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George
Orwell
How the Poor
Die
In the year 1929 I spent several weeks in
the Hôpital X, in the fifteenth
arrondissement of Paris. The clerks put me
through the usual third-degree at the
reception desk, and indeed I was kept
answering questions for some twenty minutes
before they would let me in. If you have
ever had to fill up forms in a Latin country
you will know the kind of questions I mean.
For some days past I had been unequal to
translating Reaumur into Fahrenheit, but I
know that my temperature was round about
103, and by the end of the interview I had
some difficulty in standing on my feet. At
my back a resigned little knot of patients,
carrying bundles done up in coloured
handkerchiefs, waited their turn to be
questioned.
After the questioning came the bath — a
compulsory routine for all newcomers,
apparently, just as in prison or the
workhouse. My clothes were taken away from
me, and after I had sat shivering for some
minutes in five inches of warm water I was
given a linen nightshirt and a short blue
flannel dressing-gown — no slippers, they
had none big enough for me, they said — and
led out into the open air. This was a night
in February and I was suffering from
pneumonia. The ward we were going to was 200
yards away and it seemed that to get to it
you had to cross the hospital grounds.
Someone stumbled in front of me with a
lantern. The gravel path was frosty
underfoot, and the wind whipped the
nightshirt round my bare calves. When we got
into the ward I was aware of a strange
feeling of familiarity whose origin I did
not succeed in pinning down till later in
the night. It was a long, rather low,
ill-lit room, full of murmuring voices and
with three rows of beds surprisingly close
together. There was a foul smell, faecal and
yet sweetish. As I lay down I saw on a bed
nearly opposite me a small,
round-shouldered, sandy-haired man sitting
half naked while a doctor and a student
performed some strange operation on him.
First the doctor produced from his black bag
a dozen small glasses like wine glasses,
then the student burned a match inside each
glass to exhaust the air, then the glass was
popped on to the man's back or chest and the
vacuum drew up a huge yellow blister. Only
after some moments did I realize what they
were doing to him. It was something called
cupping, a treatment which you can read
about in old medical text-books but which
till then I had vaguely thought of as one of
those things they do to horses.
The cold
air outside had probably lowered my
temperature, and I watched this barbarous
remedy with detachment and even a certain
amount of amusement. The next moment,
however, the doctor and the student came
across to my bed, hoisted me upright and
without a word began applying the same set
of glasses, which had not been sterilized in
any way. A few feeble protests that I
uttered got no more response than if I had
been an animal. I was very much impressed by
the impersonal way in which the two men
started on me. I had never been in the
public ward of a hospital before, and it was
my first experience of doctors who handle
you without speaking to you or, in a human
sense, taking any notice of you. They only
put on six glasses in my case, but after
doing so they scarified the blisters and
applied the glasses again. Each glass now
drew about a dessert-spoonful of
dark-coloured blood. As I lay down again,
humiliated, disgusted and frightened by the
thing that had been done to me, I reflected
that now at least they would leave me alone.
But no, not a bit of it. There was another
treatment. coming, the mustard poultice,
seemingly a matter of routine like the hot
bath. Two slatternly nurses had already got
the poultice ready, and they lashed it round
my chest as tight as a strait-jacket while
some men who were wandering about the ward
in shirt and trousers began to collect round
my bed with half-sympathetic grins. I
learned later that watching a patient have a
mustard poultice was a favourite pastime in
the ward. These things are normally applied
for a quarter of an hour and certainly they
are funny enough if you don't happen to be
the person inside. For the first five
minutes the pain is severe, but you believe
you can bear it. During the second five
minutes this belief evaporates, but the
poultice is buckled at the back and you
can't get it off. This is the period the
onlookers enjoy most. During the last five
minutes, I noted, a sort of numbness
supervenes. After the poultice had been
removed a waterproof pillow packed with ice
was thrust beneath my head and I was left
alone. I did not sleep, and to the best of
my knowledge this was the only night of my
life — I mean the only night spent in bed —
in which I have not slept at all, not even a
minute.
During my first hour in the Hôpital X I had
had a whole series of different and
contradictory treatments, but this was
misleading, for in general you got very
little treatment at all, either good or bad,
unless you were ill in some interesting and
instructive way. At five in the morning the
nurses came round, woke the patients and
took their temperatures, but did not wash
them. If you were well enough you washed
yourself, otherwise you depended on the
kindness of some walking patient. It was
generally patients, too, who carried the
bedbottles and die grim bedpan, nicknamed la
casserole. At eight breakfast arrived,
called army-fashion la soupe. It was soup,
too, a thin vegetable soup with slimy hunks
of bread floating about in it. Later in the
day the tall, solemn, black-bearded doctor
made his rounds, with an interne and a troop
of students following at his heels, but
there were about sixty of us in the ward and
it was evident that he had other wards to
attend to as well. There were many beds past
which he walked day after day, sometimes
followed by imploring cries. On the other
hand if you had some disease with which the
students wanted to familiarize themselves
you got plenty of attention of a kind. I
myself, with an exceptionally fine specimen
of a bronchial rattle, sometimes had as many
as a dozen students queuing up to listen to
my chest. It was a very queer feeling —
queer, I mean, because of their intense
interest in learning their job, together
with a seeming lack of any perception that
the patients were human beings. It is
strange to relate, but sometimes as some
young student stepped forward to take his
turn at manipulating you he would be
actually tremulous with excitement, like a
boy who has at last got his hands on some
expensive piece of machinery. And then ear
after ear — ears of young men, of girls, of
negroes — pressed against your back, relays
of fingers solemnly but clumsily tapping,
and not from any one of them did you get a
word of conversation or a look direct in
your face. As a non-paying patient, in the
uniform nightshirt, you were primarily a
specimen, a thing I did not resent but could
never quite get used to.
After some
days I grew well enough to sit up and study
the surrounding patients. The stuffy room,
with its narrow beds so close together that
you could easily touch your neighbour's
hand, had every sort of disease in it
except, I suppose, acutely infectious cases.
My right-hand neighbour was a little
red-haired cobbler with one leg shorter than
the other, who used to announce the death of
any other patient (this happened a number of
times, and my neighbour was always the first
to hear of it) by whistling to me,
exclaiming ‘Numéro 43!’ (or whatever it was)
and flinging his arms above his head. This
man had not much wrong with him, but in most
of the other beds within my angle of vision
some squalid tragedy or some plain horror
was being enacted. In the bed that was foot
to foot with mine there lay, until he died
(I didn't see him die — they moved him to
another bed), a little weazened man who was
suffering from I do not know what disease,
but something that made his whole body so
intensely sensitive that any movement from
side to side, sometimes even the weight of
the bedclothes, would make him shout out
with pain. His worst suffering was when he
urinated, which he did with the greatest
difficulty. A nurse would bring him the
bedbottle and then for a long time stand
beside his bed, whistling, as grooms are
said to do with horses, until at last with
an agonized shriek of ‘Je fissel’ he would
get started. In the bed next to him the
sandy-haired man whom I had seen being
cupped used to cough up blood-streaked mucus
at all hours. My left-hand neighbour was a
tall, flaccid-looking young man who used
periodically to have a tube inserted into
his back and astonishing quantities of
frothy liquid drawn off from some part of
his body. In the bed beyond that a veteran
of the war of 1870 was dying, a handsome old
man with a white imperial, round whose bed,
at all hours when visiting was allowed, four
elderly female relatives dressed all in
black sat exactly like crows, obviously
scheming for some pitiful legacy. In the bed
opposite me in the farther row was an old
bald-headed man with drooping moustaches and
greatly swollen face and body, who was
suffering from some disease that made him
urinate almost incessantly. A huge glass
receptacle stood always beside his bed. One
day his wife and daughter came to visit him.
At sight of them the old man's bloated face
lit up with a smile of surprising sweetness,
and as his daughter, a pretty girl of about
twenty, approached the bed I saw that his
hand was slowly working its way from under
the bedclothes. I seemed to see in advance
the gesture that was coming — the girl
kneeling beside the bed, the old man's hand
laid on her head in his dying blessing. But
no, he merely handed her the bedbottle,
which she promptly took from him and emptied
into the receptacle.
About a dozen beds away from me was Numéro
57 — I think that was his number — a
cirrhosis-of-the-liver case. Everyone in the
ward knew him by sight because he was
sometimes the subject of a medical lecture.
On two afternoons a week the tall, grave
doctor would lecture in the ward to a party
of students, and on more than one occasion
old Numéro 57 was wheeled in on a sort of
trolley into the middle of the ward, where
the doctor would roll back his nightshirt,
dilate with his fingers a huge flabby
protruber-ance on the man's belly — the
diseased liver, I suppose — and explain
solemnly that this was a disease
attributable to alcoholism, commoner in the
wine-drinking countries. As usual he neither
spoke to his patient nor gave him a smile, a
nod or any kind of recognition. While he
talked, very grave and upright, he would
hold the wasted body beneath his two hands,
sometimes giving it a gentle roll to and
fro, in just the attitude of a woman
handling a rolling-pin. Not that Numéro 57
minded this kind of thing. Obviously he was
an old hospital inmate, a regular exhibit at
lectures, his liver long since marked down
for a bottle in some pathological museum.
Utterly uninterested in what was said about
him, he would lie with his colourless eyes
gazing at nothing, while the doctor showed
him off like a piece of antique china. He
was a man of about sixty, astonishingly
shrunken. His face, pale as vellum, had
shrunken away till it seemed no bigger than
a doll's.
One morning my cobbler neighbour woke me up
plucking at my pillow before the nurses
arrived. ‘Numéro 57!’ — he flung his arms
above his head. There was a light in the
ward, enough to see by. I could see old
Numéro 57 lying crumpled up on his side, his
face sticking out over the side of the bed,
and towards me. He had died some rime during
the night, nobody knew when. When the nurses
came they received the news of his death
indifferendy and went about their work.
After a long dme, an hour or more, two other
nurses marched in abreast like soldiers,
with a great clumping of sabots, and knotted
the corpse up in the sheets, but it was not
removed till some dme later. Meanwhile, in
the better light, I had had dme for a good
look at Numéro 57. Indeed I lay on my side
to look at him. Curiously enough he was the
first dead European I had seen. I had seen
dead men before, but always Asiatics and
usually people who had died violent deaths.
Numéro 57's eyes were still open, his mouth
also open, his small face contorted into an
expression of agony. What most impressed me,
however, was the whiteness of his face. It
had been pale before, but now it was little
darker than die sheets. As I gazed at the
tiny, screwed-up face it struck me that dlis
disgusting piece of refuse, waiting to be
carted away and dumped on a slab in the
dissecting room, was an example of ‘natural’
death, one of the things you pray for in the
Litany. There you are, then, I thought,
that's what is waiting for you, twenty,
thirty, forty years hence: that is how the
lucky ones die, the ones who live to be old.
One wants to live, of course, indeed one
only stays alive by virtue of the fear of
death, but I think now, as I thought then,
that it's better to die violently and not
too old. People talk about the horrors of
war, but what weapon has man invented that
even approaches in cruelty some of the
commoner diseases? ‘Natural’ death, almost
by definition, means something slow, smelly
and painful. Even at that, it makes a
difference if you can achieve it in your own
home and not in a public institution. This
poor old wretch who had just flickered out
like a candle-end was not even important
enough to have anyone watching by his
deathbed. He was merely a number, then a
‘subject’ for the students' scalpels. And
the sordid publicity of dying in such a
place! In the Hôpital X the beds were very
close together and there were no screens.
Fancy, for instance, dying like the little
man whose bed was for a while foot to foot
with mine, the one who cried out when the
bedclothes touched him! I dare say ‘Je
pisse!’ were his last recorded words.
Perhaps the dying don't bother about such
things — that at least would be the standard
answer: nevertheless dying people are often
more or less normal in their minds till
within a day or so of the end.
In the
public wards of a hospital you see horrors
that you don't seem to meet with among
people who manage to die in their own homes,
as though certain diseases only attacked
people at the lower income levels. But it is
a fact that you would not in any English
hospitals see some of the things I saw in
the Hôpital X. This business of people just
dying like animals, for instance, with
nobody standing by, nobody interested, the
death not even noticed till the morning —
this happened more than once. You certainly
would not see that in England, and still
less would you see a corpse left exposed to
the view of the other patients. I remember
that once in a cottage hospital in England a
man died while we were at tea, and though
there were only six of us in the ward the
nurses managed things so adroitly that the
man was dead and his body removed without
our even hearing about it till tea was over.
A thing we perhaps underrate in England is
the advantage we enjoy in having large
numbers of well-trained and
rigidly-disciplined nurses. No doubt English
nurses are dumb enough, they may tell
fortunes with tea-leaves, wear Union Jack
badges and keep photographs of the Queen on
their mantelpieces, but at least they don't
let you lie unwashed and constipated on an
unmade bed, out of sheer laziness. The
nurses at the Hôpital X still had a tinge of
Mrs Gamp about them, and later, in the
military hospitals of Republican Spain, I
was to see nurses almost too ignorant to
take a temperature. You wouldn't, either,
see in England such dirt as existed in the
Hôpital X. Later on, when I was well enough
to wash myself in the bathroom, I found that
there was kept there a huge packing case
into which the scraps of food and dirty
dressings from the ward were flung, and the
wainscodngs were infested by crickets. When
I had got back my clothes and grown strong
on my legs I fled from the Hôpital X, before
my time was up and without waiting for a
medical discharge. It was not the only
hospital I have fled from, but its gloom and
bareness, its sickly smell and, above all,
something in its mental atmosphere stand out
in my memory as exceptional. I had been
taken there because it was the hospital
belonging to my arrondissement, and I did
not learn till after I was in it that it
bore a bad reputation. A year or two later
the celebrated swindler, Madame Han-aud, who
was ill while on remand, was taken to the
Hôpital X, and after a few days of it she
managed to elude her guards, took a taxi and
drove back to the prison, explaining that
she was more comfortable there. I have no
doubt that the Hôpital X was quite untypical
of French hospitals even at that date. But
the patients, nearly all of them working
men, were surprisingly resigned. Some of
them seemed to find the conditions almost
comfortable, for at least two were destitute
malingerers who found this a good way of
getting through the winter. The nurses
connived because the malingerers made
themselves useful by doing odd jobs. But the
attitude of the majority was: of course this
is a lousy place, but what else do you
expect? It did not seem strange to them that
you should be woken at five and then wait
three hours before starting the day on
watery soup, or that people should die with
no one at their bedside, or even that your
chance of getting medical attention should
depend on catching the doctor's eye as he
went past. According to their traditions
that was what hospitals were like. If you
are seriously ill and if you are too poor to
be treated in your own home, then you must
go into hospital, and once there you must
put up with harshness and discomfort, just
as you would in the army. But on top of this
I was interested to find a lingering belief
in the old stories that have now almost
faded from memory in England — stories, for
instance, about doctors cutting you open out
of sheer curiosity or thinking it funny to
start operating before you were properly
‘under’. There were dark tales about a
little operating-room said to be situated
just beyond the bathroom. Dreadful screams
were said to issue from this room. I saw
nothing to confirm these stories and no
doubt they were all nonsense, though I did
see two students kill a sixteen-year-old
boy, or nearly kill him (he appeared to be
dying when I left the hospital, but he may
have recovered later) by a mischievous
experiment which they probably could not
have tried on a paying patient. Well within
living memory it used to be believed in
London that in some of the big hospitals
patients were killed off to get dissection
subjects. I didn't hear this tale repeated
at the Hôpital X, but I should think some of
the men there would have found it credible.
For it was a hospital in which not the
methods, perhaps, but something of the
atmosphere of the nineteenth century had
managed to survive, and therein lay its
peculiar interest.
During the past fifty years or so there has
been a great change in the relationship
between doctor and patient. If you look at
almost any literature before the later part
of the nineteenth century, you find that a
hospital is popularly regarded as much the
same thing as a prison, and an
old-fashioned, dungeon-like prison at that.
A hospital is a place of filth, torture and
death, a sort of antechamber to the tomb. No
one who was not more or less destitute would
have thought of going into such a place for
treatment. And especially in the early part
of the last century, when medical science
had grown bolder than before without being
any more successful, the whole business of
doctoring was looked on with horror and
dread by ordinary people. Surgery, in
particular, was believed to be no more than
a peculiarly gruesome form of sadism, and
dissection, possible only with the aid of
bodysnatchers, was even confused with
necromancy. From the nineteenth century you
could collect a large horror-literature
connected with doctors and hospitals. Think
of poor old George III, in his dotage,
shrieking for mercy as he sees his surgeons
approaching to ‘bleed him till he faints’!
Think of the conversations of Bob Sawyer and
Benjamin Alien, which no doubt are hardly
parodies, or the field hospitals in La
Débâcle and War and Peace, or that shocking
description of an amputation in Melville's
White-jacket! Even the names given to
doctors in nineteenth-century English
fiction, Slasher, Carver, Sawyer, Fillgrave
and so on, and the generic nickname
‘sawbones’, are about as grim as they are
comic. The anti-surgery tradition is perhaps
best expressed in Tennyson's poem, The
Children's Hospital, which is essentially a
pre-chloroform document though it seems to
have been written as late as 1880. Moreover,
the outlook which Tennyson records in this
poem had a lot to be said for it. When you
consider what an operation without
anaesthetics must have been like, what it
notoriously was like, it is difficult not to
suspect the motives of people who would
undertake such things. For these bloody
horrors which the students so eagerly looked
forward to (’A magnificent sight if Slasher
does it!’) were admittedly more or less
useless: the patient who did not die of
shock usually died of gangrene, a result
which was taken for granted. Even now
doctors can be found whose motives are
questionable. Anyone who has had much
illness, or who has listened to medical
students talking, will know what I mean. But
anaesthetics were a turning point, and
disinfectants were another. Nowhere in the
world, probably would you now see the kind
of scene described by Axel Munthe in The
Story of San Michele, when the sinister
surgeon in top hat and frock coat, his
starched shirtfront spattered with blood and
pus, carves up patient after patient with
the same knife and flings the severed limbs
into a pile beside the table. Moreover, the
national health insurance has partly done
away with the idea that a working-class
patient is a pauper who deserves little
consideration. Well into this century it was
usual for ‘free’ patients at the big
hospitals to have their teeth extracted with
no anaesthetic. They didn't pay, so why
should they have an anaesthetic — that was
the attitude. That too has changed.
And yet every institution will always bear
upon it some lingering memory of its past. A
barrack-room is still haunted by the ghost
of Kipling, and it is difficult to enter a
workhouse without being reminded of Oliver
Twist. Hospitals began as a kind of casual
ward for lepers and the like to die in, and
they continued as places where medical
students learned their art on the bodies of
the poor. You can still catch a faint
suggestion of their history in their
characteristically gloomy architecture. I
would be far from complaining about the
treatment I have received in any English
hospital, but I do know that it is a sound
instinct that warns people to keep out of
hospitals if possible, and especially out of
the public wards. Whatever the legal
position may be, it is unquestionable that
you have far less control over your own
treatment, far less certainty that frivolous
experiments will not be tried on you, when
it is a case of ‘accept the discipline or
get out’. And it is a great thing to die in
your own bed, though it is better still to
die in your boots. However great the
kindness and the efficiency, in every
hospital death there will be some cruel,
squalid detail, something perhaps too small
to be told but leaving terribly painful
memories behind, arising out of the haste,
the crowding, the impersonality of a place
where every day people are dying among
strangers.
The dread of hospitals probably still
survives among the very poor, and in all of
us it has only recently disappeared. It is a
dark patch not far beneath the surface of
our minds. I have said earlier that when I
entered the ward at the Hôpital X I was
conscious of a strange feeling of
familiarity. What the scene reminded me of,
of course, was the reeking, pain-filled
hospitals of the nineteenth century, which I
had never seen but of which I had a
traditional knowledge. And something,
perhaps the black-clad doctor with his
frowsy black bag, or perhaps only the sickly
smell, played the queer trick of unearthing
from my memory that poem of Tennyson's, The
Children's Hospital, which I had not thought
of for twenty years. It happened that as a
child I had had it read aloud to me by a
sick-nurse whose own working life might have
stretched back to the time when Tennyson
wrote the poem. The horrors and sufferings
of the old-style hospitals were a vivid
memory to her. We had shuddered over the
poem together, and then seemingly I had
forgotten it. Even its name would probably
have recalled nothing to me. But the first
glimpse of the ill-lit murmurous room, with
the beds so close together, suddenly roused
the train of thought to which it belonged,
and in the night that followed I found
myself remembering the whole story and
atmosphere of the poem, with many of its
lines complete.
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