A Necessary Disposition by Kate Venables


My father and I were both doctors. I use the past tense for my father, Harry Walker, because he died young. For myself, it is because I am no longer a real doctor. I became an epidemiologist and my clinical skills gradually atrophied. I was a child when Harry died and I never had a conversation with him about medicine. Never about anything. Can an adult be said to converse with a five-year-old, a seven-year-old, a ten-year-old?

When I was a young woman, I packed Harry away as images in a photograph album and as a few inherited books and objects. But if I visited a large medical library and walked past a collection of old Medical Directories, I would look up his entry and wish I knew more about his life and work. When I opened a package of my father’s testimonials, a phrase stuck in my mind, that he had ‘the necessary disposition for an anaesthetist’.

Why do people choose medicine as a profession, why are they are drawn to particular specialties, how much do these choices relate to ‘disposition’? These large generalities are all interesting, but this essay looks at the subject at a microscopic and personal level, through the lenses of my own career choice of epidemiology and Harry’s of anaesthesia.

In many ways, epidemiology and anaesthesia could not be more different. Much of epidemiology is desk work. It’s about big-picture thinking, looking at disease patterns at the population level, comparing regions and countries, using statistics to define the factors that cause disease and those which influence its outcome. We have all become acquainted with it during the coronavirus pandemic as, night after night, we look at graphs and listen to discussions about projections and risk factors and the parameters of the latest regression model. Harry, on the other hand, dealt with one patient at a time and in a highly practical manner. His work required him not only to be familiar with every aspect of the machinery and chemicals he used, but also to touch his patients and understand the quirks of their anatomy and physiology, as well as the pathology that forced them into the operating theatre.

But maybe there are some fundamental similarities which explain why a father and daughter might have chosen such apparently different fields. We epidemiologists work in teams, or, these days, Teams. Anaesthetists, too, don’t work in isolation. Although the specialty has expanded its boundaries considerably since Harry’s time, it started as a partnership with surgery and this partnership remains fundamental in the operating theatre. The anaesthetist and the surgeon dance round each other, the patient between them. They share responsibility for the patient’s outcome.

Maybe there is something about not wanting the limelight? The epidemiologists on our television screens are backroom creatures, unused to media interest until now. And, on a surgical ward, each patient ‘belongs’ to a surgeon, not to an anaesthetist, and most anaesthetists appear content with this superficially subordinate position.

And what about the magical properties of our respective specialties? Epidemiologists are oracular now. We predict the future and advise governments. And Harry had the shamanic power to render a person unconscious and powerless.

But they are very different disciplines. I was never interested in anaesthesia. I don’t think I have the right skills or mindset to be an anaesthetist. It is a field which, more than many medical specialties, marries clinical skill with the basic anatomical, physiological and biochemical underpinnings of medicine and which merges both with an interest in pharmacology and in tinkering with bits of kit. Anaesthetists are often inventors, introducing new chemicals or perfecting new connectors or valves.

I lack an interest in technology. I admire people who can make things work, who can build things, are good with their hands like Harry. I enjoy the beauty of my father’s woodworking tools rather than wishing to have a go at carpentry myself. Although I have some manual facility and can draw and sew, I lack the ease with three-dimensional shapes that a real craftsman has. I can read maps and diagrams but I have to think it through with my intellect rather than trust to my gut feelings. It follows that I stick laboriously to a step-by-step leaflet to assemble a piece of furniture whereas my husband could scan instructions then set to with screwdriver and drill, humming with satisfaction as he worked out how pieces fitted together. I used to do what I called ‘inventing’ as a child but it was a species of collecting. I would requisition particularly attractive sweet tins and within them hide an assortment of rubber bands, hair-grips, old coins, pebbles, shells, feathers, broken brooches and doll’s limbs. These assemblages had more resemblance to a seventeenth-century antiquarian’s cabinet of curiosities than to an inventor’s bench.

When I was a child, I took it for granted that not only was my father a doctor, but he was an anaesthetist. When he came home from work his clothes were aromatic with the smell of anaesthetic gases. He kept a brown, ribbed glass bottle of ether in the house because it was good for dissolving the sticky grey crumbs of residual gum left after removing sticking plaster from children’s limbs. I always had skinned elbows and scabbed knees and I got through a lot of Elastoplast. The ether was an important tool in making me presentable for visitors.

At school we asked each other what our fathers ‘did in The War’ and there were hierarchies of glamour from fighter pilot downwards. When a television appeared in our house I became fascinated by Sergeant Bilko, who always had a scheme to make money and managed his gimcrack crew of American soldiers with fast, wisecracking humour, always getting the better of the dim officers who nominally commanded him. I found Sergeant Bilko immensely clever and funny and I wanted him on my side. A sergeant was clearly a prestigious being and I suppose I had heard of people ‘learning a trade’ in the Army so I started to boast that my father had learned how to be a doctor when he was a sergeant in the war. This story must have spread because my mother was cross and made me learn how to spell ‘a n a e s t h e t i s t’ and that my father left the Army as a major.

Harry was a practical man who did most of the house-painting and minor repairs around the house himself and I have memories of playing round his feet while he did something: digging the garden, painting doors in the house, writing letters at his desk. When he was reading or watching television, I used to clamber over him, turning the signet ring round his finger, exploring his pockets, stealing his handkerchief, combing his hair.

Harry’s carpentry tools came to me after my mother died. Then they moved to my first house. Much later, they went into storage until finding their current home in a chest in my hall in my current house.

There’s a Bailey No 4 plane, Made in England stamped on the baseplate in a plain font and Stanley in raised letters on an orange ground on the blade. It is heavy wood and iron. The heft of it is not familiar but I can tell it would fit a larger hand and a stronger arm comfortably. Rust blooms on its base and there are wear scratches and a few streaks of white paint. The wood is thickly varnished a dark brown. The handle and the knob did not have to be as elegantly turned as they are. The worn areas show the wood grain. In the chest there is also a tenon saw and a few chisels, an awl, a punch.

I like the tenon saw especially. I probably misuse it, looked at from a technical, carpentry perspective, but it fits my hand and its weight feels good in my wrist. The wooden handle is polished with skin oils and fixed to the heavily rusted oblong blade with two big bolts. The metal guard on the handle has a curved, finished shape. I could be part of a dragon carving on a sword from the Dark Ages. It’s rusty but it cuts.

Our house had a garage at the bottom of the back garden, with tall folding doors that opened into a back alley behind the houses. Part of the garage was a workshop and this side was almost completely filled with the boat lying propped and wedged on its sawhorses. The floor was cobbled with a gutter running down the centre to a drain. There was a workbench under the side window, black with oil and the window glass was gauzy with oily cobwebs. In the workshop Harry built an Enterprise dinghy from a kit sponsored by The News Chronicle. I used to play on the floor in drifts of sweet sawdust, a radio mumbling in the background, Harry rubbing down the wood with different grades of sandpaper. He painted the hull a shade of blue I had never seen before. Not pale. Not dark. A blue in between. He varnished its other parts: the mast, the rudder, the stern and transom. Several coats. We didn’t talk but I chattered. I missed the boat’s presence when it was finished and launched and left the workshop, with much reversing and re-aligning to move it onto its trailer in the narrow alley.

The testimonials are folded into a brittle, foxed envelope and held together by a rusted paper clip. ‘I have every confidence in him when he undertakes anaesthetics for me’ writes the senior surgeon, a referee for Harry’s consultant post at the start of the NHS in 1948. Another writes ‘Because of his knowledge and skill in the practice of all the most modern types of anaesthetics, there is a great demand for Dr. Walker’s services in this area, where his abilities are now held in high regard by all his colleagues.’

The centrepiece of anaesthetic practice has always been surgical pain relief, assessing the patient’s physical condition prior to surgery and deciding if he has sufficient resilience to withstand the surgeon’s assault, preparing him for surgery, inducing unconsciousness safely, monitoring his bodily responses to the surgeon’s cuts and probings and stitchings, returning him to consciousness and relieving his pain while he heals. It’s a fine balance. Too little anaesthesia and the patient is agonisingly aware of the surgeon’s intrusions; too much and the patient dies.

But it is not solely knowledge and skill that matter. There is something more nebulous and difficult to describe. Along with these technical attributes, a really good anaesthetist also needs a certain type of personality. The referees strain to describe it, using words like interested, conscientious, loyal, pleasant, stimulating, likeable, courteous, agreeable, enthusiastic. ‘He has the necessary disposition for an anaesthetist’. He is ‘in every way a first class man’.

It is curious that personality should be such an important factor in these testimonials because anaesthetists, like psychiatrists and orthopaedic surgeons, are the frequent butt of medical jokes. ‘Gasmen’, they are called. Putting people to sleep is a favourite trope, many jokes riffing on ‘the half-asleep looking after the half-awake’. Status and charisma are other themes, surgeons always asserting their superiority over anaesthetists.

Most likely, what the writers of these testimonials meant is an ability to work flexibly with temperamental surgeons and to manage emergencies in the operating theatre firmly. ‘He didn’t suffer fools gladly’, said one of his colleagues. He (or today, often she) has a complicated relationship with the surgeon. The surgeon is in charge of the surgical procedure, makes the diagnosis, chooses the technique and carries it out in theatre. But the anaesthetist is in charge of the patient. The anaesthetist protects the patient from the harm the surgeon inflicts. If resuscitation becomes necessary during an operation, it is the anaesthetist who takes charge and who directs the surgeon’s actions to preserve the patient.

Some people see the relationship between surgeon and anaesthetist (whatever the sex of either) as akin to the stereotype of a traditional marriage, where the surgeon is a demanding husband and the anaesthetist a competent wife, who is apparently subservient in the background, but quietly in charge. The quality of the relationship is important, not only for the working atmosphere in an operating theatre, but also for the welfare and survival of the patient. Some partnerships last for decades.

Anaesthesia is much more than playing Darby and Joan in the operating theatre. Anaesthetists are entrepreneurs and inventors. They have always had a wider role than sitting at a patient’s head during surgery and today they take the lead in trauma teams, intensive care, emergency pre-hospital care and pain management. I feel that Harry would have relished being part of these territorial takeovers by his specialty. He took anaesthesia seriously.

His copy of The Development of Inhalation Anaesthesia: with Special Reference to the Years 1846-1900 is bound in azure blue fabric-covered boards, sun-faded to grey on the spine and on the top inch of the front cover and with neat gold lettering on the spine in the Oxford University Press manner. Inside the front cover is the bookshop sticker: Donald Ferrier, Medical Bookseller, 8, 9 & 18 Teviot Place, Edinburgh 1, Phone 21551 – 22321. Harry has pencilled above it: 2/47 and 35/-.

When Harry bought the book it was the height of the severe winter weather of 1947 and he was a postgraduate student in an unheated Edinburgh flat, his pregnant wife and undergraduate brother huddling with him in coats and army-surplus blankets. But it was important to buy The Development of Inhalation Anaesthesia as soon as it was published, for thirty-five shillings, the equivalent of about fifty pounds today. It has become a classic, reissued by medical history societies. Buying it at the start of his post-war professional life was an investment in his library, the un-thumbed condition of its shiny mid-century paper suggesting that he put it aside to read in a more leisurely future that never came.

I am surprised at the frontispiece. John Snow (1813-58) is a titan in my own specialist area and I have never seen him in my father’s world. In the photograph John Snow has Darwin-like beetling eyebrows under a receding hairline. His neat mutton-chop whiskers meet his stiff white collar and black, loosely-tied tie. He has a pointed nose, wide mouth and inquisitive, intelligent eyes looking off beyond the photographer’s left shoulder. He leans his right elbow on a small table, arge, practical hands loosely folded in his lap.

In my field John Snow is the man who removed the Broad Street pump. Water was supplied to pumps and houses by a variety of water companies in Victorian London. At the height of the cholera epidemic in Lambeth in 1854 Snow drew a map of cholera cases and showed that their water supply came from one water company. Although it must have been a more complicated process than usually portrayed he is described as persuading the local public health authorities to remove the handle of the suspect pump, thus preventing people drinking the contaminated water, halting the epidemic and saving lives. His mapping and his simple, logical approach to the cause and prevention of cholera means he is claimed as ‘the father of modern epidemiology’ and ‘a pioneer of statistical mapping’. Epidemiological societies are named after him and any respectable School of Public Health has a page on its website devoted to him.

But John Snow was also the first professional anaesthetist. Already interested in the physiology of asphyxia and resuscitation, he read in 1846 of the use in America of ether during surgical operations. Snow developed a mechanical inhaler, testing it on animals and on himself, and this allowed greater control of the anaesthetic process and therefore greater safety for the patient. He became the pre-eminent practitioner in London and personally administered chloroform to Queen Victoria during the births of two of her children. He advocated a scientific understanding of anaesthesia, wrote instructional manuals, and trialled innovations. The Broad Street pump merits only a short footnote in The Development of Inhalation Anaesthesia, whereas Snow’s work on anaesthesia gets a full column in the index.

I like to think of John Snow as a connection between my speciality and Harry’s. To strengthen the connection Snow, like my father and me, came from Yorkshire. Only forty-five when he died, he demonstrates how much can be achieved in a short life when nineteenth-century rationalism, inquisitiveness and respect for education are applied widely instead of being channelled down narrowly-specialised streams.

If Harry had lived long enough to retire, his last decade or so of practice would have overlapped with my first. Harry would have had something to say about the surgeons I worked for in my surgical house job, good surgeons both. In the hospital where I worked as a junior physician my ‘firm’ was in charge of patients on ventilators on the intensive care unit. We called an anaesthetist only rarely and I realise now that we treated the ‘gasmen’ as if they were superior technicians unsuited to managing patients for any period longer than a few hours. Harry would have had something to say about that. He would have lived into the days when anaesthestists were branching out, negotiating turf wars as they expanded their remit beyond the operating theatre. All of it highly practical work, technically competent, physiologically aware, patient-focussed. Very different from my desk work. He would have had something to say about that, too. 

Kate Venables is a PhD student at Goldsmiths College, where she is writing a hybrid memoir-biography which draws on her father’s life. A poem about her father’s books was selected for the 2014 Hippocrates Prize Anthology and her poetry and flash fiction have appeared in The Frogmore Press, Envoi, Ink Sweat & Tears, Brittle Star, Lighthouse, and Flash.

4 August 2021