, were the students: an un-uniformed, disorderly bunch of stragglers.

  The Chief spent two hours examining the candidates for the afternoon's operating list, with whom he illustrated to us the principles of surgery. Sometimes he passed all morning on one case, if the patient contained a lump of sufficient interest to him; on other Tuesdays he would whip round the whole ward, diagnosing like a machine-gun. Sitting was forbidden, and towards lunchtime the students shifted heavily from one foot to the other. Sir Lancelot thought any young man incapable of standing on his own feet for a couple of hours as another disagreeable product of modern life, like socialism.

  On our first ward round we were pushed easily into place by the precision with which the rest of the troupe fell in. Sir Lancelot strode across the ward, drew up sharply, and looked over the patients in the two rows of beds, sniffing the air like a dog picking up a scent. He thundered over to the bedside of a small, nervous man in the corner. The firm immediately rearranged itself, like a smart platoon at drill. The Chief towered on the right of the patient's head; Sister stood opposite, her nurses squeezed behind her; the students surrounded the foot and sides of the bed like a screen; and the registrar and housemen stood beyond them, at a distance indicating that they were no longer in need of any instruction in surgery.

  Sir Lancelot pulled back the bedclothes like a conjurer revealing a successful trick.

  'You just lie still, old fellow,' he boomed cheerfully at the patient. 'Don't you take any notice of what I'm going to say to these young doctors. You won't understand a word of what we're talking about, anyway. Take his pyjamas off, Sister. Now you, my boy,' he continued, gripping me tightly by the arm as I was nearest, 'take a look at that abdomen.'

  I stretched out a hand
to feel the patient gingerly in the region of the umbilicus. I noticed his skin was covered with goose-pimples and twitched here and there nervously.

  'Take your dirty little hand away!' said Sir Lancelot savagely, flicking it off the surface of the abdomen like a fly. He paused solemnly, and continued in a heavy tone, wagging his finger: 'The first rule of surgery, gentlemen-eyes first and most, hands next and least, tongue not at all. Look first and don't chatter. An excellent rule for you to remember all your lives. Now look, boy, look.'

  I gazed at the abdomen for a whole minute but it appeared no different from any that might be seen on Brighton beach. When I thought I had inspected it long enough to satisfy the Chief, who rose uncomfortably above me, I diffidently stretched out my arm and prodded about with my finger in search of a lump.

  _'Doucemong, doucemong,'_ Sir Lancelot began again.

  'Gently, boy-you're not making bread. Remember'-his finger came up again warningly-'a successful surgeon must have the eye of a hawk, the heart of a lion, and the hand of a lady.'

  'And the commercial morals of a Levantine usurer,' murmured Grimsdyke under his breath.

  With a glow of relief, I finally discovered the lump. It was about the size of an orange and tucked under the edge of the ribs. We lined up and felt it one after the other, while Sir Lancelot looked on closely and corrected anyone going about it the wrong way. Then he pulled a red grease-pencil from the top pocket of his coat and handed it to me.

  'Where are we going to make the incision?' he asked. By now the patient was forgotten; it was the lump we were after. Sir Lancelot had an upsetting habit of treating the owners of lumps as if they were already rendered unconscious by the anesthetic.

  I drew a modest line over the lesion.