(2013) Looks Could Kill

by David Ellis

  Emma inspected the face and was impressed by the nobility and strength she saw. She felt compelled to look at the eyes and gently lifted the eyelids. She took a sudden step back when she noticed both the eye sockets were empty and in place of the eyes there was some sort of dead insect. She was aware that sometimes certain organs were removed before being embalmed and then sent on to medical schools but she’d never heard of the eyes being removed,

  “Is that someone you know, Emma?” asked Michael, a geeky looking student on the other side of the dissection table.

  “Don’t be an idiot,” said Emma. She turned her attention back to the matter in hand: the dissection of the upper limb and, in particular, the dissection of the axilla and brachial plexus, which was the bit that was generally dreaded by medical students.

  As well as tables of cadavers, each surrounded by a quartet of students, the dissecting room was policed by anatomy demonstrators who were usually junior doctors in training to be surgeons. Some saw the spell as a demonstrator as an archaic rite of passage; others saw it as a means of passing an initial surgery exam; and others saw it as a bit of a career break which looked good on their CV. Personalities varied hugely, but the best tended to be those who were a bit more ambivalent about their career path.

  Following the dissection class, Emma decided to see whether she could find out more about the man who’d donated the body on their dissection table. She knocked on the door of the technician’s office and waited for the onslaught of formalin on her olfactory senses.

  “Oh, hi, Mick,” said Emma. “I was just wondering whether you had any details about the cadaver on table four, just for personal interest, really.”

  “Let me see what I can do,” said Mick, the anatomy technician. He turned to a battered filing card drawer and rummaged through the cards before finding what he was looking for. “Yes, you’re lucky, miss, we’ve got some details. Let’s see… Okay, he was 82 when he died from a heart attack and his first name was Bert, short for Cuthbert. No family name. And that’s the sum of it, I’m afraid. Is that what you were looking for?”

  “Yes, thanks, Mick,” said Emma. “But there’s a strange thing I noticed: both his eye sockets are empty apart from some dead insect which presumably had crawled in. Do you know why that should be?”

  “Yes, that’s very strange,” said Mike. “Let me have another look at the card… well, nothing about eyes, but it says on the other side that the body was transferred here from the medical school at Glasgow, which is also rather curious.”

  “Oh well,” said Emma, “at least it’s nice to have a name to attach to the body. I think I’ll call him Cuthbert; it sounds like a name with some dignity. Bert just sounds too common for someone with that noble face. And at least he won’t be able to see what a mess we’re making of the dissection.”

  They both laughed.

  On her way up the stairs from the dissecting room, Emma had the fleeting thought that perhaps it wasn’t she who chose Cuthbert but that Cuthbert chose her.

  May 1982

  When Emma went to check for post in her pigeon-hole, she found a rather official looking envelope with the name of a firm of solicitors at the top. It had originally been sent to her home address and then forwarded to St Helena’s by her mother. Opening it, she was surprised to read that it related to the will of her old kindergarten teacher, Mrs Brown, and that she had left her some sort of inheritance and the solicitor was asking her to go to their offices in Guildford to collect it.

  Emma took a coach from Oxford to Guildford and found the solicitors office on the High Street quite easily. The office was in an old, gabled building, which looked reassuringly solid and official. Emma was greeted by one of the partners who showed her into his office.

  “I hope we haven’t raised your expectations too much, Miss Jones,” he said, “but the deceased was very clear in her will that she wanted you to have the items in question. I believe there is also a letter.”

  “I’m just so surprised that she left me anything,” said Emma. “It was a long time ago that I was at the kindergarten and I’d never have thought that she’d remember me in her will.”

  “On the contrary, Miss Jones, I think you must have left quite an impression on her. Now, let me get the items for you. Please excuse me for a moment.”

  The solicitor left the office briefly and returned with two objects wrapped up in paper. It didn’t occur to Emma immediately what they might be and her mind was more focused on how to get them back safely to Oxford. Fortunately, the solicitor was able to find some bags, which he thought would reduce the risk of damage to whatever was inside.

  Although she considered opening the packages on the coach, she decided to bide her time until she was back in her college room; a bequest like this needed some privacy.

  Turning out of the office onto the High Street, Emma almost collided with a tall man with dark, wavy hair. They stared at each other.

  “It’s Emma, isn’t it?” he said.

  “Oh, god, I don’t believe it… you’re Danny,” said Emma, in amazement.

  “Guilty as charged. What are you doing in this neck of the woods?” he asked.

  “Oh, just collecting something from the office here,” she said, pointing at where she’d come from.

  They stared at each other again.

  “And what about you?”

  “Oh, just some business, you know.”

  “Look, Danny, I’m really sorry, but I’m going to have to dash or else I’ll miss my coach. I’m really sorry…”

  “No problem, Emma. Look, keep in touch. Here’s my phone number.” He found a pen and scrap of paper and wrote down his number.

  “Thanks Danny. I’ll be in touch.”

  Emma ran down the High Street, struggling with her bulky packages, in the direction of the coach station.

  Danny watched her, hoping that she wouldn’t fall over and break something. Like an arm, for instance. He chuckled to himself.

  May 1982, two hours later

  The first and largest package was quite heavy. Tearing off the packing material, Emma discovered a glass-fronted, dark wood cabinet about two foot square and a few inches deep with a plush, red velvet board. In the top left-hand corner, there was a single butterfly which she recognised as a Large White, a widespread species in the UK but beautiful because of its simplicity and the black spots on the wings of the female. Although Mrs Brown had collected many other rarer, and more beautiful, species, this was always the one she returned to as it was the first butterfly she’d collected.

  The second package was much smaller, perhaps five inches square. Inside the packing material she found the glass jar that Mrs Brown used for killing butterflies, or as she put it, for ‘sending them to sleep’. At the bottom of the jar, she noticed a piece of folded, almost transparent paper. It had her name on it – ‘Miss Emma Jones’ – in tiny, intricate writing. She unfolded the paper, drew a breath and started reading:

  “My dear Emma,

  It seems so many years since the first day you came to the kindergarten with your parents. I have kept in touch with them over the years and it has given me great pride to see your academic career go from strength to strength. Who would guess that the little girl who somehow caused that mischievous boy to fall out of the tree should now be up at Oxford studying medicine? But the fondest memory I have of you is our time together sharing my love of butterflies. I could have left you my entire collection, but I wanted you to have the satisfaction of building your own. I have, of course, started your collection with the same butterfly that started my interest: the common, but uncommonly beautiful, Large White. Both the case and sleep jar are Victorian and belonged to my grandfather who was an eminent entomologist; I think he would have been as delighted as I am for them now to be in your hands.

  With fondest memories.

  Mrs (Georgina) Brown”

  September 1982

  During the summer vacation, Emma decided to put Mrs Brown’s bequest to use and s
tarted looking for butterflies in the hedgerows around Hindhead. Initially, this was just to see what species were around, but eventually she picked up the courage to go armed with a butterfly net. Given her somewhat macabre interest in tending to wounded animals at the roadside, this didn’t surprise her father at all and he thought it was a more appropriate hobby for the summer. Emma’s mother wasn’t quite so convinced and said she felt queasy when Emma showed her the killing jar.

  The business of killing butterflies still seemed strange to Emma, and she had to remind herself that she’d had to despatch much larger and arguably more thinking creatures in the course of ‘A’ level biology. Emma had read that there was quite a knack to killing butterflies if you wanted to keep their wings intact; lepidoptery instruction manuals advised pinching the thorax to stun the butterfly before plunging them into the killing jar. At the end of the day, there were just bugs really, so the lepidopterist’s technique for killing them was no worse and probably rather better than using a fly swat on a bluebottle in the kitchen.

  So Emma arrived back at St Helena’s for her second preclinical year with a handful of carefully preserved butterflies, and the first thing she did was to mount them in Mrs Brown’s case together with the common and scientific names that she’d written on tiny pieces of paper.

  The second year introduced yet more subjects into the curriculum and some of these appealed to Emma more than others. She found neuroanatomy fascinating but also difficult to get her head around without being able to visualise things in 3D. More immediately accessible for her were newer subjects like sociology, ethics and psychology, which helped Emma to start thinking outside the rather strict medical box.

  For one particular seminar, a small group of students had to come up with a topic and then generate moral dilemmas which they then had to discuss. Emma suggested: ‘Is doing harm always wrong?’

  Emma started her presentation:

  “Okay, let’s suppose that on occasions someone harms her/himself by self-cutting on her/his arms and that doing so relieves unbearable psychological suffering. Is it morally right for an individual to do that?”

  The unanimous vote from her group was ‘yes’.

  She continued:

  “Let’s suppose that the same person has broken both arms which are now in plaster casts. She/he still wants to harm her/himself in the same way in order to relieve suffering, but is in even more distress because of the broken arms. She/he therefore asks a best friend to do the cutting. Is it morally right for the friend to do that?”

  A complicated discussion ensued along the lines of “couldn’t she/he cut herself using a razor blade held between her/his toes”, “perhaps response prevention would be helpful” and “perhaps a stranger with no emotional attachment might be better.” The final vote was split with 60% saying ‘yes’ and 40% saying ‘no’.

  Emma moved on to the next question:

  “Now, what about if a patient with a terminal illness wants to die and is able to devise and carry out a way of doing that without involving anyone else. Is it morally right for an individual to do that?”

  The group thought that same principle of autonomy applied as in the first case, so the vote was a unanimous ‘yes’.

  Emma finished off with her last dilemma:

  “Finally, what if a patient with the same terminal illness also wants to die and whilst he/she’s able to devise a way of carrying it out he/she cannot do this without involving others. Is it morally right for someone else to do that?”

  Everyone in the group agreed that this was a dilemma with no clear moral solution, although some thought that if the patient took an active part in the process with assistance from a third party, then this might be morally acceptable.

  Emma concluded that morals and ethics were very difficult to get one’s head around, particularly if it was a head like hers that demanded a fair degree of certainty. She thought it was brave of her to bring her own problem to the group, albeit rather obliquely, although she thought that very few of her year knew anything about it. She’d been told by nice Robert the counsellor that self-harm amongst Oxford students was as common as 1 in 10, particularly in the first year or when Finals was about to happen. That was faintly reassuring, but it did make Emma search the rows of fellow students in the lecture theatre looking for the tell-tale signs of self-harming; it was usually the long sleeves that gave the game away.

  November 1983

  Once Emma had started her first clinical year, medicine suddenly opened up and seemed to escape from the confines of the dissecting room and the endless textbooks filling her shelves. But she found herself frustrated by the constant moving on as she went from one clinical attachment to another. And the never-ending making and breaking of relationships with staff and patients seemed at odds with the therapeutic bond that’s meant to develop over time between doctor and patient.

  There’s no doubt that Emma’s self-harming went a little off the rails during this time and she became a well-known customer at the local Boots, stocking up on steri-strips and plasters. She’d learnt from an early age that drawing attention to her self-harming usually caused more problems than it solved, so self-presenting to an A&E department was a definite no-no.

  So, being so close to home, psychiatry held something of a morbid fascination for Emma.

  One Friday afternoon, when Emma really wished she was doing something entirely different, she found herself waiting to see a new patient that she’d then have to present to the senior registrar. She’d seen a referral letter from a GP, but it was the typical one-liner – “This woman is depressed, please do the needful” – from an overworked, single-handed GP, which gave virtually nothing away.

  “Hello, you must be Julia Thompson,” said Emma, with a beaming smile. “I’m Emma Jones, a medical student, and I’ve been asked to take a full history and do a mental state examination.”

  Emma realised as soon as the words escaped from her mouth that that was a bad start, although that is what the senior registrar had told her to do.

  “Well, no insult meant, love, but I was told I’d be seeing the consultant,” said Mrs Thompson.

  “Oh, yes, you will see the senior registrar, but he asked me to see you first.”

  “No insult meant, love, but you don’t look old enough to be my daughter, and anyway, I was told I’d see the consultant.”

  After this unfortunate introductory sparing, which is commonplace when medical students get asked to see patients without them receiving some forewarning, the two of them reached an agreement that she would talk to Emma for a bit, but that she would have to leave soon to top up the parking meter.

  “So, Mrs Thompson, can you tell me what brings you here today?” asked Emma, using the open-ended introductory question suggested in her psychiatry hand-out.

  “Well, it’s like, it’s this thing that, I don’t know how to put it, but it’s like I don’t, you know what I mean, don’t you?”

  Emma was going to ask her to repeat what she’d just said, but she decided on a different tack in the hope that it would resolve her patient’s expressive dysphasia.

  “I’ve got a letter from your GP here, and it mentions you being depressed. Can you tell me about that?”

  “Well, it’s like, it’s this thing that, I don’t know how to put it, but it’s like I don’t, you know what I mean, don’t you?”

  Now someone once told Emma that when people are as tongue-tied as this poor woman clearly was, it’s usually because they’re embarrassed about something. And reading between the lines, Emma got the impression that the embarrassment was related to something ‘down there’. Emma caught her eye and the wave of embarrassment she experienced immediately confirmed her feminine intuition.

  “Now, Mrs Thompson, I’m going to make a stab in the dark, but I think you’re embarrassed about something and that you haven’t been able to talk to anyone about it, and it’s that what’s made your GP think you’re depressed. Am I right?”

  And that
unleashed the floodgates. It turned out that her husband was a “philanderer” and he accused her for being a “frigid cow”, which is why he had to “get it” elsewhere.

  As far as Emma was concerned, there wasn’t actually the slightest hint of clinical depression, just utter frustration with an appalling husband who seemed to enjoy mistreating her in any way he could. Emma couldn’t see much point in doing a full history and mental state examination, but she did it anyway to keep the senior registrar happy.

  So Emma presented her case to the senior registrar and then he invited the patient into his consulting room so that he could confirm her findings.

  “So, Mrs Thompson, I gather from your GP that you’ve been feeling depressed.”

  “Yes, terribly depressed, doctor. I can’t sleep, I can’t eat, I can’t concentrate, I’m crying all the time and I’ve got no interest in anything. To be honest, I’ve even thought of, you know, doing something.”

  “Do you mean like harming yourself or even taking your own life?”

  “To be truthful, doctor, I have.”

  So the senior registrar concluded that the GP had been right all along and started her on an antidepressant.

  The senior registrar told Emma that the key learning point from that case was to accurately diagnose depression. The learning point that Emma took home that afternoon is that sometimes patients will say anything in order to get a prescription.

  And Emma decided that the parking meter ploy was an excellent way for a patient to do a bit of boundary setting.