At twenty minutes before the hour, a lone student came into the laboratory. Professor McGowan didn’t look up or greet the large young man; he dipped his steel pen into the ink and continued to write as the student went directly to the middle seat in the front row and claimed it with his notebook. He didn’t take the seat, but instead strolled through the laboratory on an inspection tour.
Stopping before the brine tank, to Dr. McGowan’s amazement he picked up the wooden staff with the iron hook at the end of it, and began fishing among the body parts in the saline solution, like a small boy playing in a pond. In the nineteen years Dr. McGowan had taught first lessons in anatomy, no one ever had behaved in such a fashion. New students came to anatomy class for the first time with portentous dignity. Usually they walked slowly, often with dread.
“Here, now! Stop that at once. Put the hook down,” McGowan commanded.
The young man gave no sign he had heard, even when the professor clapped his hands sharply, and McGowan knew suddenly whom he was dealing with. He started to rise, but then sank back, curious to see where this might lead.
The young man moved the hook selectively among the items in the brine. Most of them were old, and many had been cut upon by other classes of students. Their general condition of mutilation and decomposition was the key element in the shock of a first anatomy class. McGowan saw the youth bring a wrist and hand to the surface, a tattered leg. Then he brought up a lower arm and hand that evidently was in better shape than most of the anatomical pieces. McGowan watched as he used the hook to bring the desired specimen into the top-right corner of the tank and then covered it with several disreputable objects. Hiding it!
At once the youth placed the hooked stick where he had found it and moved to the table, where he proceeded to inspect the scalpels for sharpness. When he found one he liked, he moved it slightly above the others on the table and returned to the amphitheater to take his seat.
Dr. McGowan chose to disregard him, and for the next ten minutes continued to work with the records. Eventually students began to drift into the laboratory. They took seats at once. Many were already pale, for there were odors in the room that gave flight to their fantasies and fears.
Precisely on the hour, Dr. McGowan put down his pen and moved in front of the desk. “Gentlemen,” he said.
When they had fallen silent, he introduced himself. “In this course we study the dead in order that we may learn about, and help, the living. The first records of such studies were made by early Egyptians, who dissected the bodies of poor wretches they killed as human sacrifices. The ancient Greeks are the true fathers of physiological investigation. There was a great medical school in Alexandria, where Herophilus of Chalcedon studied the human organs and viscera. He named the calamus scriptorius and the duodenum.”
Dr. McGowan was aware that the eyes of the young man in the center seat of the first row never left the professor’s mouth. They literally hung on to his every word.
Gracefully he traced the disappearance of anatomical study into the superstitious void of the Dark Ages, and its renaissance after A.D. 1300.
The final portion of his lecture concerned the fact that after the living spirit has left, researchers must treat the body without fear but with deference. “In my student days in Scotland, my professor likened the body after death to a house whose owner had moved. He said the corpus must be treated with careful dignity, out of respect for the soul who had lived there,” Dr. McGowan said, and was annoyed to see that the youth in the front row was smiling.
He told them each to take a specimen from the brine tank and a knife, and to dissect their anatomical object and make a drawing of what they saw, to be turned in before they left the class. Always at the first class there was a moment’s hesitation, a reluctance to begin. During this hanging-back, the youth who had arrived early was first again, for he’d risen at once and gone to the tank to collect the specimen he’d stashed, and then the sharp scalpel. While the others began to mill about the tank, he was already setting up shop at the dissection table with the most favorable light.
Dr. McGowan was acutely aware of the pressures of the first anatomy class. He was accustomed to the sweetish stink that rose from the brine tank, but he knew of its effect on the uninitiated. He’d given some of the students an unfair task, because many of the specimens were in such poor condition it would be impossible to dissect them well and draw them accurately, and he took that into account. The exercise was a discipline, the first blooding of green troops. It was a challenge to their ability to face unpleasantness and adversity, and a harsh but necessary message that the practice of medicine consisted of more than collecting fees and enjoying a respected place in the community.
Within minutes several people had left the room, one of them a young man who departed in a great hurry. To Dr. McGowan’s satisfaction, at length each of them returned. For almost an hour he strolled among the dissection tables, checking on their progress. The class contained several mature men who had practiced medicine after apprenticeships. They were spared the nausea of some of the other students. Dr. McGowan knew from experience that some would be excellent doctors; but he watched one of them, a man named Ruel Torrington, slashing away at a shoulder, and he sighed, thinking of the terrible surgery this man must have left behind him.
He paused a fraction longer at the last table, where a fat youth with a sweating face struggled to work on a head that was mostly skull.
Across from the fat youth, the deaf boy worked. He was experienced and had used the scalpel well to open the arm in layers. The fact that he’d known to do this revealed a prior knowledge of anatomy that both pleased and surprised McGowan, who noted that joints, muscles, nerves, and blood vessels were neatly depicted in the drawing, and labeled. As he watched, the young man printed his name on the drawing and handed it to him. Cole, Robert J.
“Yes. Ah. Cole, in the future, you must make your printed letters a bit larger.”
“Yes, sir,” Cole said quite distinctly. “Will there be anything else?”
“No. You may return your specimen to the tank and clean up after yourself. Then you may go.”
The dismissal brought half a dozen other drawings to Dr. McGowan, but each of the students was turned back with a suggestion for revision of the drawing or several ways to improve the dissection.
While he conferred with the students, he watched Cole return the specimen to the tank. He saw him wash and wipe the scalpel before replacing it on the table. He observed that Cole carried water to the dissection table and scrubbed the side of it he’d used, and then took brown soap and clean water and washed his own hands and arms carefully before rolling down his sleeves.
Cole paused by the chubby youth on the way out and examined his drawing. Dr. McGowan saw him lean over and whisper. Some of the desperation left the other boy’s face, and he nodded as Cole patted his shoulder. Then the fat one went back to work, and the deaf one left the classroom.
46
HEART SOUNDS
It was as if the medical school were a remote foreign land in which Shaman occasionally heard fearsome rumors of impending war in the United States. He learned of a Peace Convention in Washington, D.C., attended by one hundred thirty-one delegates from twenty-one states. But the morning the Peace Convention opened in the capital, the Provisional Congress of the Confederate States of America convened in Montgomery, Alabama. A few days later the Confederacy voted to secede from the United States, and everyone was sickeningly aware there would be no peace.
Still, Shaman was able to give the nation’s problems only passing attention. He was fighting his own war for survival. Fortunately, he was a good student. He pored over his books at night until he couldn’t see any longer, and most mornings he managed several hours of study before breakfast. Classes were held Monday through Saturday, from ten to one and from two to five. Often a lecture was delivered before or during one of the six clinics that gave the medical school its name: Tuesday afternoons, diseases of the
chest; Tuesday evenings, venereal diseases; Thursday afternoons, children’s diseases; Thursday evenings, the ailments of females; Saturday mornings, surgical clinic; and Saturday afternoons, medical clinic. Sunday afternoons, students observed the staff physicians in the wards.
It was on Shaman’s sixth Saturday at the Polyclinic that Dr. Meigs lectured about the stethoscope. Meigs had studied in France under doctors who had been taught by the instrument’s inventor. He told the students that one day in 1816 a physician named René Laënnec, reluctant to place his ear against the chest of a bosomy and embarrassed female patient, had rolled up some paper and tied the resultant tube with a piece of string. When Laënnec had placed one end of the tube to the patient’s chest and listened at the other end, he was surprised to note that, instead of being a less efficient way to listen, the method amplified the chest sounds.
Meigs said that until recently stethoscopes had been simple wooden tubes listened to by doctors who used one ear. He had a more modern version of the instrument, in which the tube was of woven silk, leading to ivory earpieces that fit into both ears. During the medical clinic that followed the class, Dr. Meigs used an ebony stethoscope with a second outlet to which a tube was attached, so both the professor and a student could listen to a patient’s chest sounds at the same time. Each student was given an opportunity to listen, but when it was Shaman’s turn he told the professor of medicine it was no use. “I wouldn’t be able to hear anything.”
Dr. Meigs pursed his lips. “You must at least try.” He was careful to show Shaman precisely how to hold the instrument to his ear. But Shaman could only shake his head.
“I am sorry,” Professor Meigs said.
There was to be an examination in clinical practice. Each student was to examine a patient, using the stethoscope, and make a report. It was clear to Shaman that he was going to be failed.
On a cold morning he bundled himself in his coat and gloves, tied a muffler around his neck, and hiked away from the school. A boy on a corner was hawking newspapers that told about Lincoln’s inauguration. Shaman walked down to the riverfront and along the wharves, deep in thought.
When he returned, he went into the hospital and walked through the wards, studying the orderlies and nurses. Most were men, and many were drunkards who had gravitated to hospital work because the standards were low. He observed those who seemed sober and intelligent, and finally determined that a man named Jim Halleck would serve his purpose. He waited until the orderly had carried in an armload of wood and dumped it on the floor near the potbellied stove, then approached him.
“I’ve a proposition for you, Mr. Halleck.”
The afternoon of the examination, both Dr. McGowan and Dr. Berwyn showed up at the medical clinic, heightening Shaman’s nervousness. Dr. Meigs tested the class alphabetically. Shaman was third, after Allard and Bronson. Israel Allard had an easy time of it; his patient was a young woman with a strained back, whose heart sounds were strong, regular, and uncomplicated. Clark Bronson was assigned to examine an asthmatic man, no longer young. He stumblingly described the sound of rales in the chest. Meigs had to ask him several leading questions to get the information he needed, but evidently he was satisfied in the end.
“Mr. Cole?”
It was evident that he expected Shaman to decline to participate. But Shaman came forward and accepted the monaural wooden stethoscope. When he looked to where Jim Halleck was sitting, the orderly rose and joined him. The patient was a sixteen-year-old male, of husky build, who had cut his hand in a carpentry shop. Halleck held one end of the stethoscope to the boy’s chest and placed his ear on the other end. Shaman took the patient’s wrist and felt the push of the boy’s pulse against his fingers.
“The patient’s heartbeat is normal and regular. At a rate of seventy-eight times per minute,” he said at length. He glanced inquiringly at the orderly, who shook his head slightly. “There are no rales,” Shaman said.
“What is the meaning of this … theater?” Dr. Meigs said. “What is Jim Halleck doing here?”
“Mr. Halleck is serving as my ears, sir,” Shaman said, and was unfortunate enough to note broad grins on the faces of several of the students.
Dr. Meigs did not smile. “I see. As your ears. And would you marry Mr. Halleck, Mr. Cole? And take him with you wherever you would practice medicine? For the rest of your life?”
“No, sir.”
“Then, will you ask other folks to be your ears?”
“Perhaps I shall, at times.”
“And if you’re a physician who comes on someone in need of your help, and you are alone, just you and the patient?”
“I can get the heart rate from the pulse.” Shaman touched two fingers to the carotid artery in the patient’s throat. “And feel whether it is normal, or bounding, or weak.” He spread his fingers and placed his palm on the boy’s chest. “I can feel the rate of respirations. And see the skin, and touch it to learn whether it is feverish or cool, moist or dry. I can see the eyes. If the patient is awake, I can talk with him, and conscious or not, I can observe the consistency of his sputum and see the color of his urine and smell it, even taste it if I have to.” Looking at his professor’s face, he anticipated the objection before Dr. Meigs could make it.
“But I’ll never be able to hear rales in the chest.”
“No, you will not.”
“For me, rales will not be warnings of trouble. When I see the early stages of croupy breathing, I will know that if I could hear them, the rales in his chest doubtless would be crackling. If my patient becomes markedly croupy, I will know that there are bubbling rales in the chest. If there is asthma or an infection of the bronchia, I’ll know there are sibilant rales. But I won’t be able to confirm that knowledge.” He paused and looked directly at Dr. Meigs. “I can’t do anything about my deafness. Nature has robbed me of a valuable diagnostic tool, but I have other tools. And in an emergency, I would care for my patient, using my eyes and my nose and my mouth and my fingers and my brain.”
It wasn’t the deferent answer Dr. Meigs would have appreciated from a first-year student, and his face showed annoyance. Dr. McGowan came to him and leaned over his chair, speaking into his ear.
Soon Dr. Meigs looked back at Shaman. “It is suggested that we take you at your word, and give you a patient to diagnose without using the stethoscope. I am ready to do so, if you agree.”
Shaman nodded, although his stomach lurched.
The medical professor led them into the nearest ward, where he paused before a patient whose card at the foot of his bed revealed he was Arthur Herrenshaw. “You may examine this patient, Mr. Cole.”
Shaman saw at once from Arthur Herrenshaw’s eyes that the man was in terrible trouble.
He pulled back the sheet and blanket and raised the gown. The patient’s body looked extremely fat, but when Shaman placed his hand on Mr. Herrenshaw’s flesh, it was like touching raised dough. From his neck, where the veins were distended and pulsating, to his shapeless ankles, the swollen tissues were laden with fluid. He heaved with the effort of breathing.
“How are you today, Mr. Herrenshaw?”
He had to ask again, in a loud voice, before the patient responded with a slight shake of his head.
“How old are you, sir?”
“… I … fift … two.” He gasped profusely between syllables, like a man who has run a long way.
“Do you have pain, Mr. Herrenshaw? … Sir? Do you have pain?”
“Oh …” he said, his hand on his sternum. Shaman noted he seemed to be straining upward.
“You wish to sit up?” He helped him to do so, supported his back with pillows. Mr. Herrenshaw was sweating profusely, but he also shivered. The only heat in the ward came from a thick black stovepipe that bisected the ceiling as it ran from the wood-burning stove, and Shaman pulled the blanket up over Mr. Herrenshaw’s shoulders. He took out his watch. When he checked Mr. Herrenshaw’s pulse, it was as if the second hand suddenly slowed. The pulse was light a
nd thready and incredibly fast, like the desperate skittering footsteps of a small animal fleeing a predator. Shaman had trouble counting fast enough. The animal slowed, stopped, took a couple of slow hops. Began to scurry again.
He was aware that now was the time Dr. Meigs would have used the stethoscope. He could imagine the interesting, tragic sounds he could have reported, the noises of a man drowning in his own juices.
He held both of Mr. Herrenshaw’s hands in his own and was chilled and saddened by their message. Without knowing he did it, he touched the bowed shoulder before he turned away.
They went back to the clinic room for Shaman’s report. “I don’t know what caused the fluids to collect in his tissues. I don’t have the experience to understand that. But the patient’s pulse was light and thready. Irregular. His heart is in failure, beating one hundred and thirty-two times a minute when racing.” He looked at Meigs. “In the last several years I helped my father to autopsy two males and a female whose hearts failed. In each, a small portion of the heart wall was dead. The tissue appeared burnt, as if it had been touched by a live coal.”
“What would you do for him?”
“I would keep him warm. I would give him soporifics. He’ll die in a few hours, so we should ease his pain.” At once, he knew he had said too much, but the words couldn’t be recalled.
Meigs pounced. “How do you know he will die?”
“I sensed it,” Shaman said in a low voice.
“What? Speak up, Mr. Cole, so the class may hear.”
“I sensed it, sir.”
“You do not have enough experience to know about body fluids, but you are able to sense impending death,” the professor said cuttingly. He looked at his class. “The lesson here is clear, gentlemen. While there is life in a patient, we never—you shall never!—consign them to death. We struggle to give them renewed life until they are gone. Do you understand that, Mr. Cole?”