Fingal had made the diagnosis. The woman in the bed was two stone overweight. Her complexion was dusky yellow. Almost certainly a gallstone had lodged in her common bile duct, which had contracted forcibly trying to expel the obstruction. She was suffering from biliary colic with blockage of the duct that carried the breakdown products of red blood cells from the liver to the gut. One of those components, a yellow pigment called bilirubin, entered the bloodstream and coloured the skin. Colic was often provoked by eating a fatty meal. The condition was recurrent and most common in certain women over the age of forty who had borne many children. There was a way to remember. It was called “the five Fs,” and Fitzpatrick was spouting them while he smirked at Mister Kinnear.
“This case is fecund, female, fair, forty.” He smirked. “I’ll refrain from mentioning the fifth F, but she is that too.”
Fingal nodded. Perhaps Fitzpatrick had learned a modicum of tact. Calling a patient “fat,” the fifth F, to her face would have been unconscionable.
She struggled to sit, digging her beefy elbows into her pillows. Redness in her cheeks shone through the jaundice. “I beg your pardon, I beg your pardon, did youse call me a ‘feckin female’? W’at’s wrong wit’ being a woman?”
Fingal could barely hide a smile. Mister Kinnear hadn’t bothered to. “Come now, Mister Fitzgerald—”
“It’s Fitzpatrick, sir.”
“Explain to the patient what you actually said.”
Fitzpatrick blushed. His wattles shook and he took an enormous breath. “I said, dear—”
“Who’s dear? I’m not your dear anyroad. I’m Mrs. Colleen Donovan from Gloucester Street. My friends call me Bluebell, but I’m Mrs. Donovan ’til youse. And youse said I was a feckin’ female, just dere now. Everybody heard.” She looked from face to face. “Didn’t yiz all?”
Fingal resisted the temptation to nod.
Fitzpatrick swallowed. “Fecund.”
“Jasus,” she yelled, “dere youse goes again. I’m not feckin’ anything. If I was a man and me guts didn’t hurt like bejasus I’d ask youse to step outside.”
“Mrs. Donovan,” Mister Kinnear said, “Mister Fitz—” He frowned.
“Patrick, sir.”
“Used a medical word to mean you have had a number of pregnancies.”
“I have. Dat’s true. Far too many.”
“That word is f-e-c-u-n-d. Feh-kund. Doctor talk.”
“Oh.” A great smile split her face. “And I t’ought— Och well, we can all make mistakes.”
Use language the patient understands. Fingal could still hear Geoff Pilkington’s advice, unless it’s one of the unmentionables like cancer or TB.
“Continue, Mister Fitzpatrick.”
“As you can see the patient is jaundiced. She is still tender in her right upper quadrant—”
“Is there a specific sign we should seek if we believe, as I am sure you do, that the gallbladder is acting up?”
“Yes, sir. If we put our hand flat on the patient’s abdomen beneath the right rib margin, press in, and ask the patient to inhale, the inflamed gallbladder will be brought down onto the fingers and the pain will cause the patient to catch her breath. It’s named, after an American doctor, John Benjamin Murphy, Murphy’s sign. I’ll demonstrate.” Fitzpatrick started to turn down the bedclothes.
“More like Jesus Murphy’s sign,” the patient said, clinging on to the blanket. “Or Jesus, Mary, and Joseph’s sign. I t’ought youse had stuck a red-hot poker in dere the other night.” She looked at Mister Kinnear. “Please, sir, tell him not to do it again.”
“We do believe you, Fitzpatrick.” The surgeon spoke to the whole class. “Sometimes to confirm a diagnosis, as for example in this case or cases of acute appendicitis, it may be necessary to elicit pain. If so keep the number of times it is done to an absolute minimum.” He smiled at the patient. “We’ll not be prodding you anymore.”
I’ll remember that advice, Fingal thought.
Mister Kinnear continued, “Diagnosis?”
“I told Doctor Ellerker I was sure we had a case of cholelithiasis precipitating an acute attack of biliary colic, that an X-ray was indicated, and that the probable treatment would be a cholecystectomy. Sister.”
Sister Henry produced an X-ray film. “Doctor McDonogh, the radiologist, says this is one of the best Roentgenograms the department has taken,” she said.
The class studied it by passing it from hand to hand and holding it up to the light.
Fingal watched Colleen Donovan’s gaze flit from face to face. He bent over and whispered, “It’s all right, Mrs. Donovan. You’re having an attack of gallstones, cholelithiasis, and a tube in your belly had a spasm.”
Her face relaxed. She whispered back, “Dat’s all right den. Biddy Mulligan had dat last year. She had an operation and she’s been going round like a bee on a hot brick since.”
“We call that a cholecystectomy. Taking out your gallbladder.”
“You’re a great translator, young lad. T’anks.” She looked at Fitzpatrick. “I wish to Jasus that fellah’d speak the King’s English.”
Before he could reply, Charlie handed Fingal the X-ray film, named for the discoverer of X-rays, Doctor Wilhelm Röntgen. Fingal held it up to the light. Just under the ribs, a collection of irregular small shapes were visible, stones in the gallbladder. Beneath them was a single stone, the culprit in the common bile duct.
“O’Reilly,” Mister Kinnear said, “you and Greer there are Sir Patrick’s great hopes for Irish caps in rugby, I believe?”
“Charlie Greer is, sir.” Fingal knew that the surgeon had played three times for his country in 1908.
“Good luck to the pair of you.”
“Thank you, sir.” Good of the man to be interested, but Fingal wasn’t sure how much time he would be devoting to rugby football.
“Now, Mister O’Reilly. Your opinion of the case?”
Fingal rapidly summarised his thoughts.
“You’re right,” the surgeon said. He looked at Fitzpatrick, then to Fingal. “You both did well. Keep it up.” He turned to Sister. “Put her on my emergency list for this afternoon. Now. Who’s next?”
Sister started to lead the little crowd further down the ward.
Fingal bent. “You’ll have your operation today.” He touched her shoulder. “Don’t worry. You’ll be fine.”
“T’anks, sir. T’anks a lot for explaining,” she said, and smiled at him. “I’ll not be sorry to have no more pains like dem ones I had two nights back. It was worse dan pushing out a babby, and dat’s like trying to shit a feckin’ football.”
She looked so serious as she spoke that Fingal was able to keep a straight face. And her thanks had warmed him. He’d be lying to himself if he failed to acknowledge that being thanked and feeling he had made a difference were wonderful rewards. He was no hair-shirt-wearing saint who required no thanks. Satisfaction and contentment were important, and it was the first time Fingal had felt at ease since two weeks ago when Doctor Micks had said Father did not have glandular fever.
* * *
“Your patient’s in bed 64, Fingal,” Sister Daly said, and handed him a chart. “He’s a sick one, so, I’m sorry to say.”
“Thanks, Sister.” Fingal set off down Saint Patrick’s Ward. Today, Wednesday, was his first day on ward duties, and they included taking admission histories. Fingal scanned the notes.
Seamus Farrelly, aged thirty-four of Talbot Street in Monto, was a butcher by trade according to a letter sent by his local dispensary doctor.
These GPs earned a small annual salary from the government for providing free medical care to poor patients and charged more affluent ones like Mister Farrelly a fee. Funny term Fingal thought, dispensary doctor. It signified one who practised medicine and on the same premises compounded and dispensed medications. Many practised in Dublin, and most country GPs were dispensers. Fingal was grateful to Trinity for insisting its students were well grounded in materia medica.
&nbs
p; The GP had recorded a detailed history and the results of his examination. He had noted that the patient had started to develop upper abdominal pain and vomiting shortly after midnight three nights ago. Within twenty-four hours, the pain had moved to the right lower abdomen.
Despite advice the next day from the renowned chemist Mister Harry Mushatt of Francis Street that the patient should be brought to hospital, Farrelly had refused and taken to his bed. His granny had treated him by soaking broken-up figs in olive oil overnight, making him take the mixture in the morning, and putting bread poultices over the sorest spot.
Fingal had used poultices to treat skin abscesses. White bread was rolled in a tea towel, soaked in boiling water, wrung out, and the soggy bread-laden towel bound over the sore. The heat increased the blood flow and the rate of pus formation so the abscess came to a point and burst, releasing the pus within.
They might work on abscesses, but in Seamus Farrelly’s case there had been no improvement and this morning the family had taken the butcher to see Doctor O’Gorman, who had made a diagnosis of neglected acute appendicitis and recommended immediate transfer to hospital and consultation with Mister Kinnear. By then the patient was too sick to refuse. He’d been admitted, Doctor Harry Ellerker had examined the man, and had arranged for Mister Kinnear to come from the operating theatre later today to see the butcher.
Fingal reached the bed—one of those not yet endowed. “I’m O’Reilly,” he said. “I’ve come to examine you.” He closed the screens.
The man propped up on pillows was a round, jowly person, probably one with a sense of fun when well, but today his cheeks were hectic, sweat beaded his forehead, his breath was foul, and he barely acknowledged Fingal’s presence. The chart above his bed said his fever was 101.2 degrees F, his pulse 110 beats per minute.
“Not feeling so grand?” Fingal asked, sat on the bed, and took the patient’s hand. It was hot and sweaty.
“Feckin’ useless,” the man managed in a hoarse whisper, “and I’m jacked. Utterly jacked. I can hardly bend me little finger I’m so tired.”
It took little time to confirm the history as taken by the GP and the findings recorded by the nurses on the charts. “I’m going to take a look at your tummy,” Fingal said, pulled down the blanket and sheet and pulled up the hospital gown. The belly was convex and moved only slightly with the man’s respiration. The lower right quadrant was reddened as the result of Granny’s poultices.
Fingal laid his left hand flat on the upper region and struck the middle and index fingers with the crooked first and middle fingers of his right. He repeated this procedure over all the abdomen. Everywhere his percussion produced a resonant sound, except on the lower right where all he could get was a dull thump. There was fluid or a solid mass there. Probably the latter.
A series of gurgles came up the tubing of his stethoscope as Fingal moved the bell across the belly. Good. The bowel was contracting and moving its liquid contents. It was not obstructed.
Fingal steeled himself; the next step was to palpate the entire abdomen, finishing in the right lower quadrant. If there was inflammation of the peritoneum, the examination would hurt there, but he knew the elicitation of pain was an important sign. “Sorry, Mister Farrelly,” he said, but before he could start, the screens were drawn back and Doctor Ellerker accompanied by Mister Kinnear appeared.
“So, young O’Reilly,” the consultant said, “what do you reckon?”
Fingal, well practised by now in its format, trotted out the history and his findings to date.
“You agree, Doctor Ellerker?”
“Yes, sir.”
“Let’s assume the patient developed acute appendicitis eighty-six hours ago—untreated appendicitis now, what do you think is going on?”
Fingal struggled to remember what the Regius Professor of Surgery, Charles Ball, had said in his lecture. “If the pulse rate is under one hundred—and it isn’t, it’s one hundred and ten—and there’s an increased white cell count, he probably has an appendix abscess. No lab tests are back yet. If there’s a tender lump in the lower right abdomen and the other quadrants are pain-free—I haven’t palpated yet—I’d say there was an appendix mass, a peri-appendicular phlegmon, from the Greek for inflammation, sir, that hasn’t formed a pus-filled abscess yet.”
“From the Greek?” Mister Kinnear chuckled. “Classical scholar, O’Reilly?”
“Hardly, sir, but we did have to do some at school.”
“And your father’s a professor of classics, isn’t he? I’ve met him at college dinners.”
“Yes, sir.”
“Latin and Greek are useful in our trade. No question. Helps us to understand anatomy because the old anatomists were all classical scholars and named things accordingly.”
Fingal remembered having to learn the name of a muscle of the face, Levator labii superioris et alequae nasii. Mister Kinnear was right. Knowing Latin had helped.
“Still,” the chief continued, “we need a bit of science these days too. How many species have an appendix?”
“How many species?” Fingal was at a loss.
“Man, anthropoid apes, and an Australasian nocturnal burrowing marsupial, the wombat,” Mister Kinnear said. “So if you’re ever Down Under and find a wombat clutching its right lower belly, it probably has acute appendicitis.” He chuckled.
“I’ll remember that,” O’Reilly said. He refrained from mentioning that he’d already been to Australia. Twice. “Should I palpate the abdomen now, sir?”
“You remember what I said this morning about the gallbladder case?”
“Mrs. CD?” The woman was Colleen Donovan, “Bluebell” to her friends, but by now Fingal was savvy enough not to mention her real names. For all he knew this patient might well know her.
“That’s her, and by the way she’s better off without it. It was stuffed to the gills with stones.” Kinnear smiled. “She’ll be right as rain in no time.” His smile went. “But do you remember when your friend Fitzwhatsit wanted to demonstrate Murphy’s sign?”
“Yes, sir. Don’t repeat painful procedures unless you absolutely have to.”
“Well done. I must examine the patient because it’s ultimately up to me to decide on treatment. I’ll spare you the need, and don’t feel you’re missing out on learning something. You’ll get plenty of opportunity to feel things in theatre when it’s your turn to scrub and the patient is asleep.”
Fine by me, Fingal thought, and watched as his senior kneaded the patient’s belly, accompanying his endeavours with a series of noncommittal grunts. By the way Seamus Farrelly’s breath kept catching in his throat the examination had hurt.
Mister Kinnear straightened. “There’s a bloody great lump there all right,” he said. “So now it’s time for a bit of Hamlet.”
Hamlet? Fingal frowned but he noticed Doctor Ellerker grinning. He’d probably heard the line before.
“To cut or not to cut, that is the question,” Mister Kinnear intoned. “What’s your opinion, Ellerker?”
“Not, sir. That’s what you taught us last year. Implement the Ochsner-Scherren conservative regime.”
“Which is?”
“Special charting of pulse and temperature, draw the margins of the mass on the abdominal wall, show there with shading which areas are most tender. Nothing by mouth and pass a nasogastric tube if the patient vomits. Intravenous fluids. If things go well, the temperature and pulse will fall within twenty-four hours and the margins of the lump and areas of tenderness will shrink.”
“Good lad. We’ll make a surgeon of you yet,” the consultant said.
Doctor Ellerker blushed.
“Of course,” Mister Kinnear said, “if those things don’t happen and his condition worsens we will have to operate because he’ll be forming an abscess. At the moment there’ll be little pus and the infection is walled off, but if it starts to spread?” He shook his head. “The adage is absolute, ‘Where there is pus you must let it out.’ Remember that, both of you. Un
der those circumstances the benefits of operating outweigh the risks.”
Fingal’s “Yes, sir,” was echoed by the houseman’s.
“And, O’Reilly, can you remember what Professor Ball told you about long-term management in cases like these?”
“If all goes well, the infection doesn’t spread, and the mass shrinks, the appendix should be removed after three months. It will still be a danger to the patient that it will become infected again.”
“So why wait?”
“Because now everything is inflamed. It’s easy to tear bowel, cause haemorrhage. In three months the inflammation will have resolved and removing the appendix will be reasonably risk free.”
“Correct.” He chuckled and said, “So in three months we’ll readmit this man. I see you’ve been paying attention, O’Reilly, and if you’ve continued to impress me, in three months Doctor Ellerker will be sick and tired of doing simple appendicectomies. He’ll not mind letting you do this one. Will you?”
The houseman shook his head.
“Thank you, sir,” Fingal said, excited to be offered a chance actually to operate, but vividly remembering his trepidation when he’d had to tap Paddy Keogh’s pleura. Perhaps it would be different when the patient was under an anaesthetic.
“And don’t look so bothered, boy,” the surgeon said. “I’m told by my colleagues you’ve been developing a good pair of hands in outpatients. Keep that up and who knows? We might make a surgeon of you too.”
And after only three days working in surgery Fingal O’Reilly had to consider that it might be a professional direction worth thinking about. He liked the way most surgical conditions were relatively simple to diagnose and except for the cancers many responded well to an operation. It certainly might, but he had six months to go here and other branches of medicine to sample before he’d be sure.
34
A Time to Every Purpose Under Heaven