Against the Tide

by Noël Browne

  Midhurst was a beautifully situated hospital, well run by an Australian, Dr Geoffrey Todd. The visiting surgeon was Dr Wynne Edwards, one of the many Welsh doctors who completely dominated chest surgery and medicine at that time in Britain. With the best possible intentions I was subjected to many extraordinary drugs, some of them positively dangerous, and all useless. At least one of them, a gold preparation named Sanocrycin, damaged my blood cells by inducing a blood disorder and I became very ill. All else having failed, it was decided in 1942 to operate on my right lung.

  The disease in both of my lungs being so advanced, it was not possible for the surgeon to use the conventional mutilating but fairly safe thorocoplasty operation, under which four, six, or even eight ribs were removed in their entirety. My disease was too unstable and too unpredictable, so an entirely new and relatively untried operation called extra-pleural pneumothorax was proposed. Part of two ribs would be removed and air would then be injected under pressure into the space created. It was later shown to be a dangerous and impractical procedure and was rapidly discontinued, but the doctors did not tell me quite how new and dangerous it was.

  The reality was that there was no choice. A slow and painful death was otherwise inevitable. It was quite common for patients to be told that because of the extent of their disease, there was simply nothing that could be done for them. I suspect that I was in this category, but my two physicians courageously refused to concede it. My distressing symptoms of drenching night sweats and sleeplessness became exacerbated, and I had lost over two stone. I had never seriously contemplated the possibility of dying from the disease, but now for the first time I became frightened, and agreed to have the operation.

  Because of the state of my chest, the operation had to be carried out under a local anaesthetic; a general anaesthetic would have been too dangerous. In spite of the cotton wool in my ears, I could hear the terrifying sound of my ribs being cracked painlessly by the giant shears which I was later to come to know so well, when working on my own patients. My fear stemmed not only from the unpleasantness of the operation, or of the operating theatre; sedation and anasthesia were not as effective then as they are now, but there was yet another reason for my fears.

  I had been invited to go to Mass with the Irish nurses in the nearby village of Midhurst on the Sunday prior to my operation. Though I had given up the practice of my religion, I went lest I should hurt their feelings, and met the priest. I am sure that the sermon which he gave about the beauties of Heaven and the angels was a good one, but understandably, it seemed to me peculiarly inappropriate at a time when the air was full of German fighters and bombers. Damage in cities was widespread, and sudden death was frequent. The Battle of Britain was being fought out over our heads, for weeks on end. Because of pilot losses and shortages, our sanatorium was scoured for men who though ill might be fit enough to fly. We were warned daily not to walk around the hospital grounds, lest we be machine-gunned by the German fighters. Death was near to so many of us, in so many ways.

  The priest had been told of my operation. On the night before it was to take place he came to offer me the Last Rites. I happened to believe that I did not want his kindly help and, as gently as I could, told him so. Somewhat brutally, he told me what the surgeons had thoughtfully kept to themselves — that the operation which I was to have on the following day was a dangerous and virtually untried procedure, which I already knew, and that the same operation had recently been carried out at Midhurst on a young Dublin doctor, who had bled to death. Shocked by this revelation, I was above all else repelled by his unfeeling timing. It did not have the hoped-for effect; I sent him away. I entered the operating theatre on the following day a very fearful soul indeed, frightened not by hellfire but of dying painfully like my young predecessor.

  I survived the operation, though for technical reasons the procedure was a failure. I had bled copiously; when the bleeding stopped, the space which had been intended to be occupied by air was now filled with blood. So it remains to this day.

  There was little else that could be done for me. Dr Nicholson, Dr Todd and the nursing staff with great care and skill helped me over the operation itself. I still marvel at the generosity of a society which, in the middle of a war of such ferocity, could have turned aside to concern itself with saving the life of an unimportant outsider, whose own country had chosen not to concern itself with the struggle.

  5

  Medical Practice

  AS SOON as I became fit to do so, I completed my final examinations in 1942 and became a doctor. My first post was in Dr Steevens’ Hospital, where I had been a student, and I then moved on to Newcastle Sanatorium, Co Wicklow. While in Newcastle, it became clear that I was wasting my time working in an Irish sanatorium. The facilities were grossly inadequate. Because of the delays experienced by waiting patients, treatment was almost useless by the time a bed was available; at one time there were almost one thousand sick people on the waiting list.

  My first clash with politicians arose over my refusal to give priority over the year-long waiting list to a Dáil deputy, a member of the government party. I was afterwards told that the department official I had refused advised my hospital to get rid of me.

  Possibly the busiest room in the average sanatorium was the mortuary. The ‘Pigeon House’ at Ringsend was kept especially busy in this regard, although it was under the care of an unusually fine physician, Dr. John Duffy, who did his best with little or no help from anyone. The building was a former cholera isolation hospital, and no conversion had been considered necessary by Dublin Corporation because the inmates were all terminal cases of tuberculosis. They were terminal mainly because of lack of diagnostic and treatment facilities.

  Most of the sanatoria in the country were in the same bad repair, but the Pigeon House was one of the worst. It was cold and, as at Newcastle, the roof leaked into buckets in the centre of the ward floors. Inevitably there was a continuous line of undecorated, cheap deal coffins, in the simple glass-sided horse-drawn hearses of the poor, leaving the hospital. Because the hospital was at the end of the road these hearses had to pass the windows of the men and women who waited their turn to be put into the ground in the ‘Nevin’ (Glasnevin cemetery).

  As with so much else in the new Irish state, all the old rigid arrogant class attitudes common to the ascendancy doctor were readily assumed by the newly emergent Irish successor. The rigid class-structured pecking order observed in Irish hospitals is shown in a story told by a psychiatric nurse. One morning he had passed the outgoing medical superintendent while walking in through the door of the psychiatric hospital. The nurse muttered a brief ‘hello’ and went on. Instantly he was called by the medical superintendent, who asked him his name and his work. The nurse gave his name. The RMS then said: ‘You had better know that if you are to survive long in this hospital, you’ll always address me as “Good Morning, Sir”.’

  Another incident of this type happened me at Dr Steevens’ Hospital. Early one morning I had tumbled out of bed and run down the steep stairs from the ‘cock-loft’, where doctors and medical students slept, to care for an emergency in the casualty room. Having dealt with the accident I was strolling back to the Mess to have my breakfast. I was shouted at — ‘Hey, you!’ I turned in some disbelief and saw that the caller was a particularly pompous member of the consultant staff with a considerable opinion of himself. I leaned back against the wall, my arm resting easily on the iron handrail; the consultant was compelled to continue making a fool of himself by shouting at me, or move towards me, and the latter he eventually did. I asked him quietly, ‘Who do you think you’re shouting at?’ Clearly surprised by the reception, he quietened down and settled for giving me a lecture about the propriety of seeing patients in my bedroom slippers and no socks. I did not trouble to explain the emergency nature of the call when, understandably, my first concern was for the patient. The consultant went on his way, yet, vindictively, he reported me to the hospital medical board for having been di
srespectful to him. I survived the encounter.

  In 1943 I set out for wartime England to gain experience at the best sanatoria, with the intention of returning to Ireland. Hospital work and staff relationships in England were remarkably different from those of my recent Irish experience. In the first of these hospitals, the Cheshire Joint Sanatorium, I was to learn much more than the imaginative, unorthodox, original diagnostic and care procedures devised by a remarkable, infinitely charming, autocratic bully, Dr Peter Edwards. Incredibly, he ran a sanatorium staffed almost entirely with former consumptives; nurses, administrative staff, laboratory staff, doctors and even Peter Edwards himself had all recovered, or were recovering, or indeed, had no hope of ever recovering, from tuberculosis. Yet they were carefully ambulant and mentally active. This was unheard of in tuberculosis practice at that time, but Dr Edwards had original and heterodox ideas on virtually every subject you could think of.

  He despised Catholicism as a ‘primitive, idolatrous, pagan, yellow-ochre religion’, and regarded my education and background as a disqualification when I later applied for a permanent post in his sanatorium. But there were times when he could be completely indifferent to religious convictions, particularly if the person concerned was ‘good company’. He formed a lifelong friendship with an Irish colleague, Dr Joe Logan, later head of Peamount Sanatorium, Co. Dublin. Dr Logan, who exercised a valuable restraining effect on Peter Edwards at the Club bar, had that most priceless asset, a fine sense of humour. He was a very entertaining raconteur, could accompany himself singing at the piano and in fact was the quintessential good-humoured Irishman. Peter forgave Joe Logan his Catholicism and they had some great times together. In contrast I was inclined to be a solitary serious fellow in bibulous company, and, alas, still am.

  Peter confided in us that he had developed the principle of employing tuberculosis staff in his hospital on the general thesis that the healthy doctor who chooses to go to work at the rather somnolent pace of a TB sanatorium must be either ‘a drug addict, an alcoholic, or a lazy bastard’. While it is true that he himself lived a relatively wild and rumbustious existence, the régime imposed on his patients and expected from his staff was one of monastic sobriety and asceticism.

  As well as a considerable store of information about the care of tuberculosis, I also learned from Dr Edwards his insistence on the egalitarian values of a good radical Welsh liberal. There was no distinction whatever in his sanatorium between the disparate roles of the hospital staff. We all contributed equally to the struggle to help and to care for our patients. There were no titles; we all used Christian names. Technicians, technocrats, male nurses, doctors, porters, ambulance drivers and administrative staff were all on equal terms, and co-equal members of a fine social and recreational club. It was here that we had the bar, staffed by each of us in turn, Peter excepted. Even the exception of Peter was an exercise in democracy, since it was agreed on by all of us that we could not permit him to enjoy its freedom unsupervised.

  This camaraderie and lack of pretension was a refreshing contrast to my experience among the medical staff of the average Irish hospital, and was invariable among the Welsh medical men whom I had the pleasure to work with later in England. There was no cap-tipping deference to the doctor among the Welsh, so many of them distinguished and world-renowned members of the medical profession, particularly in the speciality of chest diseases.

  It was the practice when I was in Dr Steevens’ Hospital for a medical student or a junior doctor to carry the consultant’s bag with medical equipment during morning rounds of the hospital, walking a respectful three or four feet behind the consultant. He would like to be left alone when he ducked into a private patient’s room or behind the curtain of a cubicle when that sacred ritual of settling or collecting his fee was negotiated.

  During the latter part of the war the Atlantic blockade was particularly effective, and there were serious shortages. Hospital food was nearly always ‘spam’ or an indescribable concoction of dried eggs. There were times when a handful of vitamin C tablets appeared to be the only meal of an evening. Yet this was also a time when a state could and did take those powers needed to establish a system of priorities, so depressingly absent in our free enterprise societies at other times. All young children and babies, irrespective of wealth, were better fed in Britain under the rationing scheme than ever before or since. Just as I found the easy-going but sensitive working democracy of the Cheshire Joint Sanatorium valuably educative, so was I deeply impressed by the possibilities open to a caring society. We watched a society under siege establish Aneurin Bevan’s ‘gospel of socialism’, which is about priorities. In this socialist system, unlike monopoly capitalism where the strong prevail over the weak, it was the weak and the helpless who were the privileged and protected ones.

  Later, in a fine new chest hospital at Harefield near London, I continued my education in a working democracy. Harefield was run by the Middlesex County Council, and its superintendent was Dr Kenneth Stokes, yet another utterly charming Welsh doctor. I could watch the emergent British welfare society in action. In Dublin, the almoner’s role was to collect hospital and consultant fees. At Harefield, it was the almoner’s function to cater for those in economic or personal distress. The almoner could provide anything from a new mattress or cradle for a newly-born infant to advice for a lady in distress whose marriage had irrevocably broken down, helping her with the details of getting a divorce. It was at Harefield that I heard a patient tell an officious ward sister, ‘Please don’t speak to me like that, sister, it is I who pay your salary’.

  Standing in my white coat in the magnificent front hall of this enormous modern chest hospital, I was approached by a visitor who politely asked me if it would be possible for him to see over ‘his’ hospital some time. Possibly accustomed to being a master race for centuries, the British had no small opinion of themselves. Yet I infinitely preferred this easily presumptuous ‘arrogance’ of the masses to that of our own small privileged wealthy few who liked to see around them the suitably obsequious and grovelling masses. This new experience I found very refreshing.

  For security reasons the famous London hospital of St Mary’s at Paddington with its distinguished staff, including Sir Thomas Dunhill, Dr Tom Holme Sellars and Dr Pickering, was evacuated to Harefield, which had been expanded enormously through the use of what seemed to be hundreds of well-equipped Nissen huts. Because of this, and since battle casualties were sent directly to Harefield from the Normandy beaches, our surgical and medical experience was limitless. Simply by signing our name to a consultation request chit we had access to some of the finest surgeons and physicians in London. In spite of the harrowing nature of our work, medical practice was broad, rich, and rewarding. Meetings, discussions, seminars and consultations went on continuously, in spite of the fact that the first V-bomb fell a few miles away; we happened to be in the middle of what was known as ‘bomb alley’. The work continued uninterrupted; nursing, domestic, medical or administrative staff casualties from the civilian bombing were simply replaced. The cosmopolitan staff included refugees or volunteers of many nationalities and races. I heard a consultant remark that of the thirty or so men in the mess he was the only Englishman amongst us.

  All of these experiences constituted an exciting and attractive new life. My archaic Irish and public school snob values were healthily upended in a consciously liberating way. It is possible that I had recovered the egalitarian instincts and fairminded values of my own home, which had been distorted by my class-orientated school experiences. Whatever the cause, after my English hospital service, I had found my real self, and I was changed irrevocably. In those hospitals in Britain I had met consultants who were among the world’s leading physicians and surgeons, and yet worked for state salaries. They worked ceaselessly, conscientiously, and with complete satisfaction at their profession. I have always found the cash nexus between the patient and doctor indefensible. It cannot be a link, and frequently it can be an impediment.
It is little wonder that Bernard Shaw could write about it with such satirical accuracy. Being a doctor, with all its connotations of relieving human distress, was to me such a privilege that I could not consider the need to take money from a patient for any help which I might have given to them. Within this heterodox attitude to medicine, I found myself to be very much of a misfit with many of my Irish colleagues. Their approach seemed to be just the same as that of the butcher, the baker and the candlestick maker, that you made the customers pay as much as you could get out of them.

  Because of these beliefs, that money should not be made out of the misfortunes of others, I chose throughout nearly half a century in medicine to work for an institution, or for the state, receiving a salary; no matter what the amount of work or how many hours I attended to patients, no money passed between the patient and myself, and every patient, I like to believe, was treated with the same care. My sheer inability to compromise on this principle became very clear on one occasion, when a colleague in private practice developed tuberculosis, and died. I was asked to take on the practice. Since my pay at Newcastle at the time was but £21 monthly, with a lodge, in the interests of my uncomplaining, financially hardpressed wife and family, I agreed to the proposal. Yet it was impossible for me to continue that form of private practice; I simply could not ask for money from men and women who clearly had difficulty in paying. After a time, I compromised with the device of a plate on my table in the hallway, mentioning to the patients that they might put into the plate whatever they thought they could afford. This amounted to far less than the cost of rent of the rooms, the necessary medicines, the drive from Newcastle, and above all, it did not help my patient and long-suffering wife. Yet we decided to discontinue the practice, while continuing to care for the patients at Newcastle. It was an experience of this kind, no doubt, added to what I had known in my early life, which, in the end, helped to turn my mind towards finding a way in which I could change life for the underprivileged sufferers from tuberculosis, and ill-health generally, in Ireland. Had my wife and family not shared these beliefs with me, I could not have taken the adamantine stand on those principles which I did, later on, when Minister for Health.