He sighed as together they began the walk back to the sick bay. Talk about being chucked in at the deep end? Only on board for a few hours, not yet able to find his way around the labyrinth of passageways, hatches, and lobbies, and now about to give an anaesthetic, something for which he was hardly trained. Still, what did the lower-deck sailors say? “You shouldn’t join if you can’t take a joke,” a way of expressing that all sailors were expected to take everything the service threw their way and deal with it. He just hoped he could.
To add insult to injury, dinner was going to be served in ten minutes and almost certainly by the time they’d finished with the patient the meal would be over. Unless things had changed since the last time Fingal O’Reilly had set foot on one of his majesty’s ships, tonight he was going to have to settle for a late supper of bully beef sandwiches and hot greasy cocoa.
* * *
“Any change?” Wilcoxson asked Paddy O’Rourke, who had met them in the sick bay.
“He’s thrown up twice more, sir, and his temperature’s one hundred and one point eight.”
“Come on then,” said Wilcoxson, “let’s take a look at the victim.”
“Ronnie Barker’s setting up next door,” Paddy said.
When they arrived at the patient’s cot, Fingal became aware of a smell of vomit and the man’s clearly worsening condition.
“The doctors have come back to see you, Stewart,” said Paddy O’Rourke.
Commander Wilcoxson stood beside the cot looking down. “How are you feeling?”
“Pretty crock, sir. Pain’s down in my right side and it’s a damn sight worse now.”
“You’ve upchucked?”
“Aye, sir. Three times.”
“Stick out your tongue.”
O’Reilly could see how furred it was and even from where he was standing on the far side of the bed he could smell the patient’s halitosis.
Wilcoxson sat on the cot and was taking the man’s pulse. “Hundred and twenty,” he said. “Now let’s see your belly.” He pulled the blankets down, opened the patient’s pyjama jacket.
O’Reilly noticed a likeness of Popeye the Sailor Man tattooed on the patient’s chest and “Janet” in a scroll underneath a heart pierced by an arrow.
Wilcoxson undid the trousers string, and began a running commentary. “No obvious abnormalities. Abdominal wall moves on respiration.”
So, Fingal thought, there’s probably no generalised peritonitis. If the membrane lining the abdominal cavity was infected, breathing would cause the patient severe pain and he would tighten up his abdominal muscles to prevent that.
“No visible peristalsis…”
The bowel was not obstructed.
Wilcoxson put the earpieces of his stethoscope in his ears and the bell on the patient’s belly. “Plenty of borborygmi.”
So, the bowel was contracting and making its usual rumbles and gurgles, more evidence that it wasn’t paralysed because of infection of the entire peritoneal membrane. If that were the case, the belly would be as silent as the tomb, and if a sulphonamide couldn’t cure the infection, it would indeed be Davy Jones’s locker for the victim. Fingal gave an involuntary shudder and was grateful that Stewart’s condition was not so dire.
“Tell me if this hurts,” Wilcoxson said, and began gently to palpate the abdomen, initially avoiding the right lower quadrant. The patient lay quietly until Wilcoxson’s questioning fingers reached there, then Stewart sucked in his breath. “Bit of guarding,” Wilcoxson said, and suddenly released the pressure.
“Yeow. Jings, sir, that hurt like the very devil.”
“Sorry, Stewart.”
So there was localised peritonitis over the spot where the appendix lay. The patient, by tightening his muscles, was trying to protect himself from pain—called guarding—but the sudden movement when the fingers’ pressure was released caused the muscles to spring out, thus moving the undoubtedly inflamed membrane. It was called rebound tenderness and the finding of it in that precise spot, taken in conjunction with the other symptoms and signs, was pretty conclusive of a diagnosis of—
“Appendicitis,” Wilcoxson said. “You were right, Paddy.”
The CPO inclined his head.
“It’ll have to come out,” Wilcoxson said.
O’Reilly was surprised to see the width of the patient’s grin, which he quickly hid. “So will I have to go to the Glasgow Royal Infirmary, sir?”
Where Robert Lister had first described aseptic surgical techniques in 1860 and revolutionised the whole discipline of surgery. Fingal had a sudden memory of being back at Trinity College, sitting in Professor Ball’s classroom.
“Or mebbe the Royal Alexandra Infirmary in Paisley?”
“’Fraid not, Stewart. It’s a pretty simple procedure. Doctor O’Reilly here will give the anaesthetic.”
O’Reilly inhaled deeply.
“And CPO O’Rourke will assist and look after the instruments.”
“Och, and I’m from the Gorbals, sir.”
A tenement district of Glasgow as notorious for its squalor and poverty as was the Liberties in Dublin.
“I thought I could mebbe have recovered at home.” Stewart’s voice was crestfallen.
O’Reilly could feel for the man and was going to ask why that couldn’t be arranged. After all, some of the injured after the last convoy had been sent ashore. But a look from Wilcoxson killed the unspoken words. “Regulations. Sorry about that,” Wilcoxson said. “Now, CPO O’Rourke, will you see to the prep, please?”
“Aye, aye, sir.”
The unfortunate would need a pubic shave and the painting of his belly with an antiseptic before he was taken through to the operating theatre.
O’Reilly thought it was pretty cavalier not letting the man go to a civilian facility, especially as his home was nearby. It was a matter O’Reilly was going to raise when the patient and CPO were out of earshot.
“Come along, Doctor O’Reilly, and we’ll change and start getting ready.” Wilcoxson walked to the curtain at the end of the sick bay.
O’Reilly now knew what was in there. He closed the curtain.
“We change in here,” Wilcoxson said, stripping off his sweater. “Lockers beside you have surgical whites and you can hang your clothes in the left-hand locker.”
O’Reilly began to strip. “Commander Wilcoxson,” he said. It was always tactful to show deference to rank if you were going to question the judgment of a senior officer. “I’d have thought it would have made a lot of sense to transfer the man ashore, and it would be a kindness to let him convalesce at home. He is entitled to sick leave after all.” As he spoke, O’Reilly asked himself, Are you honestly consumed with compassion for the man or trying desperately to get out of giving the anaesthetic?
“No,” Wilcoxson said, hauling on a pair of white trousers, “we’ll operate on board, and”—he pointed at a set of double doors directly ahead—“the isolation ward’s through there, remember?” He lowered his voice. “We’ll nurse Stewart in it postoperatively.”
O’Reilly frowned. “Why, sir? I thought postappendicectomy cases were usually looked after on the general ward.”
Wilcoxson laughed as he hauled on a white linen top. “First of all, Fingal, it’s Richard. Secondly, I never mind younger doctors questioning my judgment. Shocking as you may find it, even surgeon commanders can be wrong from time to time, and remember, the patients’ welfare always outranks the feelings of anyone with a medical degree.”
“Thank you, Richard,” O’Reilly said, and thought, I admire that attitude. It’s not one often found in senior surgeons.
“You’re wondering why do him here and why isolation? Because I don’t want him talking to anyone. I want him kept incommunicado. He can’t have his mates visiting him in there. If he’s all right by postop day three we will quietly send him home for a few weeks’ recuperative leave—as long as we are still in port.”
“I don’t understand, sir. I mean, Richard.”
??
?Lord, Fingal, if word gets out before we’ve gone to sea again that appendicitis, which is easy enough to pretend you have, is a sure ticket to Glasgow or Paisley, we could have every last man-jack or—” He smiled. “—perhaps since I’m in Scotland I should be saying every man-jock, reporting sick, clutching his belly, and hoping to get sent ashore too. We’ve no time for that.”
“I’d never have thought of it.” Fingal laughed. “And a friend of mine used to call me the Wily O’Reilly. I admire your reasoning.”
“Experience, my boy. Experience. It’ll all come to you with time, but now,” he strode to the double doors, “let me show you the anaesthetic gear we have here. I’m sure you’ll do perfectly fine with that.”
O’Reilly followed his chief’s example, tied on his own mask, and followed. His laugh faded. He wished he felt as confident in his abilities.
11
Nuisance of the Tropics
“Thanks, Barry,” O’Reilly said. They were both breathing heavily. Rory Auchinleck was no featherweight, but with Donal’s help they got him up on the examining couch in the surgery.
“Do you need me, Doctors? Should I be driving Rory anywhere once you’ve done your doctoring?”
“That’s kind, Donal,” said O’Reilly, “and thanks, but we’ll take it from here. You get that van back to Bertie Bishop’s builder’s yard before his milk of human kindness starts to curdle.”
“Right you are, Doc. Good luck, Rory; you’re in grand hands with these two learnèd men, so you are.” Donal tipped the brim of his duncher to the trio, turned on his heels, and left the surgery.
“Aspirin, aspirin,” said O’Reilly, rummaging in a drawer of the rolltop desk. “Here.” He shook two from the bottle and filled a glass with water. “Get those into you, lad.”
“Thanks, Doc,” Rory said.
“To bring you up to date, Doctor Laverty—I couldn’t in the Duck or in front of Donal in the van—Rory was stationed in Cyprus for a year with the British contingent of the United Nations peacekeeping force that was making sure the Greek and Turkish Cypriots weren’t at each other’s throats.”
“Your dad’s delighted to have you home, Rory,” Barry said, “and, coincidentally, so is his back.”
Rory gave a short laugh, but his voice was weak. “Dad’s been taking cricks in his back since I was a wee lad. It’s all the lifting with his job, so it is.” He grimaced and sucked in a breath.
“Anyway,” O’Reilly said, “since Rory’s been home in Ulster he’s had two bouts of high fever, shivering, night sweats. Both were diagnosed as flu, by two different MOs. Today he’s started to have a third attack. Without examining him, have you any notion what might be wrong, Doctor Laverty?”
“No,” said Barry, “and to be honest I don’t think examining you, Rory, would help me much either.” He must have seen the man’s frown. “But don’t be worried,” Barry said. “It’s not because you’ve got something terrible, it’s because Doctor O’Reilly made a point of telling me you were in a foreign country. I’d be willing to guess that he thinks you’ve picked up some foreign disease. Doctor O’Reilly knows much more about them than I do. My textbook of medicine only had fourteen pages on tropical diseases. They’re pretty rare in Ulster so I didn’t pay much attention.”
“Aye,” said O’Reilly, “things like kwashiorkor, beriberi, and bilharzia aren’t exactly ten a penny here. But Doctor Laverty is being modest, Rory. He has diagnosed a tropical disease and his patient was most grateful.” O’Reilly could tell by Barry’s smile that he was remembering Alice Moloney’s amoebic liver abscess. “And he’s right about my thinking you picked up something in Cyprus. I just need to take a quick shufti at your neck and belly and do a simple blood test and we’ll have a pretty good idea.”
Rory shuddered. “Just go ahead, Doc. I feel foundered, so I do.”
“I can believe it,” O’Reilly said. “A high fever will make you feel cold.” He moved to a small instrument cabinet. “I’m going to take a blood sample before I examine you. Usually we do the tests last, but this one needs time to develop. Can you roll up your left sleeve?”
O’Reilly took out a small syringe and deftly went through the steps to fill the barrel with blood, then removed the needle, put the swab over the puncture, and said to Rory, “Hold that there for a few minutes.”
“Right, sir.”
“Good.” O’Reilly removed the rubber stopper, squirted the blood into the sample tube, and restoppered it. “It’ll take about five or ten minutes and while that’s going on I’ll have a look at you, Rory. I’m sorry, I know you’re cold, but I’m going to have to ask you to take off your pullover and shirt.”
“Let me help you,” Barry said, and did. “You do have a fever, Rory,” he said.
Meanwhile O’Reilly left the sample tube on his desk and washed the syringe. He held his hands under a stream of warm water from the sink’s tap. “Might as well get my paws warm before I start.” He dried his hands and approached the couch. “Now,” he said, “I’m going to give Doctor Laverty a running commentary, but don’t let it worry you, Rory, because it won’t take long and as soon as I’ve done I’ll explain everything. One quick question. Were the bugs bad in Cyprus?”
“Aye. There were wee buggers called sand flies. The bites stung like bejizzis and you got a hell of an itchy bump.”
“Mmmm,” said O’Reilly, “we had those flies in Egypt too.” He started to palpate Rory’s neck. “No enlarged lymph nodes,” he said. “If I’m right about what ails you, swollen nodes would be a rare finding anyway.” And, he thought but didn’t say, almost invariably present in cases of the lethal cancer of the lymphatic system, Hodgkin’s disease, which, with its propensity to causing fevers and night sweats, could perhaps be confused with what O’Reilly sought. His hands moved into Rory’s armpits each in turn. “No axillary nodes either.” Even better. The diagnosis of Hodgkin’s was becoming progressively more remote.
He listened with his stethoscope to Rory’s breathing and heartbeat. Although both were rapid, as was to be expected in a patient with a fever, there were no abnormalities of either.
“Tummy now,” he said, and, starting at the top right, rapidly percussed the belly wall using his bent right index and middle fingers to rap the backs of his left middle and ring fingers. These were laid on the skin and produced a hollow sound except for a more dull note in an area extending about six inches below the margin of the left ribs. “Hear that, Barry?”
“I do. Is it the spleen?”
“I think so.” O’Reilly laid his right hand flat, with his fingers pointing to the ribs on Rory’s belly at a level slightly below the lower margin of the area that had been dull to percussion. He exerted pressure so his fingers pushed the abdominal wall inward. “Take a deep breath.”
Rory did. Nothing touched O’Reilly’s fingers. “And out.” He moved his hand upward as Rory exhaled. “And in.” This time the expansion of the young man’s lungs and accompanying downward excursion of the diaphragm, the sheet of muscle that separates the chest from the abdominal cavity, pushed something solid inside against O’Reilly’s questing fingertips. “It’s spleen all right,” O’Reilly said. That organ did become enlarged in Hodgkin’s but usually late in the course of the illness. He repeated the examination on the patient’s right side. “Liver’s not enlarged.” He handed the clothes back to Rory. “Put these on. You must be freezing.”
While Rory got dressed, O’Reilly summarized the situation for Barry. “So we have a relapsing fever that started coming on several months after Rory left an area where sand fly bites were common, headache, shivering, night sweats, no enlarged lymph nodes, splenomegaly, but no hepatomegaly.” He saw Rory’s eyes widen. “Don’t be scared, Rory. I promised I’d explain and I will in just a minute. The main thing is it’s not cancer.” Old Doctor Micks had drummed that into his students. Every sick patient had one overwhelming, usually unspoken, fear and as soon as any physician was certain that the patient was cancer-free it was the d
octor’s responsibility to allay those fears.
“Thanks, Doc,” Rory said.
“Any ideas now, Barry?” O’Reilly asked.
Barry was frowning. “You’ve pretty well told me it’s a tropical disease and the one that I can think of that half-fills the bill, recurrent bouts of fever and an enlarged spleen, is malaria, but it’s spread by mosquitoes, not sand flies.”
“You’re right about the mosquitoes and close to being right about the condition,” O’Reilly said, “but I know for a fact that Cyprus is the only foreign country Rory has been to, isn’t that right?”
“Yes, sir.”
“And malaria is not present in Cyprus.”
“Then I’m stumped,” Barry said.
“And I would be too if I hadn’t served in the Mediterranean.” He turned to Rory. “Doctor Laverty made a pretty good stagger at making a diagnosis. I doubt if many GPs in Ireland could put their finger on what I think you’ve got, but I was lucky to have seen a number of cases during the war. Those bloody sand flies. The female sand flies need proteins from blood from some animals, and that includes us humans, to ripen their eggs. When the flies bite, they inject an anticoagulant, something to keep the blood flowing. That anticoagulant is what makes the bite swell up and itch. Sadly, though, the bugs carry a tiny wee beastie called Leishmania donovani, and they usually inject some of the wee beasties too, when they bite. When they multiply inside you, they’re what give you a fever and make your spleen, the organ that removes old dead blood cells, get bigger. That’s what ‘splenomegaly’ means. ‘Hepatomegaly’ means an enlarged liver and the disease can cause that too, but you don’t have it.”
“I’ll be thankful for small mercies,” Rory said. “But have I still got the wee buggers inside me?”
“I’m pretty sure you do,” O’Reilly said. “If the test I’m doing is positive, I’ll be ninety percent certain and we’ll get you up to the fever hospital at Purdysburn where a specialist will take a sample from your bone marrow or possibly your spleen. I’ll not lie. It’ll sting for a minute or two when it’s being done, but the only way to be absolutely certain is to look for the Leishmania there.”