Doldrums and Deep Waters

Chapter 4: A test of quality

A little of my low mood lifted during the walk to St Thomas's, and I allowed myself to dwell on what being welcomed back into the fold in a large teaching hospital would mean.

I would be at the frontier of surgical developments. There would be openings into the top-end private institutions. A good surgeon is always welcome. I could bid farewell to the litany of trivial ailments which trailed in a desultory fashion into the practice that was not even mine, and concentrate instead on curing real illnesses, relieving suffering. I would still engage in charitable work, I promised myself virtuously, but could do so without worrying where next month's rent was to come from.

The headache I had woken with that morning - the type of nagging, insistent pain that is thoroughly wearing – was beginning to fade, and each footfall no longer jarred my cranium painfully.

I should have been excited, filled with keen anticipation. Instead, I could not fully shake off the permeating gloom that had plagued me all of yesterday. Perhaps I was still a little guilty from my outburst, and also feeling that brand of discomfort which comes from knowing other people are working far harder than you. Holmes was out on his dull case, and I had accepted his reassurance that he would not need my assistance with a hint too much alacrity.

I arrived at the bustling main entrance of St Thomas's, trying not to be intimidated by the grand new building, with its multiple mullioned windows, and its venerable situation facing the Houses of Parliament.

I had been instructed to meet my colleague, Fraser, and another consultant surgeon, outside the main theatre suite. Upon my arrival, I was told the gentlemen had been delayed, and had sent a message asking that I return in forty minutes. I took myself off accordingly to purchase a cup of coffee and enjoy a restorative pipe.

The wait did my jangling nerves no good at all, and I seemed to be fighting a strange haziness of my thought processes, which I put down to apprehension.

Finally, it was time to return to the operating theatres, and Fraser and a tall, stout companion emerged. I shook hands with my erstwhile colleague and comrade-in-arms, and was introduced to his companion, Professor Beaumarris.

Fraser shook my hand heartily enough, but I thought there was something strained in his manner, and, to my surprise, I noted Professor Beaumarris looking at me rather dubiously. I put these impressions from my mind, upbraiding myself for indulging the self-pitying melancholy that had taken hold of me recently, and giving in to paranoia.

We repaired to the Professor's office, and he waved for me to be seated. Concentrate, I scolded myself, for the fog clouding my faculties seemed worse than ever. I was also conscious of a sense of irritation at the peremptory way with which the eminent man addressed me.

"So, Dr Watson. You wish to work for me?" asked he, in a self-satisfied manner that grated upon me.

"I wish to resume my surgical career in earnest, yes, Professor Beaumarris," I answered, pleased at my small victory in circumventing his proprietary leanings.

"Have you kept yourself up to date with surgical practise?"

"I have endeavoured to. As Major Fraser might have informed you, my health has been most indifferent for the last few years, but has improved recently, sufficient that I can allow myself to contemplate full time work...."

"And you are confident in that improvement?" he interrupted. I ignored his rudeness, and continued.

"Yes, Professor, touch wood, I am. As to the matter of keeping myself up to date, in the theoretical arena, I am conversant with all recent developments in the Annals and the BMJ, and I read any article that strikes me as being of interest in the other major journals. I have studied Dr Bell's Manual of the Operations of Surgery in depth, for any changes since my days, as well as scanning Weiss' latest products.

"Practically, I have been a frequent visitor to the dissecting rooms at Barts, to perfect those newer surgical techniques that can be gained thus. In my patients' homes or the clinics, I have also performed frequent minor surgery, excision of laryngeal web, caesarean sections, reduction of strangulated hernias, and four appendicectomies."

I was proud of that last achievement, as the technique was new and revolutionary. Professor Beaumarris looked at me from under his bushy eyebrows

"Do you not feel that so novel a procedure would be better carried out in a reputable hospital?"

I smiled deprecatingly in return.

"I am afraid my patients have not been of a class to afford care in a prestigious hospital, and, perhaps rightly at times, they have the greatest dread of the charity institutions. My operating table is often the kitchen table scrubbed down well with carbolic, but my patients have made good recoveries for the most part, and contracted little by way of infection."

The Professor muttered something non-committal in reply, and I had the strong suspicion that it was the penury of my patients which led to his disinterest.

"What think you of the hysterectomy for the female afflicted with nervous disorders?" he asked, and I should have been alerted by his expression that it would behove me well to tread carefully. Instead, I replied with some heat.

"I cannot see how mutilating an otherwise healthy woman can help substantially with hysteria. Surely it must simply add to her problems."

I became aware that Fraser was desperately trying to catch my eye, and shaking his head, and I caught the haughty stiffening of Beaumarris.

"You would do well to research it a little more thoroughly before making such sweeping generalisations, young man. I have myself performed the procedure several times, and am convinced the dampening of the women's symptoms is dramatic."

Fortunately for my chances, he appeared to take my comment as ignorance rather than insolence, and to relish the opportunity of boasting of his surgical prowess. I listened composedly enough, but could neither be convinced of the efficacy of the procedure, nor of the morality of its performance.

Apparently satisfied by my attention, Beaumarris went on to ask me several further questions pertaining to surgery and practise. I am certain my answers were far from erudite, as I was conscious of a deepening of my hazy mental state, and could barely collect myself to return sensible replies. However, it cannot have been too disastrous, as he asked that I assist him in a procedure that afternoon, that he might further assess my prowess. Fraser, oddly, seemed to be regarding me with fresh disappointment, that I could only assume stemmed from my inarticulate replies.

I felt some degree of perhaps prophetic anxiety when I realised the operation I was to assist was to be conducted in the large open operating theatre, and that the walls were to be lined with medical students.

The patient was wheeled in, face down, mercifully anaesthetised before the sea of curious faces was revealed.

The operation was to be a ligation of a popliteal artery aneurism*, I realised with alarm. The procedure had a high mortality rate, and would not normally be undertaken unless the rupture was considered imminent. As I palpated behind the knee and felt the swelling, I frowned with surprise.

"Professor Beaumarris, this aneurism does not appear to in danger of rupture," I muttered, sotto voce. He regarded me with amusement.

"The new theory is that the recovery rate is improved by an earlier intervention," he replied. "How would you proceed, Dr Watson?"

Rather doubtfully, I supplied, "I would use the procedure of ligation of the superficial femoral."

He gave a little crow of triumph. "Then you would be a stick-in-the-mud, Sir! The latest thinking is to approach the popliteal artery directly, thus sparing more of the leg should complications occur."

Rather surprised, I blurted out, "I had rather thought that technique tried and superseded. Surely the confined space, the lack of a collateral blood supply, the proximity of other nerves and vessels..."

He laughed now, and patted me on the shoulder. "You have been reading too much, dear boy. There is no substitute for hands-on experience. This fellow will be thankful when he is able to return to gainful employment."

I buried the thought that the fellow would probably be able to remain in gainful employment for many years, with no more discomfort than I faced from my own injured leg. The condition was a rare one, and the Professor was a highly esteemed surgeon, after all, and it was true that I had not been associating with the higher echelons of my profession for years.

Professor Beaumarris seemed better disposed towards me since I had supplied him with an opportunity to display his superior knowledge. He whistled cheerily as I began to prepare the patient.

My long association with Holmes led me to notice the man's callused hands and feet, and the shearing of hair from his shins, where he was obviously used to spending much time upon his hands and knees. He was a labourer, then. The fact caused my uneasiness to increase, as I had already decided the Professor was not the charitable type.

"Have you performed this operation often before, Professor Beaumarris?" I murmured, my voice quietly neutral. He did not appear to hear me, but turned to address his flock of students.

"I imagine you will not have seen this surgery performed, as, as my esteemed-" he put a tiny emphasis on the "esteemed" which caused me to bristle involuntarily, "-colleague has pointed out, the established thinking has been to approach the vessel from above. You are fortunate, in that what you will witness today is at the forefront of surgical expertise."

Beaumarris gave an affected little bow to his audience, at which I suppressed a snort of disgust, and turned his attention to the patient.

His dissection was admittedly impressive, and we were soon gazing upon the artery in its white sheath, nestled into its hollow bed beneath the vein. The aneurism bulged obscenely, but, I noted with further misgivings, it was barely two inches across; surely not significant enough to warrant a risky procedure? I glanced up at Beaumarris, but he showed no sign of discontinuing. I reminded myself of his "early intervention" theory, and had to wonder just how theoretical it was.

Beaumarris had been complimentary of my part in the dissection so far, telling the students how very helpful it was to have such an obviously experienced pair of hands to help him, in a way I considered extremely patronising. Now however, I was beginning to struggle. I was experiencing a bad resurgence of my headache. Bright lights played shapes across my retinas, and I was finding it difficult to focus. Worse still, my shoulder ached unbearably, and my hands had developed an increasingly evident tremor. Gritting my teeth, I forced myself to rise above the situation and concentrate upon my work.

I explored the extent of the aneurism with my fingertips, and picked up the forceps to dissect further up the leg, in order to get above the body of it. Beaumarris saw me.

"What are you doing, Watson?"

"I am accessing the vessel above the aneurism to ligate it."

"No need. Just place the ligature here."

"But it is calcified – it is almost solid, Professor."

"It does not matter. It will only take moments to do our repair."

Dubiously, I pulled the ligature as tightly as I could around the point he indicated. It was extraordinarily difficult, as the space was so tight, and the structures so densely packed, and my shoulder became to scream in protest, while perspiration trickled down my face.

Beaumarris opened the aneurism, getting me to suction the resultant blood with a three way syringe device. He commenced scraping the debris that lined the aneurismal sac, and deftly excised an elliptical segment of the vessel wall. There was no doubt he was a talented surgeon, and I was beginning to relax, when suddenly a great pulsatile torrent of blood erupted from the wound. I could not refrain from a cry of alarm, and the students, whose presence I had begun to forget, roared disgracefully in appreciation.

"Watson! Your ligature was not sound!" raged Beaumarris, but I was too busy with attempting to staunch the flow of blood to object. My fingers were slippery, and there was blood in my eyes, weighing down my eyelashes. I scrabbled in the wound, attempting to locate the end of the artery that I might clamp it, but it was out of reach of the tiny dissection field. I managed to slow the flow a little, by pinching the suggestion of an edge, but by no means stop it.

To my horror, Beaumarris stamped his foot in an appallingly inappropriate display of pettish rage, stated; "The procedure is quite ruined!" and stamped from the room.

The poor man on the table continued to bleed profusely. I looked up at the audience, and snapped, "I will require some assistance immediately! Somebody come and apply a tourniquet to this leg!"

A short youth with a round face and smug visage sauntered over to me.

"I shall help, Sir."

"Thank you. What is your name?"

"My name is Lucet." He paused, much to my frustration. "I do not believe Professor Beaumarris thinks tourniquets should be much used in modern surgical techniques."

"This is not a modern surgical technique, it's barbaric, and the patient is exsanguinating! Do as I say!" I barked, in my best army tones. Thankfully he obeyed, and the flow of blood slowed, so that I could inspect the damage. I groaned at what I found. The calcified vessel had split along the plane of Beaumarris' incision, and the tear was travelling up the vessel, past my perfectly good but now sadly useless ligature. I fingered the remains of the aneurismal sac, and found it hopelessly brittle. It would not support stitches, let alone the flow of blood. The leg below the knee could not be salvaged.

"This man's leg will have to be amputated." I stated, and my voice rang hollow in my ears. "Could somebody please find Professor Beaumarris and inform him."

"I doubt the Professor will agree to that, Sir." Lucet stated, in a tone that suggested he was about to commence a lecture. I had no energy to spare for this kind of idiocy, so I despatched him to find Beaumarris himself, and a much more satisfactory assistant, a pleasant faced youth called West, came to my aid.

I remembered performing surgery on the battle field. A good deal of my work had been amputations, or the rapid staunching of bloody wounds. I closed my eyes, only to open them with a shudder as memories of hot blood, scorching sun, yet limbs that seemed cold to the touch, rose to the fore, and I felt my gorge stir as I recalled the stench, and the sounds.

The strength required to perform a successful amputation is considerable. In the battlefield, where anaesthesia is usually an unheard-of luxury, the faster the procedure, the higher the survival rate, and the lesser the suffering of the poor soul beneath the knife. At least here, my patient was blessedly oblivious, but speed still lessened the chances of shock and heart failure.

Following circumferential division and retraction of the soft tissues, the leg must then be immobilised whilst the bone is severed with a saw. Ruefully, I flexed my shoulder experimentally. Did I still possess that necessary combination of deftness and strength, especially after my recent accident?

Unlikely, supplied the irksome voice within.

There was little choice in the matter, and, ignoring my exhaustion, I began the procedure. My tremor was becoming ever more evident, and I noticed West giving me the odd worried glance. However, we had successfully exposed the bone between us.

I hefted the bone saw, and attempted to find a firm grip upon the limb that my injured shoulder could manage to maintain. It was excruciating, and the resultant technique far from ideal, but eventually the thing was done, and I was shaping and attaching the flap to cover the stump.

As I straightened stiffly, and slowly released the breath I had not realised myself to be holding, I became aware of a presence at my elbow. I turned slowly, and there was Beaumarris, his pompous little acolyte at his elbow.

"You chose to amputate from very close to your faulty ligature. You may have found the procedure a good deal less fiddly had you gone higher up the leg."

I stared at the man incredulously. "The lower the amputation, the easier the patient finds it to adapt to a prosthesis, which, incidentally, I hope the hospital will provide, since this ill-advised operation has led to the loss of his leg." A rage was beginning to creep up upon me; my ears were ringing, and an unpleasant bitter metallic taste was in my mouth.

Beaumarris looked supremely disinterested in the degree of future handicap his patients may expect, and I could tell he was about to employ his patronising manner again. My fury boiled a little higher, and I felt strangely as if my usual ability to reign in my temper was being overcome by some external force.

"Watson, I see you are carrying an injury to your shoulder."

"Yes," I answered through gritted teeth. "A relic of my Afghan campaign, recently exacerbated by a fall."

"Hmm. Remove your shirt a moment." I was so taken aback, that I obeyed him. I blinked, feeling the effects of the encroaching haziness again. Beaumarris began lifting and flexing my shoulder, then performing a manoeuvre that caused me to cry out in pain.

"See the wasting of the deltoid here gentlemen, and the ugly scarring and deformity of the scapula. Watson here is unable to maintain a full range of movement, presumably due to the secondary fibrosis. The strength and dexterity is bound to be reduced as well, which would explain his rather feeble execution of the amputation you just witnessed, and is also likely to account for the failure of his ligature.

"This arm is effectively crippled, and I'm afraid Watson's ability to perform surgery is negligible because of it. He was probably not aware of this fact, as he has done no work to speak of in the several years since he was wounded. This is a lesson to you all gentlemen; know your limitations."

At first, I had listened to this cruel recital in shocked disbelief, but the inevitable anger was not long in coming. Again, I felt that strange dissociation between my rage, and my ability to control it, and I heard my in advisably furious reply as if from outside myself.

"Know my limitations? What of yours, Professor Beaumarris? This operation never needed performing in the first place, and this poor man has lost his leg and possibly his livelihood because of it! He is evidently a poor man, I do not see him producing a fee for you. You cared so little for him, when it was obvious to you your exciting new procedure had failed, you left him in my so-called incompetent hands – he could have died, man! So, why the surgery? Well, you tell me of the "new theories"; I have a theory, and it is that the "new theories" are your theories, and you needed a victim to practise upon!"

Beaumarris had gone very white, but he kept his composure, and suddenly forced his countenance into a sympathetic expression.

"Gentleman, I shall not be prosecuting this gentleman for slander, despite an entire room full of witnesses, because I am saddened to see a veteran of the British Army brought so low. You will have observed his constricted pupils, his excessive perspiration, his tremor, his evident agitation. He is obviously under the influence of some drug which is acting adversely upon his nervous system. I understand addiction is a tragic blight following a difficult war, and that he was not always thus. His erstwhile friend, Mr Fraser, was most disappointed to witness the change in him, and I think suspected the cause at once." He turned to me now, and I wondered if anyone else could see the red glint beneath his veneer of humanity.

"Go home now, Doctor Watson, and see if you cannot get yourself clean of the drug's evil influence. If you are successful, perhaps you can make a return to general practice at some point, but I am afraid I can never allow you to practise surgery in any of this country's institutions again."

I had no choice. My rage was ebbing, and a dreadful hopelessness was taking its place, as the excitement from the surgery subsided. The fog in my mind would not allow me to offer a clear and defensible riposte, and I had no doubt that the excuse to prosecute would be seized upon, should I provide further opportunity.

I turned to leave, conscious that many of the students were jeering, and that Beaumarris was not trying to stop them, despite his pretence of sympathy. I held my back as straight as I was able, and walked away; away from the hateful man, away from the cold-blooded students, away from the operating theatres and the poor unfortunate patient, and away from any hope of salvaging my career and my self respect.


* Popliteal artery: the main artery to the lower leg, running behind the knee. An aneurism (also spelt aneurysm) is a ballooning of the vessel, leading to eventual weakness, and sometimes rupture, of the vessel wall. Watson was quite correct; this is a rare condition, and would not normally present a danger until it reached a very large size.

Poor Watson. I think you might have suspected his interview might contain one or two hiccups.

I hope nobody felt too queasy about all the gory surgical details.

Thanks for the lovely reviews – always much appreciated, and please keep them coming – even the bad ones!

Quite a mini debate that's going about the word "insinuating" on my review table! (If you were remotely interested in it, read on; otherwise, there's nothing much of interest until the next chapter, I'm afraid – which I hope will come along soon!) I thought I'd take a couple of minutes to settle it: here's the Oxford English Dictionary definition:

insinuate

/insinyooayt/

verb 1 suggest or hint (something bad) in an indirect and unpleasant way. 2 (insinuate oneself into) manoeuvre oneself gradually into (a favourable position).

— DERIVATIVES insinuating adjective insinuator noun.

— ORIGIN originally in the sense enter (a document) on the official register: from Latin insinuare 'introduce tortuously', from sinuare 'to curve'.

That's the beauty of the English language, isn't it, so many words having alternative uses?

By the way, I must apologise for adding a review to my own review table (very bad form, and I shall remove it myself for the sake of honesty in due course, unless people would prefer it to stay), but seeing as one anonymous reviewer has been courteous enough to take the time to review, yet seems more interested in the critical process than the story, I thought it only polite to reply.

Cheers everyone!