V
THE CORPSES WERE delivered at noon to the Ecole Pratique d’Anatomie and then distributed to the various dissecting rooms; by two o’clock, Jacques found himself up to his elbows in the abdominal cavity of an old woman whose blue eyes seemed to look down approvingly at his rapid scalpel work.
Behind him, a skeleton was suspended from a hook attached by a chain to the ceiling; an hour earlier it had been a fleshy young woman who had died in childbirth. Her uterus was on the cast-iron table next to Jacques, where two other students were bent over it.
Jacques had a splashed textbook of anatomy propped open next to his old lady; he wore a skull cap of the kind favoured by Professor Charcot of the Salpêtrière hospital and paper sleeves over his shirt. He smoked powerful cheap cigars whose ash occasionally tumbled into the cavity. He thought this disrespectful, but had discovered, like other students, that it was the only way to tolerate the stench. The dozen bodies in the room were of different vintages, some having been retained by the supplying hospital for two or three days. Behind him, two cadavers had been prepared to show the workings of the nervous system, so that they looked, if he allowed himself to think so, like flayed martyrs.
He worked patiently but fast, because speed helped him to view the flesh as scientific material not as a person who, a few hours earlier, had had thoughts and a name. The professor of anatomy, a tall, enthusiastic man with a glittering eye, strode among the carcases and organs like a sculptor in a studio of his apprentices, nodding his approval over Jacques’s bench, pointing him to a previously prepared cadaver for purposes of comparison.
An impatient mop was shoved up against Jacques’s feet by Bernard, the porter, who swabbed the worst of the blood from the floor and collected the offcuts into a galvanised bucket. In the courtyard were stray dogs, rounded up and tied at the ankle in readiness for their own dissection; into their latticed cages, Bernard poked the contents of his bucket. The dogs snarled at him as they grabbed the human pieces.
Every medical man has been through this, thought Jacques, lighting another cigar: therefore I must not complain. Thomas cut up corpses in a filthy shed in Cambridge and I cannot allow him to outstrip me in our partnership; I must have done as much as he has when we come to share our knowledge.
So he cut on dextrously, with the fixed concentration he had first cultivated in the bedroom at Sainte Agnès. He could bear this bloody work. What he hated was when at last it was over and he staggered out into the Paris street, reeking, scalpel in one hand, textbook in the other; and, in the early darkness of the winter afternoon, he could just make out the look of distaste on the ladies he brushed past. Assaulted by the smell of his drenched clothes, they shrank back from what they took to be an ostler or a butcher’s boy.
Thomas, meanwhile, was told by Faverill that a room had been prepared for him on the second floor, and he went up the stone steps of the western belltower two at a time. His new lodging had a window overlooking the downs to the south, a gas lamp bracket and a washstand with an enamel basin; there was also a bookcase where he could at last set out not only the registers and records on which he was working, but the medical texts he had had sent on from Torrington. If only the room had been a little warmer, he might have felt almost at home, but the system of iron pipes that carried steam through the lower floors had not been extended to the upstairs parts of the asylum, and he was dependent on one bucket of coal a day, delivered after breakfast by a melancholic called Stevens.
That evening, Thomas took a taper from the mantelpiece and lit the splintered kindling in the grate; he knelt down and blew gently until he inhaled the sweetly acrid smell of the coals first catching. He stood and rubbed his hands, then moved over to the tea-chest and started to unpack. He was proud of the number and variety of the volumes he had acquired; they were in French, German and Italian as well as in English, and he had paid for them by working at often uncongenial tasks. The books he piled onto the threadbare rug represented, he believed, everything that was known about madness.
The history of the subject was shameful and brief. There had been the dark ages, when wandering idiots were mocked or pilloried; there had been the superstitious centuries when people spoke of‘possession’and other devilish nonsense; then there had been the era of cruelty, of imprisonment and taunting, when the idle sane paid to make faces at the lunatics. This had turned into the era of ‘restraint’, earlier in the century, when the gathering of many mentally afflicted people in one place for the first time had necessitated the use of manacles, irons and straitwaistcoats. Even before such practices had become widespread, however, they were starting also to become obsolete under the influence of enlightened thinkers, some medical men and some, like the famous Mr Tuke of the York Retreat, laymen of humane and philanthropic vision. This was, in Thomas’s view, the true beginning of his medical discipline.
It was curious, he had to admit, that the first medicine was not a herbal preparation or a surgical procedure, but simple kindness; odd, because the struggle of the pioneering mad-doctors had always been to establish that illness of the mind was organic, a physical malfunction, to be treated in the same way as an illness of the liver or the foot, the brain being just such an organ, entirely comparable to the others – if more complicated. Yet one did not treat cirrhosis or a broken metatarsal with kindness, so here was a paradox. It was one that Thomas could explain to himself, however. Morally, it was right to grant gentle care to the sick; practically, if a cure worked (and private asylums of France and England had had some successes) then a doctor was obliged to use it. And medically, the use of sympathy and concern was not the primary but only the auxiliary treatment specific to this illness. To the patient with the broken tibia you gave a pair of crutches; to the one with the abscess, you gave a bandage, but surgery came before the crutch or dressing. Kindness to the lunatic was like the support or bandage; the odd thing about psychiatry, he had once explained to Sonia, was that its cart had come before its horse: its task was now to discover its primary treatments, the cures of surgeon or apothecary.
The bookcase had two long shelves, and on the top one Thomas placed, in approximate chronological order, the works of his century that he believed could be taken together to show a consensus of quickening advance. On Insanity, by a Florentine called Vincenzio Chiarugi, was strictly of the previous century, but Chiarugi’s argument, that an asylum might in itself be therapeutic, seemed in spirit to belong to the modern era. Thomas, in any case, was fond of the three-volume edition he had bought from a barrow in Rome, because it was the only Italian book he had ever managed to read to the end.
Next to Chiarugi, he placed a copy of Johann Reil’s Rhapsodies of the Psychological Method of Cure in Mental Alienation, the first book, as far as he knew, to have stated that madness was not a supernatural visitation, but an affliction of the tissues of the brain, in a way that pneumonia is an ailment of the lung, no less physical for being invisible. Next to that he placed Traité médico-philosophique sur l’aliénation mentale by the Frenchman Philippe Pinel, who was known even to the dreamy undergraduates in Thomas’s lectures as the man who ‘struck the chains from the lunatics’ at the Bicêtre hospital and the Salpêtrière in Paris. Thomas’s professor had pointed out that Pinel had in fact replaced the chains with straitjackets and that his real contribution was to have believed that lunatics with periods of lucidity were curable.
In any event, there was something else Pinel had written that was of particular interest to Thomas because it seemed to have a bearing on the plight of Jacques’s brother, Olivier. Pinel had noticed a particular group of symptoms that first afflicted young people, between puberty and adulthood; he seemed to have sensed, without stating it clearly, that this might be a distinct disease entity, and Thomas was convinced by what he had seen in the asylum that a large number of patients, particularly those demented and hearing voices, were suffering from what – for lack of any other term – he and Jacques had come to call ‘Olivier’s disease’.
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sp; On this point, Thomas was also excited by the writing of an English alienist, John Haslam, a medical officer at Bethlem. In Observations on Insanity, Haslam reported how he carried out post-mortem inspections of twenty-nine Bethlem inmates and found that the lateral ventricles of the brain were noticeably larger than normal; he filled them with measured spoonfuls of water to prove it. If such physical phenomena could be shown by a teaspoon and a naked eye, Thomas thought, what might more advanced techniques not show? What, indeed, did Olivier’s brain look like?
Had Sonia been able to see the care and respect with which Thomas shelved his small library, her anxieties for him might have been allayed. His own mind had been so inflamed by enthusiasm that he was almost immune to weariness; he felt the pity of what he saw about him in the asylum, but it did not touch him with despair; it inspired him: the slavering, the shouting and the shipwreck drove him on. Next to Haslam, he placed the three volumes of Des maladies mentales, published by Pinel’s pupil, Jean-Etienne Esquirol, in 1838. Esquirol had become master of the asylum at Charenton, a place of cultivated gardens, billiards, dancing parties, tender nursing and something approaching douceur de vivre, from which patients had been sent home cured. Here, just outside Paris, the rising arc of enlightenment had seemed most exuberant.
Next to Esquirol, in the middle of the shelf, in a place of honour, Thomas placed Die Pathologie und Therapie der psychischen Krankheiten, the book most admired by the other alienists he had met. Its author, Wilhelm Griesinger, was a physician who insisted that, since lunatics suffered from a disease of the body in nerve and brain, psychiatry must become part of medicine as a whole. The training he devised bore out his belief: one of his student psychiatrists was instructed, in mid-tuition, to intervene in a complicated labour causing concern in the obstetric ward next to the lecture hall. Thomas had read Griesinger in Heidelberg; even with dictionaries to hand, he found the prose extremely difficult to understand, but all the students he had met in Germany knew by heart Griesinger’s battle cry that psychiatry must emerge from its hermetic life as a kind of guild and become an integral part of medicine. Thomas was considerably irritated to discover, on his return home, that the book had been translated into English more than a decade earlier.
These were his heroes, respectfully shelved; but now psychiatry was in need of a new one. While he sincerely believed that there was a rapid increase of knowledge and a growing consensus of the wise, it had to be admitted that there was an insidious and growing counter-movement. The setting-up of public asylums in France and Britain had brought welcome seclusion to many and had ended the use of chains and irons; but before long the huge buildings had come to falter under the mounting weight of numbers – from the jabbering multitude for ever at the gates. The trouble was that although the pioneering writers had humanely and beautifully described the problem, they had not found any cures. While Griesinger and the scholars scratched their heads, while they pored over corpses on the slabs, observed their patients and puzzled at the wondrous meeting of thought with cell, there came into being an alternative philosophy whose main tenet was simple: in the absence of cures, there can only be management. Such a brutal belief naturally did not need volumes to articulate itself, Thomas thought, because it found its purest expression in McLeish’s bookless shelves.
The last volume he put away epitomised the urgent need for rapid advance. The Physiology and Pathology of Mind by Henry Maudsley argued that lunacy was passed on from generation to generation; that characteristics not only inborn but acquired by a parent could be transmitted to a child and that the mentally ill were therefore part of a process called ‘degeneration’. As such, they were to be viewed as a waste product of healthy evolution and were fit only for excretion. Maudsley doubted whether asylums helped to cure patients and pointed out that many became better only when they were released; he thought sedation by narcotics not much better than imprisonment by ball and chain, and concluded that psychiatrists were well advised merely to watch and learn until such time as they were in possession of more information about their subject.
Maudsley was right about the need for further observation, Thomas thought, the need to study the whole length of a disease from childhood to post-mortem; but such work needed time, and time was what a medical officer in a giant asylum never had. On the contrary, he had to rush and grasp at any evidence he could find in the rooms that opened off the reeking corridor. What laboratory conditions, Thomas thought. What carnival of delusion and inconsequence. What temptation to despair. A symptom that occurred in two people might be the central diagnostic point of the illness in one, and incidental in the other. Without time, though, how would he ever tell?
He relied on certain facts and insights provided by the authorities whose books he treasured and, to support them, he depended, to an extent he admitted was undesirable, on instinct. In the confusion and the headache, there were patterns, he was sure, and he could occasionally see them. There was, for a start, such a thing as Olivier’s disease. He could predict how those afflicted by it would behave and report their symptoms; therewere common, recurring factors that gave it a profound identity. A young German called Kahlbaum had also noticed the group of symptoms and called it ‘hebephrenia’, or young madness. How it was to be cured, though, he could not say.
Then, thought Thomas, there was the case of the warship inventor, whose wife was such a friend of Gladstone and who daily expected a letter from the Queen. These symptoms were also predictable, consistent and apparently separable from other kinds of madness; they formed a stage in the general paralysis of the insane, which had been noted by Haslam and Esquirol many years before; some thought the source of the illness appeared to lie in youthful debauchery and use of prostitutes, and that it might be related to physical symptoms of syphilis earlier in life; but how it entered the mind was impossible to describe.
Thomas stood up and stretched. When he had committed himself to this life, he had been thrilled by the possibilities it offered: the chance to solve intractable problems, to bring relief to those afflicted and enlightenment to all mankind. The zeal remained – it had increased – but to it had been added, by his fuller understanding of where the science stood, a sense of urgency. If he and Jacques, and others like them, did not find solutions quickly, there was a chance that their work would be overwhelmed not only by the number of incurable patients but by the growing doctrines of despair within their own world.
Sonia’s father arrived early, grumbling about the fare of the hansom cab he had taken from St Pancras. Sonia kissed him warmly and took his travel-battered bag upstairs to the spare bedroom. In her absence, he looked about the scruffy hall, where a huge cobweb had been spun from the fanlight to the chandelier.
‘What happened to the maid?’ he said.
‘Abigail? We had to let her go. Come up to the drawing room and have some tea. I’ve got in some of that fruit cake you said you liked from the baker in Mount Street.’
In the absence of Richard, who was at his office, they were able to talk freely of the Midwinter family and its fortunes. Sonia’s mother was suffering from rheumatism and had had to give up hunting; Edgar was proving bullish and astute in the family business, to his father’s evident delight.
‘Yes,’ he said, ‘and little Lucy, what a treasure she is. Such a pretty little thing. And three grandchildren already.’
‘Yes,’ said Sonia, looking down.
‘I’m sorry, my dear, I didn’t mean to—’
‘No, no of course. Little Henry must be nine now, I suppose. How is he?’
‘Quite off his head,’ laughed Mr Midwinter. ‘And the twins. A merry little pair.’
‘Yes, I heard from Lucy that they are flourishing. She wrote to me a letter a few weeks ago. And Thomas, do you hear from him?’
‘Hmm,’ said Mr Midwinter. ‘Occasionally we have a rushed line or two from that confounded asylum. What about you?’
‘Yes, I have had two or three letters. He works such terrible long hours, from si
x in the morning until midnight some days, I believe. He seems happy in a Thomas-like way.’
‘I don’t know what possessed him to be a mad-doctor. Your mother and I dined at the Manor the other day and I was sitting next to a very distinguished lady. She asked me about my children and I told her what you all did. She gave me a very clear impression that she did not consider medicine to be on the same level as the church, or even the law. She said that the surgeon who had operated on her husband had been not quite a gentleman.’
Sonia laughed. ‘Nonsense, Papa. Thomas will make a great success of his life. You will see.’
‘Why is it that so many young medical men have to take unpaid work at the hospitals, then? What respectability is there in that?’
‘I think it is just while they make a name for themselves. I believe it is difficult to make a start in private practice without being known and without having some experience.’
‘And is that what he intends to do? Private practice?’
‘I believe so,’ said Sonia. She made no mention ofThomas’s intention of setting up with a penniless Frenchman in a foreign country.
‘But mad-doctors,’ said Mr Midwinter. ‘Everyone knows they are the hopeless ones. I read an article in the paper the other day by one of the most famous mad-doctors, I forget his name, and he said that a fully qualified young man who chose to work as an alienist must be either desperate for cash or so wealthy that he doesn’t mind the awful pay. He more or less admitted that it was not a proper branch of medicine.’
‘Well,’ said Sonia, ‘I think it is a fine and humane thing that he is doing. Now, let me take your teacup.’
‘Thank you, my dear. In the mean time, tell me about Mr Prendergast.’
‘Oh,’ said Sonia airily, setting down the china cup with a rattle. ‘He is very well, thank you. As always, he is looking for new investors. And knowing your generosity, he—’