Doctor at Large

11

When I dashed into the flat I found a note neatly pinned to the examination couch:

_Dear Doctor

I fear that some dire emergency has called you away. I fully realize the trials of a doctor's life, and that some poor soul is in a worse state than me. However, lying on your couch seems to have relieved the discomfort, and as I am so anxious to get away this afternoon I will go round the corner to an osteopath recommended by the Minister of Works. With thanks for your attention. Yrs, George Beecham_

I had lost Razzy a patient, but my personal honour, and probably my professional life, were saved by the politician. I hoped he would become Prime Minister, and since that afternoon I have always read his speeches in the newspapers.

I did not tell Razzy the full story until the day that I was leaving the practice.

'Really?' he said mildly. 'Poor Kitty! I wonder what on earth you did to her psychology, bolting like that. I really must go round and see her soon.'

'And another thing,' I said gazing at the carpet, 'there aren't any Himalayas. As far as I'm concerned, I mean. I wasn't going to let on about it, but-well, you've been so good to me, Razzy, I hadn't the heart not to confess I've worked here under false pretences.'

'But I'm glad, dear boy. Terribly glad. Frightfully uncomfortable it must be, in all that snow and ice. So what other plans have you?'

'I thought I'd stay on in, London for a bit and work for my Fellowship. Thanks to you, I've got a few quid in the bank to pay the rent, and I might be able to make a little by standing-in for doctors at week-ends. You see', I told him solemnly, 'I'm still determined to become a surgeon.'

'And good luck to you, dear boy,' he added indulgently, as though I were a schoolboy saying I wanted to be an engine-driver. 'I've always found surgery fascinating. Completely fascinating. Let me know if there's ever anything I can do for you. Would you like a bonus? The secretary will fix it up-you know I loathe discussing money.'

We shook hands, and I stepped from out of the glossy picture of fashionable medicine for ever.

I now had saved enough to pay off my hundred-pound debt to Wilson, Willowick, and Wellbeloved, and to maintain a modest medical-student standard of living until the Primary Fellowship examination of the Royal College of Surgeons in six weeks' time. I kept my room in Bayswater, took copies of Gray's Anatomy and Starling's Physiology from Lewis's medical lending library, borrowed a box of bones from a friend at St Swithin's, and continued my surgical career.

The Fellowship, like all British post-graduate examinations, is run on the Grand National principle, except that the highest fence is placed immediately in front of the tapes. Before you can enter for the Final exam you have first to pass the Primary in anatomy and physiology, subjects which are learnt in the second year of medical school and forgotten in the fourth. I had now to reopen the pages I had sweated over on coffee-drenched nights five years ago, unpleasantly aware that such traditional aides-memoire for the student as:

_The lingual nerve_ _Took a swerve_ _Around the Hyoglossus-_ _'Well I'm mucked!'_ _Said Wharton's duct,_ _'The blighter's double-crossed us!'_ were inadequate for the Fellowship examiners, who wanted to know the exact seventy-four relations of the lingual nerve and what it did in the monkey, dog, and rabbit as well.

I worked at my books fairly happily, for three months in Razzy's practice had given me the feeling of being a man of the world who could deal with dukes, manage cabinet ministers, and chum along with beautiful women, and could therefore confidently approach such prosaic individuals as the Fellowship examiners. This was my first mistake.

My second mistake was arriving for the examination in my black jacket and striped trousers. I had learnt in my first year as a medical student that the correct wear for facing examiners was a well-pressed, neatly-darned, threadbare old suit, which invited them to take a kindly attitude of superiority; appearing in a Savile Row outfit was like arriving at the Bankruptcy Court in a Rolls. But this did not occur to me as I made my way through the crowd of candidates in Queen Square.

Before the war the Fellowship was a private affair, in which a few dozen young men were treated to an afternoon's intellectual chat with the examiners and the proceedings were said to be interrupted for tea. Since the National Health Service the examination has been run on mass-production lines, but the traditional politeness of the examiners is steadfastly maintained. They politely made no comment on my Harley Street appearance, beyond smiling a little more heartily than usual in greeting; they brushed aside my ignorance of the precise location of the middle meningeal artery as unimportant among friends; they accepted my inability to identify the pathological specimens in glass jars as understandable between surgical gentlemen. The last examiner politely handed me a pickled brain and said, 'That sir, was removed post-mortem from a man of seventy. What do you find of interest in it?'

After a while I admitted, 'I see only the usual senile changes, sir.'

'They are not unusual, these changes, you mean, sir?'

'Oh, no, sir! After all, the patient was senile.'

'Alas,' he said gently. 'And I shall be seventy-six myself next birthday. Thank you, sir, for reminding me that I am rapidly getting past it all. Good day to you, sir.'

Politely, they thanked me; politely they bowed me out; just as politely they failed me.

Because I had been over-confident this depressed me more deeply than ploughing any of my student examinations. Once more I began opening my _British Medical Journal_ from the back, but I was so dispirited that all I could bring myself to read in the rest of the pages was the obituaries. These are prepared on the first-, second-, or third-class funeral principle, overworked G.P.s succumbing in early life getting small print at the end, consultants larger type well-spaced out, and leaders of the profession whom everyone has thought dead long ago appearing with a photograph taken when they were twenty-four. All that could be said about the majority of dead doctors seemed to be that they were kind to their patients, popular with their colleagues, and liked walking in Ireland; at the most they had a disease named after them. I began to get deeply miserable about the futility of my profession, and wondered if I should have gone into the Church instead.

I found a part-time job helping a doctor in Brixton, and decided that if I gave up smoking I could afford to work for the next Primary Fellowship examination three months later. After a week I began to suspect he was doing abortions on the side, and I thought I'd better leave. My money was running out again, and I saw my Muswell Hill days returning: it was a moment of gathering depression. Then late one evening I had a telephone call from Grimsdyke.

'Where the devil have you got to, old lad?' he said crossly, as I leant on the coin-box in the hall and heard every door on-the landing creak ajar. 'I've been trying to get you all over the place. Have you become a ruddy hermit, or something?'

'I've been working for my Primary.'

'Bit of a perversion this lovely weather, isn't it? I take it that now you've left Park Lane you're not in paid employment? Good. Then perhaps you could help me out. I've got an uncle who practises in the depths of the country-you know, simple rural G.P., beloved by all, full of homespun philosophy and never washes his hands-whose partner's off for his month's holiday. When I qualified I said I'd help him out, but unfortunately I have a pressing professional engagement elsewhere. Would you fill the breach?

'I thought you were a country G.P.'

'On a different sort of level. Can't explain now. How about it?'

I hesitated. I wondered if it was wholly fair to judge Grimsdyke's relations by himself.

'Say you will, old, lad,' he pressed, 'You can take your books and whistle through the work. It's a peaceful as a museum down there, but there's a nice pub next door and a pretty little bit in the post office if you feel like relaxation as well.'

'Tell me-is this uncle of yours married?'

Grimsdyke laughed. 'A widower. One daughter, permanently settled in Australia. How about it?'

I glanced round the dirty, stuffy hall of my lodgings, with the greasy green-baize board that would grow a crop of bills by next Friday morning.

'Well-'

'That's the spirit! I'll send you directions and a map. Can you start on Monday? The old boy's name is Farquharson. He's a funny old stick, but he thinks absolutely the world of me.'

After my first disastrous foray into general practice the prospect of playing the country G.P. for a month was alarming; also, I was a true Londoner who always felt uneasy beyond the friendly grin of the L.P.T.B. bus stops, or in the company of cows, sheep, cart-horses, goats, pigs, and other animals unknown in Leicester Square. But my confidence increased the next Monday afternoon as I drove Haemorrhagic Hilda deeper into the countryside, which wore a look of ripe and gentle peacefulness rarely captured outside brewers' advertisements. The village itself lay far from the main road, at the end of a winding lane in which a herd of cows, responding to the cow-attracting substance with which all cars are seemingly secretly coated by the manufacturers, licked Hilda over at their leisure. My new home consisted of a few houses, a couple of shops, the church, the vicarage, and the Four Horsehoes. In the middle was a triangular green on which a horse stared at me in offended surprise; across the green was Dr Farquharson's house, shaggy with creeper, its brass plate shining like a new penny in the sun, its front garden brilliant with flowers among which bees and wasps buzzed as contentedly as the people lunching off expenses in the Savoy Grill.

As Dr Farquharson was still on his rounds I was shown into the empty consulting-room by his housekeeper. This was a small, dark apartment tucked into the back of the house, containing a dirty sink, an old-fashioned sterilizer heated with a spirit lamp like a coffee machine, and an examination couch covered with white American cloth that looked as uninviting to lie upon naked as a fishmonger's slab. In one corner was a bookcase untidily filled with medical text-books, mostly by Scottish authors and all out of date; in another stood a dusty pile of old copies of the B.M.J. and Lancet. I shook my head sadly. Looking round, I could see no haemoglobinometer, no erythrocyte-sedimentation-rate apparatus, no sphygmomanometer, no microscope, no ophthalmoscope, no centrifuge, no auroscope, no patella hammer, no spatulae, no speculae, no proteinometer, no pipettes…It seemed to me impossible for anyone to practise medicine in the room at all.

Dr Farquharson turned out to be a tall, bony Scot with thick white hair, gold-rimmed spectacles, and big nobbly hands. He was dressed in a pair of patched tweed trousers, a black alpaca jacket, a striped shirt, a wing collar, and a spotted bow tie.

'Afternoon, Gordon,' he said dryly, as though we had parted just an hour ago. 'So you've come to help out an old fogy in the depths of the country, have you? How's that rascal of a nephew of mine?'

'He seems very well, sir.'

'How the Good Lord ever let him qualify I don't know. He hasn't half a brain in his head, and the rest of his cerebral space is filled up with a mixture of laziness and lubricity. Let's have a cup of tea.'

Tea was served under a mulberry tree in the garden by the housekeeper, whom Farquharson introduced as 'Mrs Bloxage, who's painstakingly kept my feet dry and my socks darned since my poor wife succumbed to _phthisis desperata_ eighteen years ago.' We had raspberries and cream, tomato and cress sandwiches, brown bread and honey, buttered toast and home-made strawberry jam, scones and shortbread, and three kinds of cake. 'One of the few advantages for an out-of-date old man like me practising medicine in the back of beyond,' Farquharson continued, helping himself to more cream, 'is that the patients still bring you a little something out of the goodness of their hearts. They're simple souls, and haven't tumbled to it that the doctor's now a Civil Servant, like the Sanitary Engineer. What do you think of these raspberries?'

'Delicious, sir.'

'Aren't they? Old Mrs Crockett's varicose ulcer produces them year after year.'

When he had finished eating, Farquharson lit his pipe, pressed down the burning tobacco with a metal tongue spatula from his top pocket, and went on, 'The work's pretty easy round here, I suppose. There's hardly enough for two, especially this time of the year. But I'm glad enough to have someone to yarn to-I'm a bit of an old bore, you know. I was out in West Africa a good deal of my life. I settled down here because I totted up the ages on the gravestones across the way, and averaged out that this village has the lowest death rate in the country. I find plenty to interest myself in the natural history of the countryside-which includes the inhabitants. And in a couple of years the Government's going to chuck me out as too old and incompetent for anything except sitting on my backside and drawing my pension. God knows what I'll do then. But I'm rusty all right. Can't understand half the words in the Lancet these days.' He slapped me on the knee. 'You can put me right on all that, my lad. I suppose you know about these drugs they're bringing out like editions of the evening papers? You must give me a lecture on 'em some time. I'm just an old fogy of a country G.P.' He pulled a large gold watch from his pocket. 'I'm off to see a couple of patients before surgery. Settle in, and I'll see you for supper.'

Supper was cold salmon (the squire's gall-stones), cream cheese (the postmistress's backache), and to celebrate my arrival a glass of port (the vicar's hernia). Farquharson chatted entertainingly enough about West Africa, neatly comparing his native and his present patients, but I realized that he was as out of place in modern medicine as a jar of leeches. There were clearly several points on which I should be putting him right.

Within a week I discovered that medicine in the country is wholly different from medicine practised anywhere else. In the first place, most of the patient suffer from diseases totally unknown to medical science. At St Swithin's I examined my patients confident that their condition could be found somewhere between the green morocco covers of French's _Index of Diagnosis;_ but in the country I puzzled over the significance of symptoms like horseshoes pressing on the head, larks in the stomach, and ferrets running up and down the spine at night. Even Dr Farquharson's former diagnoses were obscured by the patient's helpfully remembering the name, it taking me some time to recognize, for instance, that the woman complaining her child had been attacked by the infant tiger meant that he was suffering from impetigo.

Secondly, the visit of the medical attendant in most households provided less relief for the sufferer than entertainment for the rest of the family. The cry of 'Coo! it's the Doctor!' brought children running from their corners as powerfully, as the smell of baking cakes. Arriving in the sickroom, I found it difficult to place the finger-tips together and demand with dignity, 'And how about the bowels?' when half a dozen small boys and girls were staring at me as though I were the hanging scene in a Punch-and-Judy show. When I insisted on having them shooed away they continued the enjoyment by taking turns to peer round the door, and my careful assessment of the pitch of a percussion note was often ruined by the awestruck whisper passing down the corridor, 'He's punching poor mummy all over the chest.'

In houses where there were no children, the patients reflected the more leisurely life of the country by using their attack of gastritis or summer flu to give the doctor a resume of their life story and their opinions on their relatives. A brisk 'Good morning! And what can I do for you?' as I approached the bedside generally brought a contemplative folding of hands across the abdomen, a faraway look, a deep sigh, and the reply, 'Well, Doctor, in the 1914-18 war I was standing in a trench at Vimy…' or, 'I haven't been the same, Doctor, since that night me 'usband joined the Buffaloes…'

When I mentioned these discoveries to Farquharson after supper one evening, he said, 'Oh, folk need to unburden themselves a bit. They don't like boring their friends, and their relatives won't listen to 'em any more. They're scared of the parson, so the doctor's the only one left they can pour their hearts out to.' He began to scrape out the bowl of his pipe with a scapel he kept on the, mantelpiece. 'I've got old-fashioned ideas, but that seems to me part of the doctor's job. That's something they never took into account when they got up this Health Service. Bloody silly, isn't it? Ask any G.P., and he'll tell you half his job is sympathizing with people, and that's ten times as difficult as treating 'em. Did you use the thermometer?'

'I couldn't-there's only one in the surgery, and it's broken.'

'It's broken all right. If I can't tell when a patient's feverish, I'm not much of a doctor. But shove it under their tongue, lad, and you've shut 'em up as long as you like. Or you can stick your stethoscope in your ears-it's not much good for anything else round here, because half of 'em think they'll drop dead if they take their vests off. Or you can take their pulse and scowl at 'em while you wonder what the devil's the matter. That shuts 'em up good and proper. You don't even need a watch. I couldn't afford a watch when I qualified, so I used to stare at my cupped hand instead, and nobody found out for eighteen months.

'As for the audience, always give 'em something to do. The public loves to see the vomit coming up or the baby coming down, but they love it even better playing the nurse. Get them to boil water-pots of it. When there aren't any saucepans left you can always start them tearing up the best sheets for bandages.' He lit his pipe, and went on reflectively, 'Never start off by asking a patient, "What are you complaining of?" They'll say, "I'll have you know I'm not the complaining type, not like some I could mention", and start some rigmarole about their sister-in-law who's been living with them since Christmas. Don't try "What's wrong with you?" because they like scoring one over the doctor and they'll reply, "I thought that was what you were here to find out." That starts the consultation on the wrong foot. And never ask, "What brought you here?" because ten to one they'll tell you the tram or the ambulance. Always listen to a patient's story, however long it is and however much you want your dinner. Usually they've come about something quite different, and they're too embarrassed or too scared to bring it out. And always give 'em a bottle of medicine, even if you and the whole Pharmaceutical Society know it's useless-even a straw's a comfort to a drowning man. Never tell them they're an "interesting case". Patients have got enough sense to know the only interesting cases are the ones we don't know anything, about.

'You can diagnose half your patients as soon as you, step through their front door, with a bit of practice. Brass gongs on the wall and tiger skins on the floor mean high blood-pressure. Box of chocolates on the piano and a pekinese on the mat-that's obesity. Bills on the dresser and cigarette ash on the parlour carpet look like a duodenal ulcer upstairs. I've found aspidistras and antimacassars generally go with constipation. It's common sense. If you keep your eyes open you won't need the curate's legs sticking from under the bed to spot a case of female frustration. And never be squeamish asking about insanity in the relatives. I always start off, "How many in the asylum?" and you'd be surprised at the answers I get, even in the best families. But I'm rambling,' he said apologetically. 'You talk for a change. Seen any good cases today?'

'There was an unusual psychiatric one. A farmer came in complaining that he experienced a strong sexual sensation every time he blew his nose.'

Farquharson stared at his burning tobacco. 'Well, now, that is interesting. What did you say?'

'Nothing much. I'm not well up in psychiatry. What would you have done?'

'I should have told him' said Farquharson without hesitation, 'that some people get all the luck.'

For the first time it occurred to me that Dr Farquharson knew much more medicine than I did.