DOCTOR AT LARGE

by Richard Gordon

  DOCTOR AT LARGE

  Richard Gordon

  Richard Gordon

  DOCTOR AT LARGE

  First Published in 1955

  All characters, institutions, and incidents are fictitious

  1

  Qualifying as a doctor is an experience as exciting for a young man as first falling in love, and for a while produces much the same addling effects.

  Before my own new diploma had uncurled from its cardboard wrapper I was prancing through the streets hoping every pretty girl in sight would be seized with a fit of fainting, and longing at each crossroads for a serious accident. I scattered prescriptions like snowflakes, and squandered my now precious opinion on relatives, friends, and even people not looking very well who happened to sit opposite me in railway trains. I frequently started conversations with, 'Speaking as a medical man-' and an appeal for a doctor in a theatre would have brought me from my seat like a kangaroo.

  After six years as a suppressed medical student this sudden importance was intoxicating, and was refreshed every morning with thick envelopes pouring through a letter-box which had previously breakfasted only on slim bills and orange packets from the football pools. The drug manufacturers pressed me with free samples, diaries the size of hymn-books, and sufficient blotters to soak up the Serpentine; shops in Wigmore Street offered to sell me clinical equipment from brass door-plates to X-ray machines; societies opposed to vivisection, smoking, meat-eating, blood sports, socialism, and birth control jostled on the breakfast table for my support; the bank, that a week ago echoed my footsteps like a police court begged to advance me money, safeguard my valuables, and execute my will; even the British Medical Association officially recognized my existence by sending a free sixteen-page booklet on _Ethics and Members of the Medical Profession,_ advising me henceforward to live a pure and moral life and not associate with unqualified midwives.

  Unfortunately, both young doctors and young lovers soon descend from their rosy clouds on to the spiky realities of life. At the age of twenty-four I had to look for my first job, like a prospective office boy out of school. The quest was a serious one, for today even those students whose most thoughtful work in the lecture-room is carving their names on the benches are determined to become specialists. There seems no point in being anything else, when it is common knowledge in medical schools that general practitioners under the National Health Service are all seedy men signing forms in insanitary surgeries until they drop dead at forty through overwork.

  Long before qualifying I had decided to become a surgeon. I had rather fancied myself cutting up the dogfish, frogs, and rabbits in the first-year zoology class, and thought the principle was probably the same further up the evolutionary tree; once I had passed my finals the only problem seemed to be finding the smoothest channel for pouring my surgical energies upon the public. My own hospital, St Swithin's, did not foster its sons beyond inviting them to the annual reunion dinner, at two guineas a head exclusive of wines; but I remembered that outside the medical school office hung a secretive notice in faded copper-plate behind speckled glass saying _Newly Qualified Men Should Consult the Secretary, Who Will Advise Them on Their Careers._ Few graduates obeyed the invitation, for the office was established in the students' eyes as a magistrate's court, which could give summary punishment for minor offences and refer promising cases to the more powerful majesty of the Dean next door. The secretary himself was a shrivelled old man with pince-nez on a thick black ribbon, who must have been the last person in London to wear elastic-sided boots, and he sat surrounded by piles of dusty official papers growing slowly from the floor like stalagmites. He suggested that I become a medical officer in the Regular Army. This advice was depressing, because I knew that he was an old-fashioned man who suggested the Army only to graduates he thought unfit to attend ordinary human beings.

  Although I had won no distinctions, scholarships, or prizes at St Swithin's I boldly asked the secretary to enter me for one of the house surgeon's jobs, for these were well known among the students to be distributed in the same sporting spirit that enlivened the rest of the medical school. They were awarded by the hospital consultants sitting in committee, and represented their last chance of getting their own back on students they disliked. Youths who had sat on the front bench at lectures and asked intelligent questions to which they already knew the answers were turned down; so were earnest young men in open necks and sandals who passed round the _New Statesman_ and held intense little meetings in corners of the common room on _The Conscience of the Doctor in a Capitalist Society._ Another advantage to an applicant like myself was the consultants' habit of always voting against the favourites of colleagues they disliked. A surgeon with the overwhelming personality of Sir Lancelot Spratt had condemned several dozen promising physicians to start their careers in provincial hospitals because the Professor of Medicine had once refused to let him park his Rolls in the shade of the medical laboratory.

  'I fear you are letting your recent qualification unbalance you somewhat,' the secretary told me. 'There are over eighty-three thousand practitioners on the British Register. So you have added less than one eighty-third thousandth to the medical strength of the country. If not the Army, how about the Colonial Service?'

  But St Swithin's showed extravagant confidence in its educational ability, and the next afternoon I was appointed junior Casualty House Surgeon to the Professor of Surgery.

  'They won't allow you to go cutting up real live people for a bit,' said my landlady with satisfaction, while I was excitedly doing my packing. 'They used to let the learners do the poor people who couldn't afford to pay, but the Government's gone and stopped all that with the National Health Service.'

  'I am perfectly entitled to go cutting up whoever I like now I'm qualified,' I told her with dignity. 'Naturally, one starts in a small way, like in everything else. Bumps,' ganglions, and cysts, you know-you work your way up through varicose veins and hernias, but after your first appendix it's more or less plain sailing.'

  She sniffed. 'I certainly wouldn't want you to go cutting up anyone belonging to me.'_

  'I must ask you to remember, please, that I happen to be a doctor now, not a medical student.'

  'Well, there's twelve and six to pay, Doctor, for the breakages.'

  The casualty job was admittedly one of the lowliest in the hospital, coming ahead in academic status only to an obscure appointment known as 'Skins and V.D'. It was performed in the casualty-room, which was really nothing more than a dressing-station in the battle between London's drivers and pedestrians, and its clinical responsibilities could have been undertaken by any confident member of St John Ambulance Brigade. These thoughts did not occur to me as I crossed the hospital quadrangle the next day to start work. The subaltern joining his first regiment sees only his promotion to colonel, the new clerk plans his managerial reorganization, and even the freshly-ordained clergyman probably spares a thought for the suitability of his calves for gaiters. At the time, the end of my career was clearer to me than the beginning. I saw myself already rising through the profession to become a consultant surgeon at St Swithin's itself, collecting on the way honours, fellowships, and degrees like a magnet in a box of iron filings.

  'I say!' someone called across the courtyard, as I strode in my new stiff white coat towards the casualty entrance. 'I say, old man! Half a jiff!'

  I turned, and recognized the first obstacle in my professional path. It was Bingham, the other Junior Casualty House Surgeon. He was a pale youth with thick spectacles and bushy hair, who still looked seventeen and always had boils. As a student he was never a frontbench squatter, but he had once won the Dean's Prize in applied anatomy and thereafter always walked through the students' quarters with the Lancet sticking
from his pocket like a flag and a couple of large books under his arm. Every lunch hour he carried these books to the library, where he ate his cheese sandwiches and removed from the reference volumes dust which he transferred during the afternoon to the instructive abdomens of patients in the wards. Every Saturday when, the library closed he moved to the surgical pathology museum, where patients' organs were stored away in thick glass jars on shelves like left luggage, and carried his books round the galleries instead. Bingham seemed to absorb a good deal of knowledge from the armpit.

  'I'm jolly pleased you got the other cas, job, old chap,' he said, grabbing my sleeve. 'I wondered who it'd go to. Could have been deuced tricky. Suppose they'd given it to some awful stinker. See what I mean? But we'll get along top-hole together, won't we?'

  'Yes, we're pretty well bound to, I suppose.'

  'I say,' he went on enthusiastically. 'This is a lark, isn't it?'

  'What's a lark?'

  'Being qualified and all that. I mean, now we can get on with things properly. I've got a couple of septic fingers, a lipoma, and four circs. lined up for minor ops. already.' He rubbed his hands, as if contemplating a good dinner. 'The Prof. stuck his nose in and said I was pretty quick off the mark. By the way, old chap, he asked why you weren't there.'

  'But why should I have been there?' I asked in surprise. 'The job only starts today, surely?'

  'Yes, but from midnight last night or something, old chap. Technical point. Didn't you know? The last H.S. has cleared off, anyway. I told the Prof. you were really quite a reliable sort of fellow, and even if you were a bit prone to nip off for long week-ends you'd be back in a few days. I said I'd willingly cope with the extra work in the meantime.'

  I looked at Bingham coldly. 'And what, may I ask, did the Professor say to all that?'

  'Nothing, old chap. He just sort of snorted and went off.'

  'I see.'

  This was a bad start. Before I could seriously begin my career I would have to win promotion to senior house surgeon and work in the wards themselves under the Professor of Surgery. The appointment would be made after we had finished three months' work in casualty-and only one of us could be chosen. The reject would be turned out in his medical infancy to wail on some other hospital's doorstep.

  'I say, old chap,' Bingham continued as we walked along. 'You simply must nip up to the ward after supper and have a dekko at some wizard pancreatic cysts. There's a wonderful perf. up there too-pretty sick, you know, but I think he'll last till we've had a squint at him.' Bingham had the true surgeon's mentality, for it never occurred to him that interesting signs and symptoms were attached to human beings. 'There's a kid with a smashing ductus, too. Murmur as loud as a bus. Could hardly take my bally stethoscope away.'

  'I thought casualty house surgeons weren't supposed to go into the wards?'

  'No really, old chap, but I told the Prof. I was working for Fellowship already and he said I could nose, round as much as I liked. I expect it'll be all right for you to come too, as long as you're with me.'

  I began to hate Bingham before we first crossed the threshold of our common work-place.

  The casualty-room at St Swithin's was not likely to fire in any young man the inspiration to be a second Louis Pasteur or Astley Cooper. It was a long, tiled, semi-basement place, lit by small windows high in the walls, smelling strongly of carbolic and always crowded, like a public lavatory at a busy crossroads. As St Swithin's had to find money to buy all the latest antibiotics and isotopes, it saw no point in spending it on a department where the therapeutic technique had hardly changed since its patients were brought on shutters from beneath the wheels of hansom cabs. Everything in casualty was old: there were old horsehair examination couches, sagging screens of old sacking, dull old instruments, battered old dressing drums, and steamy old sterilizers. Even the porter was past retiring age, and all the nurses seemed to be old ladies.

  As we entered, the rows of old wooden benches were already filled with people-one-quarter men, and a quarter each women, children, and policemen. There were policemen everywhere, as thick as tom-cats in a fish market. They stood in the corners holding their helmets, they hid behind the screens with open notebooks, they drank pints of free tea solemnly round the sterilizer, they peered across stretchers and requested eternal 'particulars.' Policemen are inseparable from casualty surgery, and it was well known at St Swithin's that anyone falling over in the district and not getting up damn quickly was immediately seized by the police and enthusiastically borne into the casualty-room.

  I sat down at an old desk in one end of the room, which held a large brass ink-pot and a pile of different coloured forms. My job was simple. I handed one of these forms to any patient who I felt 'was beyond my own professional ability and thankfully disposed of him for ever into some inner department of the hospital. As my only post-graduate guidance from St Swithin's was a leaflet on what to do in case of fire and another describing the most fruitful way of asking relatives for a post-mortem, I was at first worried about matching the correct form to the case. Fortunately, the old porter had long ago accepted the responsibility of running casualty himself, and tactfully brought me the right document to sign after selecting it with the infallible diagnostic instinct of a St Swithin's employee.

  The casualty-room never emptied before evening, and for a week I was too busy even to notice Bingham. We met professionally only once a day, at the noon interlude in the clinical rough-and-tumble known as 'minor ops'. This was for surgery too lowly for the main operating theatres, and was performed by Bingham and myself in an undignified theatre made by a partitioned corner of the casualty-room, containing a galvanized-iron operating table, an Edwardian dental-chair decorated with gilt _fleurs de lys,_ and a small anaesthetic apparatus on which some former house surgeon had written _Property of the Gas, Fight, and Choke Company._ Although we made our incisions with scapels that would have been hurled to the floor in the main theatre, and probably had been, it was minor ops. that made the casualty job tolerable: as newly-qualified prospective surgeons, both of us had the same enthusiasm for the knife as the Committee of Public Safety for the guillotine.

  I shortly became aware that Bingham always had far more cases waiting on the benches outside minor ops. than I did. As we took alternate patients coming through the casualty-door I envied his luck, until I discovered that he had the habit of stopping people he saw in the street with promising boils, warts, moles, or cysts, handing them his card, and telling them to come to the casualty-room of St Swithin's at midday and ask specifically for himself. This brought him a brisk practice of taxi drivers, railway porters, bus conductors, tea-shop waitresses, newsvendors, and roadmenders, and he not only removed the lump and others found by a more searching examination than was possible in public, but usually pulled out their ingrowing toe-nails and extracted their bad teeth as well.

  This unsporting approach to surgery so annoyed me that one morning when Bingham was out of the casualty-room I felt justified in harvesting some of his crop myself. I was half-way through removing under local anaesthetic an interesting sebaceous cyst on the nose of an Underground ticket collector, when Bingham burst into the theatre.

  'I say!' he started, his white coat flapping furiously. 'That cyst's bally well mine!'

  I looked at him over my mask. 'Oh, is it?' I said in surprise. 'I thought you'd gone to lunch.'

  'Lunch! Have you ever known me go to lunch during minor ops.? Of course I wasn't at lunch, you chump. I was having a dekko at a p.m.-jolly interesting ruptured kidney-and having a chat about it with the Prof., if you must know.'

  'Well, there's plenty more,' I said, picking up the cyst in a pair of forceps. 'I'll be finished in five minutes.'

  'That isn't the bally point,' he went on crossly. 'The fact is, old chap, I particularly wanted to do that cyst. I've been looking forward to it all morning. And I might add it's pretty unethical to pinch another chap's patients, old chap.'

  'It's also pretty unethical for a chap to
go round the streets of London touting for custom.'

  He blushed. For a few seconds he said nothing. 'I don't think I like your tone, old chap,' he muttered.

  'And I don't ruddy well care if you don't.'

  The patient, now alarmed that his medical advisers were about to come to blows over his body, reminded them of their obligations with a noise through the sterile towels like the neigh of a dying horse.

  'I'll report you to the Prof.,' Bingham hissed, and swept out.

  He revenged himself immediately by directing all the 'old chronics' to my desk. These patients were a human sludge in the machinery of St Swithin's, of which it could never rid itself. They appeared regularly with notes as large as the score of a symphony, on which the words 'Rep. Mist.' were scrawled in the writing of twenty successive house surgeons. These abbreviations entitled them to another bottle of medicine, the original purpose of which was generally forgotten and the original prescriber probably dead.

  The old chronics that morning seemed unending as they shifted slowly up the benches towards me. By two o'clock there were still a dozen left; I hadn't had my lunch, and I was in a bad temper. Then I noticed a patient queue jumping.

  He was a shifty-looking, elderly man dressed in a shabby black coat and striped trousers. He had sneaked down the room and sat himself on the edge of the foremost bench. He held the finger of one hand in a bloodstained handkerchief, and he still wore his black Homburg hat. I knew his type well: we often saw head clerks and managers from surrounding offices who carried their self-importance on to the equalizing benches of the casualty-room, and we were encouraged by the Professor to stop it.

  'One minute, missus,' I told a fat woman with some obscure but ancient condition of the feet. 'Now look here, daddy,' I began sharply, crossing to the interloper. 'What's the meaning of this?'