Richard Gordon - DOCTOR IN THE HOUSE

The clinical is probably the most chancy of the three parts. The student may be allotted a straightforward case with sounds in the chest that come through his stethoscope like the noise of an iron foundry; or he may get something devilish tricky.

The cases for clinical examinations were collected from the out-patient departments of hospitals all over London, and were in the class referred to by physicians informally as 'old chronics.' They have their lesions healed as far as possible; now they walked round in fairly good health but with a collection of clicks, whistles, or rumbles inside them set up by the irreversible process of their diseases. These are just the sort of things examiners like presenting to students. A case of vague ill-health or an indefinite lump are too arguable, but a good hearty slapping in the chest gives a right to fail a man forthrightly if he misses it.

For this service the patients were given seven-and-six and free tea and buns. But most of them would happily have performed with a strictly amateur status and provided their own sandwiches. The six-monthly visits to the examination were their principal outings of the year. They attended their own hospitals monthly to show off the signs they proudly possessed to a single doctor and discuss their ailment with fellow-patients on the benches outside, but in the exam they were inspected by hundreds of doctors-or as good as-and chatted to the йlite of fellow sufferers. It is much the same as winning an international rugby cap.

I arrived at the examination building in plenty of time, to find out what I could of the cases from men who had already been examined. I knew Benskin had been in early and looked for him in the hall to ask what there was upstairs.

'There's an asthma in a red scarf, old boy,' he said helpfully. 'And an old man with emphysema just behind the door as you go in-if you get him be sure to examine his abdomen, he's got a couple of hernias thrown in.'

I made a mental note of it.

'Then there's a little girl with a patent ductus-you can't miss her, she's the only child in the room. Oh, and a woman with burnt-out tabes. He'll ask you what treatment you'd give her, and he expects the answer "None".'

I nodded, thanked him, and made my way to the examination room.

My first impression of the clinical examination was of a doctor's surgery gone into mass-production. Patients were scattered across the room on couches, beds, and wheel-chairs, the men divided from the women by screens across the centre. They were in all stages of undress and examination. Circulating busily between them were a dozen or so nurses, examiners in white coats, and unhappy students dangling their stethoscopes behind them like the tails of whipped puppies.

I was directed to a pleasant, tubby little examiner.

'Hello, my lad,' he began genially. 'Where are you from? Swithin's, eh? When are you chaps going to win the rugger cup? Go and amuse yourself with that nice young lady in the corner and I'll be back in twenty minutes.'

She was indeed a nice young lady. A redhead with a figure out of Esquire. _

'Good morning,' I said with a professional smile. 'Good morning,' she returned brightly.

'Would you mind telling me your name?' I asked politely.

'Certainly. Molly Ditton, I'm unmarried, aged twenty-two, and my work is shorthand-typing, which I have been doing for four years. I live in Ilford and have never been abroad.'

My heart glowed: she knew the form.

'How long have you been coming up here?' I asked. 'You seem to know all the answers.'

She laughed.

'Oh, years and years. I bet I know more about myself than you do.'

Just the thing! There is a golden rule for clinical examinations-ask the patient. They attend the examination for so many years and hear themselves discussed so often with the candidates they have the medical terms off pat. All I had to do was play my cards correctly. I talked to her about Ilford, and the wonderful advantages of living there; of shorthand-typing and its effects on the fingernails; of her boy friends and her prospects of matrimony (this produced a few giggles); of the weather and where she went for her holidays.

'By the way,' I said with careful casualness, 'what's wrong with you?'

'Oh. I've mitral stenosis due to rheumatic fever, but I'm perfectly well compensated and I've a favourable prognosis. There's a presystolic murmur at the apex, but the aortic area is clear and there are no creps at the bases. By the way, my thyroid is slightly enlarged, they like you to notice that. I'm not fibrillating and I'm having no treatment.'

'Thank you very much,' I said.

The tubby man was delighted when I passed on to him the patient's accurate diagnosis as my own.

'Capital, capital!' he beamed. 'Spotted the thyroid, too…glad some of you young fellers use your powers of observation. Been telling my own students for years-observe, observe, observe. They never do, though. Right you are, my lad. Now just take this ophthalmoscope and tell me what you can see in that old woman's eye.'

My heart, which had been soaring like a swallow, took a sharp dive to earth. The examiner handed me the little black instrument with lenses for looking into the eye. I had often seen it used in the wards but I never seemed to find time to learn how to employ it myself. There was a knack to it, which I did not possess; and I knew plainly enough that the defect was sufficient to fail me out of hand. I imagined the examiner's sunny friendliness turning into a storm of irritation; my hand shook as I took the instrument. Slowly I placed it closely between my eye and the patient. All I could see was something that looked like a dirty tank in an aquarium with a large, dim fish in it. The time had come for quick thinking. Looking intently through the instrument I let out a long whistle of amazement.

'Yes, it is a big retinal detachment, isn't it?' the examiner said happily, taking away the ophthalmoscope and patting me on the back. I saw myself marked over the pass number, and with a grateful smile at the redhead tripped downstairs in elation.

In the hall I met Benskin again. He was looking profoundly miserable. 'What's up?' I asked anxiously.

Benskin shook his head and explained in a choked voice what had happened. While I was examining medical cases he had been questioned in practical midwifery. One of the tests for prospective obstetricians was provided by a life-size papier mвchй model of half the female trunk, into which a straw-stuffed baby was slipped through a trapdoor. The candidate was then provided with a pair of obstetrical forceps and required to deliver it _per via naturalis._ This was demanded of Benskin. He solemnly applied the two blades to the head, taking care to put the correct one on first. He locked the handle, took it in the approved grip, and gave a strong pull. Nothing happened. He pulled harder, but the straw foetus refused to be born. He felt sweat on his brow and his mouth went dry; he saw his chances of passing fading like a spent match. He gave a desperate heave. His feet slipped on the polished floor and over his head flew mother, baby, forceps and all.

The examiner looked at him lying on the floor for a second in silence. Then he picked up one blade of the forceps and handed it to him.

'Now hit the father with that,' he said sourly, 'and you'll have killed the whole bloody family.'

'One doesn't fail exams,' said Grimsdyke firmly. 'One comes down, one muffs, one is ploughed, plucked, or pipped. These infer a misfortune that is not one's own fault. To speak of failing is bad taste. It's the same idea as talking about passing away and going above instead of plain dying.'

We were sitting with Benskin in the King George. It was immediately after opening time in the morning and we were alone in the bar. We sat on stools, resting our elbows on the counter and our heads on our hands. All three of us looked pitifully dejected. The examination results were to be published at noon.