7 June 1881
Despite my adventures in America with Dr. Joseph Bell and Sherlock Holmes, and even though I am a senior and will soon graduate, Bell continues to humiliate me in front of the entire class for my trivial errors in diagnosis. Professor Bell is a brilliant diagnostician and the most popular teacher in the medical school. Take today’s Friday afternoon clinic: Dr. Bell walked in at exactly two o’clock sharp. Sun streamed through the sooty windows of the great surgical amphitheatre of the Royal Edinburgh Infirmary. Medical students filled tiers of hard-backed seats overlooking the ‘cockpit,’ which doubled as operating theater, as well as Bell’s clinic.
I had recently finished my term as Dr. Bell’s clerk, and now, another poor, trembling third year student, Josiah Weeks, was in my place, organizing patients to see the professor. I pitied poor Weeks and did not envy his position, although I could sorely use the extra funds from the measly salary that accompanies the post.
There was a sprinkling of visiting doctors from all of Europe, as well as America, to observe Dr. Bell’s brilliant operating skills and his diagnostic acumen. Dmitry Gorchakov of the St. Petersburg faculty of Medicine and Surgery, a great bear of a man with a bushy, black beard, had taken notes during clinics and operating sessions for the past week. He was especially interested in Dr. Bell’s operation for joint excision in cases of tuberculosis and injuries. The Russian spoke broken English with a thick, guttural accent, but I suspected he understood our language better than he let on. Mr. Sherlock Holmes, the special assistant to Dr. Bell often held animated conversations in Russian with Gorckakov.
Meanwhile, I was idly thinking about Miss Jean McGill, a pretty new nurse who was sitting a few rows back, when Dr. Bell turned his keen gaze upon me. “Mr. Doyle, if you please, what causes Mrs. Connor’s cough?”
Mrs. Connor, the patient in a plain, black skirt, black coat, black hat, and black, ankle-high shoes, was spare and stooped with a sad, sharp, lined face and nearly-white hair. She had walked haltingly, resting on the arm of Weeks, the third year clerk, to a chair in front of us students. Connor could have been anyone’s grandmother. Weeks, a nervous boy of perhaps nineteen years, had stammered out the information that Mrs. Connor’s cough had resisted all treatment for the past half-decade.
For the life of me, I couldn’t think of a plausible diagnosis. Aye, I had seen several coal miners with such a cough, but never a woman. The patient hung her head and seemed to gaze at the floor, when she took a rag from her handbag, covered her mouth, and coughed out a gob of bloody phlegm.
I mumbled, “Well, sir, um, eh, she could have tuberculosis or chronic bronchitis?”
“Indeed, Mr. Doyle.” He paused for a painful moment. “I’d recommend visiting the bursar’s office this afternoon,” he advised.
“Why, sir?”
“Well, laddie, the bursar can issue a refund of your tuition, since it appears as if you have yet to learn how to truly examine a patient after four years of medical school.”
The other students burst out in raucous laughter. I flared with anger, my cheeks grew red, and I was barely able to hold my tongue.
Dr. Bell’s fierce, probing eyes twinkled with pleasure. After our trip to America a few years ago, I felt a close kinship with him. Being that my father was a worthless drunkard, when I was admitted to Edinburgh, I had hoped that Bell would fill his shoes as the sober authority figure and a mentor. Alas, upon our return, he seemed to coldly withdraw and resume a formal teacher/student relationship.
Nay, he was not truly malicious; but neither was he kind and forgiving. I looked up at him and Bell leaned back in his chair. “Doyle, how many years have you been under my tutelage?”
“Several, sir.”
“And what is the single most important precept I have taught you?”
“Never assume anything. Look at every situation with fresh eyes, observe fully, and then deduce properly.”
“Aye. ‘Tis good to know that at least your ears work . . . Now, let us begin again.” Dr. Bell folded his hands over his chest and stretched out his long legs as he questioned the patient. “Good afternoon, Mrs. Connor. Did you have a good trip from Lancashire?”
“Yissir, but for the childer was after giving me cheek on the train. I coulda give ‘em a smackin’. ”
At the sound of her lilting voice, Dr. Bell rose from his chair, went to the patient, and gently touched her cheek, then carefully examined, one by one, her fingers.
“You left Connacht during the famine?”
“Yissir, when me poor ma and pa passed on for lack of food.”
“When did Mr. Connor die in the mines?”
“It was twenty years ago, near time when our only boy passed on. The mine caved in.”
As cutting and cruel as he was, I still couldn’t help but be filled with awe and respect as he unraveled a patient’s history; keenly observing telling, minute attributes, weaving them together in his mind, and then using this web of seemingly disconnected information as the basis for an accurate diagnosis.
As he rubbed his chin, my classmates had become quiet as so many mice. Bell now had their attention; this promised to be one of his better performances and those rough-hewn boys were overcome by the woman’s sad, but gentle, visage.
“Hmm. Aye… Mr. Doyle, bring that shiny new stethoscope of yours and please give a listen to Mrs. Connor’s lungs.”
I turned her chair away from the students, and after she loosened the front of her blouse, I applied the stethoscope to the apex and then the base of her lungs. Her chest was filled with mysterious crackles, bubbling, and wheezing.
“Well, Mr. Doyle, tell us, what did you hear?”
“She has rales and wheezing, sir.”
“Do you still think the diagnosis is tuberculosis?”
“It is possible, but I don’t know, sir,” I answered.
Dr. Bell dictated two prescriptions to his clerk. “Mrs. Connor, each morning, burn a quarter cup of the leaves of Jimson weed and inhale the smoke. In the evening, put a teaspoon of dried sage and fifteen drops of oil of eucalyptus in a cup of boiling water and drink the tea. You will feel much better.” The good doctor gave Mrs. Connor his arm and personally helped her to the anteroom.
There was a stir amongst the students until Dr. Bell returned, drew a hand across his pure white hair, and spoke. “Gentlemen, this is one of the simpler cases we have seen today and yet, not a one of you made the necessary observations. I regret to say that it is a result of your innate presumptions and prejudices. Never let them get in the way of a proper diagnosis. Observe, deduce, and diagnose with a clear mind and open eyes.”
What was he getting at? I was confused and stupefied.
“Dr. Bell?”
“Did you, Mr. Doyle, or anyone, note the slip of paper pinned on her coat? It was yellow, the color of tickets for the Lancashire line. She has the dialect of West Ireland, and many of the poor Irish were forced to work in the coal mines of Scotland after the great famine. Coal dust is still embedded in her skin. When evaluating the lungs, carefully examine the finger nails. Mrs. Connor’s nails are slightly blue, pitted, and down-curved, a sure sign of chronic oxygen deprivation caused by long-standing lung disease. The diagnosis is silicosis, better known as ‘miner’s lung.’ The word, silicosis, as you surely know, is derived from the Latin, silex, or flint. When miner’s inhale dust in the mines, the silica becomes imbedded in the alveoli of the lung. Any questions?”
We students remained perfectly mute. Not a one of us stirred, overcome by Dr. Bell’s great powers of observation and his quick wit. One student finally raised his hand.
“Aye,” Dr. Bell said, pointing to the student.
“Sir, that makes sense for a man who toiled in the mines, but how does that apply to a woman?”
“Don’t assume anything just because she’s a woman… Ah, one of the great tragedies of Scotland. I would venture to say that when her husband died, she was forced to labor in the mines to support herself. Next patient, please.”
He was a ten-year-old boy whose flushed, feverish face was contorted by pain. The clerk rolled him into the amphitheatre on a cart. “Jamie McLeod here has a pain in his stomach,” he said. At the poor boy’s side was his mother — a poorly dressed, tearful, young woman twisting a handkerchief with both hands.
Dr. Bell did not question and harass us students in his usual way. Instead, he went to the cart and immediately put his finger on the boy’s pulse. There came over his face a look of intense concern. He closed his eyes and pursed his lips. “Now, mother, how long has your boy been ill?”
“He’s been down with pain in his belly these five days, sir.”
“Can he keep down his food?”
“No sir. He throws out every mouthful and hasn’t had even a drop of water this past day.”
“Have his bowels moved?”
“No sir.”
The professor loosened the boy’s trousers and gently ran his hand over the abdomen. The child winced and cried out when he touched the right lower quadrant.
Dr. Bell absently stroked his chin. “In the past, we would have diagnosed your son with a severe case of inflammation of the bowels, but these days, there are physicians in America who would posit that your son is suffering from a disease of the vermiform appendix. However, we would have to do exploratory surgery to know for certain.”
“Do whatever you need to, sir. Just ease his pain.”
“Mr. Doyle, fetch my instrument case, please,” Dr. Bell instructed.
The appendix? There was nothing in our textbooks about the appendix. Aye, my anatomy professor had mentioned it in passing, calling it a useless organ with no known function. We all murmured and twisted in our seats, not sure what to make of Bell’s diagnosis. Meanwhile, the Russian sitting behind me leaned forward, straining to understand every word.
When all was ready, the junior clerk dripped chloroform on a mask over the boy’s face. When he was asleep, Dr. Bell swabbed the abdomen with carbolic, attached a trocar to the syringe and, after a moment’s hesitation, plunged the sharp steel probe into the boy’s abdomen. We all held our breath. He pulled back the plunger, and the syringe filled with yellow, creamy pus.
“By Jove, the Americans are on to something,” Dr. Bell said and then looked at Weeks. “Take this young man and his mother straight to the Royal Hospital. Find Dr. John Hetherington and tell him that I said that this lad needs to have his appendix surgically removed immediately.”
As Weeks led the boy — still groggy from the chloroform anaesthetic — and his mother out of the theater, there was a great clatter of horse’s hooves and a jangling of bells on Lauriston Street. An agitated police officer burst into the amphitheatre. “There’s been an accident at the quarry!”
In the next instant, two burly orderlies carried a groaning, bleeding, bearded man on a crimson-stained stretcher into the amphitheatre. Something about him was familiar, but I could not place him nor was he in any condition to identify himself. Who was he and why did I feel like I knew him?
His legs below the knee were a jumble of bloody boots, mangled skin, and muscle, with white, jagged bone protruding from his torn trousers. Bright red blood bubbled up from lacerated arteries. His right hand was a scarlet mess.
In a flash, Dr. Bell with his two assistants cut away the man’s clothing and applied tourniquets above his knees. The furiously spurting blood slowed to a trickle; a great sigh of relief went up from the students.
Dr. Bell removed his coat and rolled up his sleeves. “Mr. Doyle, please administer the anaesthetic,” he said. I adjusted a cloth mask over the poor man’s nose and mouth and poured a few drops of chloroform. His moaning soon ceased and his clenched jaw relaxed.
For a moment, I thought he was dead, but there was a faint pulse at his neck. The gentleman wore a fine tweed jacket, but at the time, I was too busy with the anaesthetic to wonder at his clothing.
Dr. Bell and his assistants scrubbed their hands, then swabbed the patient’s legs with a solution of carbolic, while the clerk arranged the instruments on a clean towel. There was a sense of great urgency as he cut through the skin and layers of muscle, sawed bone, ligated arteries, and stitched up the skin. He amputated both legs just above the knees within twenty minutes of the time the patient had entered the room.
I stopped the chloroform, but the poor man remained unconscious. We worked furiously to save his life. Dr. Bell ordered coffee enemas, and we attempted to force brandy down his throat, but to no avail. He sank lower and lower.
Suddenly, he stirred, opened his eyes, and murmured with a slight Irish accent. “It was no accident. No accident.” Damn! I couldn’t determine his identity. His voice was familiar, but a beard and scars covered his face.
Bell hovered over him as his bloody hand rose and he uttered a few words. He seemed to be saying, “Proof… Dr. Hutton correct… No God… End of the old regime.”
With that effort, his entire body seemed to shrink into itself. His chest rose in a great sigh as he gave a shout with his last breath. “Tsar must die!”
The students and observers had left, but the Russian surgeon had stood by Dr. Bell’s elbow. Now, he stepped back as if struck. “No, no, no…” he murmured. “We will save the tsar. We have blood. Blood for transfusion.” All of a sudden, the Russian grabbed his notebook and stomped out of the amphitheatre.
“Sir, what was that about the tsar?” I asked.
“Doyle, when was the last time you read a newspaper?”
“It’s been a while, sir, with studying for my examinations and all …”
“If you were aware of current events, you’d know that anarchists assassinated Tsar Alexander II three months ago, on March the first.”
“Aye, I may have heard about that.”
“This is a case for Scotland Yard,” he said. “Now, Doyle, go home, get some rest, and meet me in the morgue tomorrow morning.”
While walking home, the words “No God” and “Tsar must die” kept reverberating in my mind.
Who was that injured man?
Why did he seem so familiar?
