In the Midst of Life

1963-64 THE MARIE CURIE HOSPITAL

In the early 1960s, I was ward sister at the Marie Curie Hospital in Hampstead, London. It was part of the Royal Free Hospital, and was reserved for specialised radium treatment. It had originally been built as a cottage hospital around 1900, and was small, consisting of only thirty beds. The hospital was divided into two halves, a twelve-bed ward and three small side wards for the men, and the same for the women. A similar amount of space was occupied by the radiotherapy machines, which were huge, and required a lot of room. We dealt only with radiotherapy – all operations were carried out at the Royal Free. We also had our own dispensary. A matron was in overall charge of the hospital, and I was ward sister in charge of therapeutic cases. I had two staff nurses, five or six student nurses, two ward orderlies, and a ward maid.

Cancer is a word that evokes fear in the minds of most people, and fears linger in the twenty-first century, although medical research has enabled cures for many forms of the disease. In the 1960s, the fear was even more justified. Chemotherapy was still at the research stage; radiotherapy was crude, but sometimes effective; drugs were highly toxic, and frequently created more distress and suffering than the cancer. The most reliable treatment was the surgeon’s knife, but whilst the central growth could frequently be cut away, the secondary tumours often could not be removed, nor could the encroachment into the blood, lymph and skeletal systems be prevented.

Staff nurse and I were preparing Mrs Cox for her third treatment. Heaven knows, it was hopeless, but if the radium could reduce some of the growth, and dry up a little of the exudate from an ulcerated breast that was virtually sloughing away as the malignancy digested her chest wall, it would be worth it for her.

Until the early part of the last century, when mastectomy became a common operation, thousands of women fell victim to the ghastly ‘stinking death’, as this type of cancer was sometimes called. Women afflicted with breast cancer would hide it beneath blouses and shawls, saying nothing. Perhaps a daughter would be let into the secret, but ‘women’s matters’ would be kept strictly away from the men. Very often a husband did not know of his wife’s condition, until the smell of the sticky black exudate became so overwhelming that eventually he noticed, or, reluctantly, his wife confessed. The word ‘confessed’ is used deliberately in this instance, because often women were ashamed of their bodies and even more ashamed if something went wrong. I have seen many a woman with a uterine prolapse hanging down halfway to her knees, yet uttering no complaint. A prolapse was common with multiple childbirths, and one woman had kept hers up with an apple for years, she told us, before she eventually had a pelvic floor repair.

Mrs Cox was typical of her generation: patient, uncomplaining, enduring passively all that was heaped upon her. She was in a side ward, with the windows kept open at all times, and a fan continually blowing the air in the room away from the corridor, and hopefully out of the window. But still we could not prevent the dreadful smell from penetrating the corridor. Mrs Cox barely spoke; her dull eyes flickered from the massive erupting growth, as large as a dinner plate, to the other breast, where a few smaller sores had started to discharge and bleed. Like many women of her age, she had withdrawn from her friends and family to await death, but a daughter had insisted on calling a doctor, an older GP who had seen this sort of thing before, and was unsurprised. An oncologist was consulted, who said that surgery was impossible, and advised radium treatment, which might dry up some of the exudate, and hopefully reduce some of the growth.

If we, at the Marie Curie, could make the last weeks of her life more comfortable, the treatment would be worthwhile. We were also able to administer drugs to relieve the pain. The Brompton Cocktail was frequently given, which contained morphine, cocaine, belladonna and gin. Every four hours Mrs Cox drank it gratefully. She was grateful for everything – a glass of water, a clean sheet, a face wash, or a hair brush drawn through her stringy grey hair. She did not express her thanks in words, but her eyes showed it. I often performed these small tasks myself, because I could see how close to death she was, and I knew that the young nurses, who were of another generation, and had seen nothing like Mrs Cox’s ulcerating cancer before, were afraid to go near her. We could not cover the excoriated breast with any surgical dressing, because dressings have to be changed when they become soaked in body fluids. This occurred frequently and quickly, and when we pulled the dressing off, lumps of decomposing flesh and cancerous material came away with it, causing pain. It is not surprising the nurses are afraid of her, I thought, and I wondered how the radiographers, two healthy young men, viewed this tragic woman.

‘Your treatment is helping, isn’t it, Mrs Cox?’ I said as I handed her the Brompton Cocktail. I did not say ‘making you better’, as we were taught to say, perpetuating the lie that modern medicine makes everything better.

She nodded. ‘And you will have another on Friday.’ I continued, ‘that makes four. When you have had six treatments I’m sure you will feel a lot easier.’

Again she nodded wearily.

‘Your daughter said she would come and see you tomorrow.’

Her lips moved, but any words were unrecognisable. I did not want to say any more about the daughter, who might or might not come, and I suspected that her sons never would. Mrs Cox would probably be left to die alone.

But in this I, as ward sister, had control. I had no control over the inexorable course of the disease, nor over the treatment, nor had I any influence over the sons and daughters whom she had borne and brought up, and who were now rejecting her, but I was absolutely determined that she would not die alone. In those days it was regarded as an essential nursing duty to be with a person throughout the time of dying, especially at the actual moment of death. It was regarded as a disgrace to the ward sister, or staff nurse in charge, if a patient died alone.

We prepared Mrs Cox for her third treatment with radium. Two porters came and lifted her on to the trolley and I went with her to the radiotherapy unit, holding the sheet above her breast so that the men would not have to look at it.

Half an hour later I accompanied her back to the ward. The radiographer told me that her blood pressure had dropped during treatment. Her skin was even more sallow than it had been before and her pulse was very weak, her blood pressure barely perceptible. Although her eyes flickered when I spoke to her, and she gave a little moan, she did not appear to be conscious. The porters wheeled her back to the ward and lifted her on to the bed.

We never knew whether the radium treatment had made her more comfortable, because that afternoon, peacefully, quietly, Mrs Cox accepted death with the same uncomplaining resignation that she had accepted life.

‘Dinners is hup, Sister.’

Gladys, the indispensable ward maid, stood in the doorway, arms folded, legs apart, her face expressionless. She knew more about the hospital and how it functioned than anyone, but she never intruded, never grumbled, and above all, never gossiped. One could rely on her discretion, something that, in a cancer hospital, where most of our patients would die, was essential. Thoughtless remarks, a hint or a nudge here or there, could spark off an atmosphere of uncertainty that could escalate, causing patients and their families distress.

The morning had been hectic with, as usual, a shortage of staff, too many duties, and too little time in which to get them done: dressings to change; a drip to install; blood to take; patients to prepare, take to, and return from therapy; the drugs to take round and DDAs to check; a couple of admissions; a patient discharged, with her drugs and treatments to organise and explain to the daughter who was collecting her; the linen arriving from the laundry; someone needing catheterisation; another a bath which he could not manage himself. Morning coffee had been disrupted by three or four radium patients vomiting; the telephone ringing, with a message from dispensary – a drug was available, could a nurse come and collect it? But why could the dispenser not send it up to the ward? They were too busy, the woman said. Does no one ever imagine that the ward is too busy? As we had needed the drug badly for two days, I sent a nurse to get it. And in the rush of work the oncologist – the Chief, we called him – arrived to see a new patient.

He found me in a side ward, washing the mattress of a patient who had died during the night.

‘This is a surprise, Sister. Haven’t you got a nurse or an orderly to do that sort of thing?’

All the nurses are busy, and one orderly is off sick. Anyway, a sister should never be too grand to do the menial tasks. I want this room for Mr Waters because I don’t want him to die in the main ward if it can possibly be avoided – it’s unsettling for the other patients. None of them see themselves getting to that state.’ I cleaned the sides of the mattress. ‘There, it’s done now, and I’m with you.’

Together we went to the bedside of the new patient. Hospital protocol required that I should stay with the consultant whilst he remained in the ward, but Hannah appeared in the doorway with her ‘dinners is hup, Sister’, and a look of command on her heavy features.

‘Then I had better not delay you, Sister,’ the Chief said. ‘We will be doing the full ward round tomorrow morning.’

I walked swiftly to the kitchen, to the ward orderly in pink, the half circle of nurses in blue, each holding a tray, the electric food trolley plugged into the wall, waiting my attention. It had always seemed extraordinary to me that the serving of patients’ dinners occupied such a large part of a sister’s duties (the whole process took the best part of an hour), and that all nursing staff looked to her for the lead. It was a relic of the old days, when drugs and surgery were in their infancy, and when so many people who came into hospital were chronically malnourished, so that the dietary needs of each patient were important.

I tucked the tea towel into my belt to protect my uniform from gravy splashes, and removed the aluminium lids from each container. I served a full dinner for several patients, which the nurses took, returning a few minutes later with empty trays.

‘Take this to Mrs J. and see that she can manage. Stay with her, if necessary.’

‘Yes, Sister.’

‘Mr P. doesn’t like carrots, so give him this one.’

‘Yes, Sister.’

‘Special diabetic diets for Mrs D. and Mrs H. Don’t get them mixed up, Nurse.’

‘No, Sister.’

‘There’s enough left over for the walking patients in the day room. Take it through to them please, Nurse, and see if anyone wants seconds.’

Yes, Sister.’

‘And Nurse…’

She turned, her voice bright and buoyant. ‘Sister …?’

Your cap is incorrectly folded. Attend to it before the afternoon, please.’

Her smile vanished, and her mouth tightened.

Yes, Sister,’ she muttered.

I knew just how she felt, having spent all my early nursing years kicking against the rules and regulations, but discipline had to be maintained …

The routine continued like clockwork, I, hopefully, remembering everyone’s needs and fancies. But one thing I never forgot whilst serving lunches was the mayhem I had caused one dinner time when I was a student nurse.

I was eighteen, nervous and clumsy, awkwardly trying to do my best, and failing at every attempt - every ward sister’s nightmare. I felt like a fish out of water in the rigid female hierarchy.

The sister of the ward on which I worked required a cannula that she did not have, and asked me to go to another ward to see if one might be borrowed. Filled with the importance of my commission I walked quickly (we were never allowed to run!) to Sister Collins’ ward. It was lunchtime, and no one was in sight. Assuming that the sister would be serving lunches I rushed eagerly into the kitchen. Sister and Staff were not there, but the food trolley was. The porters had left it crosswise to the kitchen door, which I was not expecting. I rushed in, and my whole body collided with it, causing the trolley to topple over and hit the floor. Dinners – meat and gravy, fish in white sauce, potatoes, cabbage, carrots, rice pudding, prunes, egg custard, stewed apple, jelly – everything shot across the kitchen floor and slithered under the sink. Horrified and rooted to the spot, I gazed at the scene. The trolley wheels turned slowly in the air; I turned and ran – yes, ran! – from the ward. Still no one was about, no one had seen me enter the ward or leave, so no one could possibly associate me with the disaster. Once round the corner, I slowed to a fast walk and went to another ward to request the loan of the cannula required by my ward sister. An hour later, in the nurses’ dining room, everyone was talking about the extraordinary upturning of a hospital food trolley full of dinners. I could never serve dinners without thinking of this, and if nurses saw me smiling, or heard me giggling quietly to myself, they must have wondered why …

After lunch I went to the male ward to supervise the moving of Mr Waters to the side ward. Not before time, I thought; that dreadful cough had been unsettling for the other men, but now his inability to cough was worse. Phlegm bubbled and rattled in his chest. Struggling with asphyxia, Mr Waters would die as hard as a man can die, unless drugs were given. I pulled the curtains around his bed and used suction to try to remove the excessive fluid bubbling up from his lungs.

‘I’m sorry about this beastly sucker, but it will make you feel better,’ I said, trying to avoid his panic-stricken eyes. His lungs were struggling under some terrible oppression and breathing was an intolerable strain. Any respiratory death is distressing to watch, but a natural anodyne – a sudden dimming of consciousness due to oxygen starvation of the higher centres of the brain – comes at the peak of suffering, and mental and physical deterioration descends as swiftly as a hawk dropping on its prey.

‘Mr Waters, we think you would be better off in the small room. It has two windows, and they can both be open all the time. It will make your breathing easier,’ I said softly. He nodded, and picked at the sheet. I was alone with him, but I could sense a figure hovering beside me. Could he see or feel this ghostly presence? None of us will know until we get there.

I had called the porters, and they arrived with a trolley.

‘I think it will be better if we move the whole bed, rather than lifting him on to a trolley, and then on to another bed,’ I said. It would be more difficult for them, because the corners were awkward, but they did not question my instructions.

Not an hour too soon, we moved him. Two days earlier he had been sitting upright in bed, leaning forward a little, his cheeks flushed, his lips tinged blue as his chest heaved tumultuously at four times the normal respiration rate. His eyes had been clear and his mind alert, as he noted people and things going on in the ward. Now the struggle to live had departed, and weariness had overtaken him.

I called a junior student nurse, and showed her how to fix up the oxygen and the sucker, and how to use them, and explained the details, which were so much better than ten years previously when I had been a student nurse. I told the girl (she was barely more than a child, with fresh features and the downy skin of youth) to stay with the dying man whilst I went to fetch the injections. What huge responsibility we place upon a nurse’s shoulders, I reflected, as I went to the dangerous drugs cupboard. So often they come straight from school, the classroom, the hockey field or the gym, and we expect them to remain with the dying, a task that the majority of mature people would run away from in fear and revulsion. Does this give nurses a heightened sensibility of living, to be so closely acquainted with death? Certainly, nurses always seem to be full of life and vitality, with an inexhaustible capacity for laughter. I had found in nurses none of the lethargy and self-absorption that one often noticed in young girls, contrary to what one might expect, given the nature of our work.

Radiotherapy could not help the malign growth in Mr Waters’ lungs. It may have halted the progress of the cancer by a hair’s breadth, but it made no real impression on the inexorable course of the disease. Mr Waters had smoked himself to death, and there was nothing that medicine could do to reverse the destruction. For two days he flickered in and out of consciousness, his lungs bubbling and gurgling as he slowly drowned. But his suffering was not as great as appearances suggested, because he received devoted nursing care – and the Brompton Cocktail every four hours. His mind was not conscious of his condition, or of his surroundings, and he showed no signs of pain. We did not try to bring him back from wherever he was, by forcing him to drink this or to take that, nor any of the multifarious futilities of energetic medicine. His perceptions were so dimmed by weakness and weariness that his life was ending slowly, in a dream state, rather than in true awareness.

Each morning when I came on duty I expected to find the side ward empty, but for two mornings he was still there. How extraordinary is life, that one can hang on in that condition, neither alive nor dead? But on the third morning the room was empty, and the night nurse reported that the flickerings of life had given way to the smothering curtain of death.