Chapter 4
Internship
I served my internship at the California Hospital in Los Angeles. It was my first choice, so I was quite happy when I received a telegram advising me of being accepted. I came to Los Angeles early in June because of the fact it was home to me. I made the mistake of appearing at the hospital early in the month. Some of the prior interns had quit and the hospital needed help, so I went to work early, for the munificent sum of twenty-five dollars a month.
The California was a nice hospital. I was assured that they had a fine teaching intern program, so I started to work with avidity. It was a rotating internship, divided between pediatrics, medicine, surgery, obstetrics, and orthopedics.
There was some time in the evening when we were to serve at the Georgia Street Receiving Hospital, which was within walking distance of the California. This was where we had an opportunity to suture wounds, apply dressings, and get some practical experience treating accidents.
In 1936 there were still many homes with those very dangerous turn-on knobs for bath tub and sink, made of a porcelain material. Because these were old, many of the plumbing fixtures were about worn out and continued to leak, requiring a tight turn off. It was surprising how many cases of lacerations of the hand we saw at the Georgia Street Receiving Hospital. When people attempted to turn the water off tightly, the fixture, being brittle from age, would break off in the hand, causing a horrible cut, sometimes deep enough to sever the tendons. We had some good practical experience suturing wounds. We also sutured wounds from family fights, automobile accidents, and other accidents to which many people in the city were prone.
The more serious accidents and the gunshot wounds and conditions which could become legal problems were turned over to the doctors on the staff. However, the time was certainly well spent there, as it was the place where most of our training for real emergency was obtained. The California Hospital itself had no outpatient department, which was really too bad, because an outpatient department furnishes a very practical place to obtain real experience in the most common complaints that a patient can have. And those common complaints are the ones that confront a doctor in his practice. No matter how busy he is, he is not going to encounter many of the rare conditions he concentrates on in medical school.
The hospital did have an affiliation with the Babies Clinic where we were allowed to work. It was here that we saw the inequities that existed in our world. Many of the patients were brought to the clinic in Cadillacs, and some of the children had beautiful clothes and dolls that ordinary people could not afford. However, we treated them all alike, and even arranged for tonsillectomies for some of them.
These were our first tonsillectomies, so we examined the children carefully and had them brought in at the appointed time, so they would be in overnight before the operation. Some of the jobs were amateurish, but we had good supervision, and that was the way we learned.
We had two months on surgical service, when we were to scrub in the morning on elective surgery with some very good surgeons, and evenings and nights we scrubbed on emergency surgery. We were to do a physical and history on each case as it came in, plus all the intravenous medication when on call. In those days they did many, many hypodermoclyses, in which a long needle injects isotonic solution under the skin, and under the breasts of women. It was painful and I deemed it unnecessary, but many of the doctors ordered it. I swore I’d never give one to one of my patients when I started to practice, and I never did.
There was one surgeon whose son was on the staff at the same time. He frequently scrubbed with his father, and of course they had to have an intern scrub, too. The father would ask anatomical questions of the son, who never could answer them correctly, so then the intern would be asked. Naturally, being just out of medical school, the intern could answer correctly, thus putting the son in a bad light. For some reason, this greatly delighted the father.
Since this was in the days before penicillin, there were patients with ruptured appendices who could not be saved. It is tragic how many people with appendicitis wait too long, or take a laxative or enema to cure their own belly aches and have a ruptured appendix before they call a doctor. This gives peritonitis a chance to develop, greatly increasing morbidity and mortality.
It was such a shame then to see an otherwise healthy individual brought in with a ruptured appendix, be operated on carefully and yet unable to be saved. Fortunately, we can do more now, but we employed drainage, heat cradles, constant watching and everything that we could think of for the patient. And patients still die today of peritonitis following a ruptured appendix, frequently because they wait too long.
“There’s a man in here with a chill that shakes his bed. Please come in and see what you think is wrong with him,” one of the interns said to me when I came on duty one Monday morning, after having some time off for the weekend.
“What has been done for him?” I asked. He had been admitted the day before and had just had the usual routine blood count and urinalysis. Now, down in Texas and Oklahoma, where malaria was rampant, it was the first thing we thought of when we saw a patient with a chill. Also, having written my paper for doctorate on the use of atabrine and plasmochin in the treatment of malaria, naturally I had malaria in mind. Upon questioning the patient, I discovered that he had been in Alabama working on a project just a few weeks before. So I ordered a blood smear examined for malarial parasites. It was loaded with them, so we instituted atabrine and plasmochin, which had to be gotten at the county hospital. It was not generally stocked anywhere in town. All this, of course, with the attending physician’s cooperation. In fact, we let the attending physician make the diagnosis and do the treatment while we stayed in the background, because after all, it was his patient and not ours. He later said he never would have thought of malaria, for he had never seen a case of it.
Another interesting case was an attractive young woman who worked in a variety store in Hollywood. She came in with a case of “measles” but was broken out all over the body, had an extremely sore throat, and was a pretty sick girl. Somehow it didn’t look like measles to me, so I ordered a Wasserman test. It was four plus, indicating syphilis. The stage she had was secondary, when it is most easily transmitted. She responded to the usual treatment but was in for at least two years of intensive treatment with neoarsphenamine and bismuth. There was no penicillin then.
There was a German doctor who was very precise in his treatments and also very demanding. One day he had a patient in whom he diagnosed lobar pneumonia. I took the history and did the physical and agreed with his diagnosis. This was when pneumonia was treated according to types, so the germs were typed, and the antitoxin acquired. When giving the antitoxin, we always made a test first to see if the patient might be sensitive to it. This is done by using a small testing vial, putting a few drops in the eye, and observing the reaction. This I did, and since I was on the left side of his bed, I gently dropped a couple of drops into his left eye. I waited a full five or six minutes, then read the results. Since there was not the least reaction in the eye, I went ahead and gave the material into his cubital vein. Fortunately, he had an easy, large vein, an intern’s paradise, as we called it, and there was no trouble getting it in. After waiting awhile to see if he reacted, I started to leave. I had told him what I was giving him, so he knew, but one thing I failed to tell him. So he asked, “What was the stuff you put in my eye?” I told him it was to test his sensitivity to the antitoxin. “Did you notice that my left eye is a glass one?” Really, I hadn’t, and was dumbfounded, thinking of a reaction I might have had.
There was romance in the hospital, too. Most nurses in those days were unmarried. There were many delightful girls who had individual ways of expressing their “willingness.” There was one poor dear who fell for Dr. Frost, one of the interns, and she was such a bother to him, I promised to try to get her off his back. It required very little effort on my part, but who was there to relieve me? Finally, however, it was achieved, but only after a struggle, ignoring her. Truthfully, we interns were too busy for romance. When on obstetrics, we were on call twenty-four hours, and my alternate, who was to be on the next twenty-four hours, was more interested in the Santa Anita race track than in OB, so he frequently did not show up. Then I had to be on another twenty-four hours. After that, I was not good for much, until a good long rest and sleep.
All the interns liked surgery, so there was often a battle over which one would serve with whom. We had our favorite doctors, and the favorites were the favorites of most interns, and there were some surgeons whom we all wished to shy away from.
My first surgical case was with Dr. Miller. I didn’t know him, nor had I had time to find out anything about him. I scrubbed, gowned, and went in to assist him. I had been working only a few minutes when he rapped my knuckles hard with a pair of forceps. I never did know what it was about, but it seemed to please him vastly, because he went through the entire operation enjoying himself that way. By the time the surgery was over, by knuckles were sore, but there was another case to follow. I scrubbed on it, with Dr. Best, who did the same thing. After the second “rap” I took off my gloves, and gown, and left the operating room, since he had an assistant to help him.
This had apparently not happened before, since he yelled and swore at me and wanted to know why I didn’t stay. He would report me to the superintendent, etc. I left the operating room without a word, and the nurses told me later he was “burned up” because of that. Anyhow, I thought if all the doctors in the California hospital acted like that, I would not cooperate, for I considered my knuckles too valuable to be rapped on. And I thought if all the doctors were like the first two, I might be in the wrong place.
Anyway, I beat him to the draw and reported him to the superintendent myself, and gave my version of the story. I told the superintendent I had come there expecting to be treated as a gentleman and to learn from the men who could teach me. I didn’t consider that as teaching and I would not work with those two doctors again, or with any other doctor who struck me. It had an effect, I suppose, for I was never again struck, and I didn’t hear of any other interns who were rapped on the knuckles.
One day during surgery, we had difficulties galore. We were doing a subtotal hysterectomy (totals were not done then) and first off, a needle broke. The surgeon showed moderate irritation but said nothing. Then a Kocher clamp he put on came off with a snap. He replaced it with another that also snapped off. This thoroughly irritated the surgeon, who threw the clamp across the room and grabbed another. Just as he was about to incise between the clamps, it too came off. He was infuriated. He shouted at the nurse, looked around exasperatedly, and yelled, “Take those damned instruments and throw them out the window! And get me another set, quickly.”
The scrub nurse picked up the tray, went over, raised the window, and threw the entire set of instruments down into the parking lot, just as the supervisor of nurses approached. She naturally heard the clattering, went over to see what it was, and came charging up in the elevator to raise a ruckus.
But the surgeon is the boss in the operating room. The poor nurse had only followed orders, but there was the Dickens to pay, and it was weeks getting straightened out. Don’t forget, the nurse had to scrub again, after opening the window.
In obstetrics there was one fellow who always worked like a Trojan, and made the delivery look extremely difficult, as if only he could have done it. Then there was another obstetrician who made all the cases seem so easy. For primaparas (women with their first babies), he always did an episiotomy (an incision enlarging the opening so it would not tear), and he always repaired ti the same way. “Nine-stitch Pete, they call me,” he always said. He was an excellent man, his patients always got along really well, and he was very nice to the interns and nurses.
In those days, See’s Candies were fifty cents a pound, and several patients or their families brought boxes of candy to the nurses.
There were some nurses who took a liking to me and always called me when they had a box of candy. One day I was called over to Five East for “something special.” Upon completing my current task, I hurried over to Five East to see what it was. A man with a broken leg had required a great deal of attention, so his kind wife had brought the girls a bottle of Champagne. After a tussle, we found an opener and succeeded in getting it open, with Champagne all over the place. We still had enough to taste all around. All agreed it tasted like old, stale ginger ale and wondered why anyone paid good money for that stuff.
At other times there were cakes, candy, and real delectables that were well worth while and were quite a treat to one who had starved his way through medical school.
The nights on duty were sometimes very busy, allowing no time for sleep. Frequently a case required a blood pressure reading every hour, and the intern had to take it, not the nurse. Also, the patient was not allowed to sleep, having to be wakened so frequently.
Only two of our interns out of twelve (counting the residents) were married at the time. This is in contrast to today’s crop of interns being married men. Another contrast to today is the salary we made. Ours was the munificent sum of twenty-five dollars per month, or three hundred dollars per year, and now in some hospitals the interns are paid fifteen thousand dollars per year. Quite a change, considering the fact that we worked just as hard and long as today’s interns.
One cold February day I was called by intercom to hurry down to the emergency entrance where there was a woman having a hemorrhage. I hurried down and found a fairly young woman in an awful mess. She was bleeding from the bowel, and there was blood all over the stretcher. We took her upstairs and transferred her to a bed. Somehow she didn’t appear to have lost as much blood as we saw. We cleaned her up and gave her an enema, and the bleeding ceased completely.
It was learned that this young lady was a nurse from the general hospital who had had polio in 1933, and she had had some psychiatric changes. Somehow she had gotten on morphine and, being a nurse and knowing that the first step in a hemorrhaging patient was morphine to quiet the nerves, she had injected as a retention enema almost a quart of beef blood.
A couple of months later she was brought in again to the emergency when I was on duty. This time she was bleeding from the vagina. I recognized her instantly. We admitted her and found that this time she had cut herself just inside the vulva with a razor blade and she was bleeding profusely, for she had done a good job of lacerating.
“Are you always on emergency duty here?” she asked. When I replied that it seemed so, she then stated she would go to another hospital next time she wanted morphine. What a mess to go through for a bit of morphine.
We loved the hospital staff meetings because of the delicious “feed” we had afterwards. The presentations lasted about an hour, and they were all by men on the staff. We interns had no opportunity to participate, but they figured we could learn by listening. After the meeting, there was one of the most beautiful spreads ever. The Norwegian really showed up in their delicious smorgasbord, and we hungry interns required no second invitation.
Each intern was assigned a doctor who was a sort of father, to whom we could go with our various problems. Each “father” was supposed to show some interest in his intern, but perhaps we had no problems to confront him with or advice to ask of him, so we received no personal attention from our “father.” From my standpoint, I knew his name, spoke to him in the hallway, and that was all.
It was one continual round of intravenous injections and hypodermoclyses, history, and physical. On Sunday afternoon, there were always patients galore coming in for elective surgery on Monday morning, and everyone required a history and physical before surgery. And there was a difference in attitudes of patients. Some would cooperate nicely, while others could see no sense in being bothered. Some of the older women were quite obstreperous, while as a rule the young women were glad to give a history and have a physical. It seems the doctor, as a general rule, had not done a physical examination in the office, and the patient wondered just what her general condition was. Young men, too, were very cooperative and talkative. It is surprising how many fellows there are who have contemplated the study of medicine, only to fall by the wayside somewhere along the road. Many of the young women were more interested in their doctors than in doctoring.
One case I shall never forget. It was a lovely coed from USC. She was a Texas girl, out here to get her teacher’s credentials, and she would have made a capable teacher. She called me John the Baptist, and had to try to put her arms around me every time I came in. She had similar biblical names for everyone who visited her, and seemed to know what it was all about. None of us could make the diagnosis, but we thought it was partly psychiatric. Finally, her temperature went up and her condition deteriorated rapidly. She died, and postmortem showed an amebic abscess in the brain. No wonder she had such weird symptoms, and no one was able to diagnose her condition prior to autopsy.
Another patient with very bizarre symptoms was an elderly woman. She became very belligerent, wanted to eat orange peel and potato peel. She swore and her family said she didn’t do so ordinarily. She told very rambling stories, had peculiar movements, together with vomiting and spastic movements. All the doctors missed the diagnosis. She had a brain tumor. Those brain conditions were difficult to diagnose.
One very amiable fellow on my service was Mr. Lorenz. His case was a simple appendectomy, his recovery was uneventful, and he was such a pleasure to visit that I spent my spare time talking to him. He was a stock broker, always had a nice smile and usually had a good story to tell. He remained in the full two weeks (we always kept surgical and obstetrical patients a minimum of two weeks, usually, in bed). The time came for his discharge. I went to his room, gave him a final checkup, and told him good bye. He was cheerful as could be, anxious as everyone is to go home. But he said, “Doctor, I don’t believe I’ll ever get out of here.”
“Why? Don’t you feel all right?”
“I feel just fine. But somehow, there is a premonition that I shan’t go.”
“Oh, cheer up. I have never seen a patient look better than you. Your wife will be here within a few minutes.” I told him good bye and went on about my rounds. There was the usual number of IV’s to give, stomachs to pump, and examinations to do, for mornings are always busy times in a hospital.
In a few minutes I was paged on the loudspeaker. I answered and received a call to go to room 534 quickly. That was Mr. Lorenz’ room, so I hurried but arrived too late to do him any good. He had died of a pulmonary embolism, showing his premonition was right. There have been many other times I have had patients tell me they felt they were going to die. I learned to believe them, for there is definitely a feeling that is not always wrong.
I am not talking about those with mental aberrations, who are always trying to get some attention from someone, or to gain sympathy. But when a patient says he or she feels the end is near, it is worthwhile to pay some attention to what he says.
There were ten of us interns, all as different as the night is from the day. A few were solitary individuals, who remained so far removed from the rest of us that their shells could not be cracked. Among most of us, however, there was a camaraderie that was enjoyable and made the extremely difficult year more bearable. We usually had our meals together and enjoyed the medical talk that young interns everywhere seem to enjoy. We had enemas, blood transfusions, intravenouses, and surgeries for breakfast, lunch, and dinner. Sometimes the young ladies who waited on us at the table became plagued or embarrassed by what they heard, but it was at the table that we had an opportunity to talk over our cases and get suggestions from one another.
It was here that a case of malaria, rare in California, was suspected, and a case of syphilis in a dime store clerk was diagnosed. So, instead of worrying about the waitress, we talked with reckless abandon (for those days) about anything that came to our mind.
One intern, who had a car, always took off alone. Even when there was a party to which interns were invited, he went alone, leaving those of us without transportation to use the streetcars. His favorite pastime, he later told us, was to go down on Main Street to the Follies, or the striptease shows. He seemed to enjoy those and to enjoy them alone. Another fellow was an avid movie fan, and he almost always attended on his night off. Two fellows were married. Their wives always had something planned for them, while the rest of us were at loose ends. Our salary of twenty-five dollars per month didn’t quite give us much leeway, so the expectant nurses around the hospital were not very royally entertained by us. There was a poker game, or some other innocent pastime in the interns’ quarters in the evening. We had small radios, but of course no TV’s to sit and watch. Still, we went to the zoo, and to some of the other points of interest, and were happy to have a day or two off, in order to rest up, after a busy run, and to take our minds off the sick and afflicted of the world. As much as one loves his science, he wants an occasional respite from it.