Jacques did as he was told, turning his face up to the sky above the cedar branches. Then he kissed Sonia’s forehead and her lips.
She smiled. ‘You look . . . I can’t describe it.’
‘I feel perplexed. I cannot believe that I should be so fortunate.’
‘It is real, Jacques. I promise you it is real. Will you sit out here a little with me now?’
‘I will sit out with you all night, my love.’
‘Good. But do not be disappointed if you hear no more nightingales.’
‘Why?’
‘I think that may have been a fancy of my overheated heart. I do not think we have nightingales in Lincolnshire. I am so sorry.’
VII
JACQUES WAS RUNNING up the rue de l’Ecole de Médecine with the taste of Madame Maurel’s stew reheated for breakfast still in his mouth. He dodged across the traffic of the Boulevard St Michel and into the straight line of the rue des Ecoles. He had fourteen minutes in which to make it to the amphitheatre for Professor Charcot’s lecture at the Salpêtrière, and he knew that the professor started on time whether the audience was assembled or not. The distinguished neurologist had left the church at a wedding because the bride – the daughter of a close friend – was late; he once closed the door to his private consulting room in the Boulevard St Germain and went to bed when his last patient had not arrived at the appointed time, even though the man had crossed the Atlantic for the appointment. Jacques jumped down into the horse droppings and the swill of grey water in the runnel that edged the pavement, as he dodged between the students, the idling matrons and the broad-shouldered tradesmen who blocked the way ahead. He had the whole flank of the Jardin des Plantes to negotiate before the great dome of the church of the Salpêtrière, gunmetal grey and glistening in the morning light, at last came into view.
He sprinted through the arch and over the gravelled walkways, where a few unfortunate women lolled on wooden benches beneath the plane trees. They were the jetsam. Up around him, behind the high windows of the long stone wards, was the ocean: the waves of gibbering infirmity, of twisted limbs and howling voices that had driven all before Charcot to despair. Successive doctors had called it an inferno, pandemonium, a Babel: an epitome of human wretchedness, after seeing which no one could talk again of God’s plan or man’s purpose. Here were people twisted into bodily contortions which, however outlandish they appeared, remained regrettably human, so that they could not be dismissed as an irrelevance. Over the centuries, it had been poorhouse, prison and asylum for the broke, the broken and the irredeemable, who were swept in off the streets as young women and discharged, at their affliction’s end, in a pauper’s coffin. Only Charcot had seen that, far from being God’s joke at the expense of mankind’s pathetic hope of dignity, the women represented a resource of medical study with no equal in the world, because nowhere else was it possible to scrutinise a disease throughout its length and then, on the post-mortem table, marry it to its precipitating lesion. So useless in their lives, the women were at last able, in the cross-sections of their brain and spinal cord, to donate something of interest to the existence that had failed them.
Jacques elbowed his way through the sightseers, journalists and hangers-on who lined the amphitheatre. He scrambled onto the raised benches and tried to still his noisy breathing as the audience of four hundred went quiet when, on the stroke of the clock, Charcot’s favoured assistants, led by his chief of clinic, Pierre Marie, then Joseph Babinski and Georges Gilles de la Tourette, walked silently onto the stage in their long white aprons. After a momentary pause, Charcot himself emerged, wearing a black frock coat and top hat, which he removed and placed carefully on a table behind him. He turned to look at his audience, unsmiling, unspeaking; his pale, clean-shaved face caught the light beneath the lank grey hair, swept back and hanging in a straight line over his collar, almost touching his shoulders. He looked for a moment like an older version of Abbé Henri, Jacques thought, then, when he stuck one hand between the buttons of his coat, like Napoleon. Jacques felt a shudder of excitement go through him: to be in the presence of genius was a transcendent experience, in the light of which the other moments of his life might be reviewed. He thought of his first frog.
Charcot spoke without rhetorical flourish, though this merely intensified the drama. ‘Ladies and gentlemen, I intend first to take some cases from the outpatients’ department that I have not seen before and to examine them. I shall share my thoughts with you as I do so. My purpose is threefold. I wish you to understand the difficulties that beset any “blind” diagnosis of a neurologic kind. Next, I want it to be clear to you that close visual scrutiny and steady observation are the keys to making a successful diagnosis. Finally, I want you to remember that it is the continuing contact with the patient and his symptoms that allows us to learn – much more than theories dreamed up in universities whose professors are far from the bedside of the unfortunate. In this respect I am a practical man, one might almost say Anglo-Saxon. Bring in the first patient, please.’
An old woman, trembling in her rags and shawls, was brought on, held at the elbow by Babinski and an elderly nurse, Mademoiselle Cottard. Charcot asked her to stretch out her hand, which had a tremor visible even to Jacques, who was close to the back of the raked seating on the ramp. Charcot asked questions about the duration of the symptoms and attached a metal clamp called a sphygmograph to the woman’s hand to measure the rate of the tremor. He asked her to undress so that the audience could see the extent to which her limbs were deformed; and in her grey under-linen, she made her way unsteadily to and fro across the stage. Jacques noticed the loss of flexion in the left ankle. A dialogue between doctor and patient ensued, though neither seemed to relish it, the woman reluctant to project her tremulous voice and Charcot preferring the evidence of his eyes: he stuck his face up close to hers, but refrained from touching her. Eventually, he asked her to replace her clothes and take a seat at the back of the stage for comparison with subsequent patients.
‘You will have noticed that the patient walks in a way wholly characteristic of her disease,’ said Charcot. ‘Like this.’ Carefully, but with precise mimicry, he walked back and forth across the stage; in his progress was exactly the mixture of spastic hesitancy and dragging determination shown by the old woman, who now sat quite still, apart from the trembling in her hands. One or two of the audience giggled at the niceness of the impersonation.
‘Listen,’ said Charcot. ‘You must listen as well as watch. The sound of the footsteps is important. The ataxic throws her legs and feet forward. The alcoholic bends his knees like a circus horse. If the ankle flexors are affected, as is the case with this patient, the foot is flaccid. As she walks, she bends the knee too much to compensate – like this. The thigh lifts more than it should, so that when she drops it, the toes hit the ground before the heel. So her step makes two sounds. Listen carefully. There. The ataxic, by contrast, has almost no flexion at the knee. He thrusts out his leg like this and his foot therefore makes only one sound. Look behind me.’
Electric lights in metal shades hung at intervals from the ceiling of the lecture hall, and there were brighter spotlights on the stage which illuminated charts and illustrations held on stands to which Charcot now pointed. ‘Some of my students will be familiar with the pattern of these footprints,’ he said. ‘Over the months, we have asked patients to dip their feet in ink, then walk on paper, My staff have drawn up these scale representations of the results.’ He took a long wooden pointer from the table next to his top hat and walked along the half dozen stands, pointing to the different patterns of footprints.
‘Parkinson’s’hesaid. ‘Locomotor ataxia. This is Sydenham’s chorea, something we encounter very often in the outpatients’ clinic. This is a rather unusual pattern. If Doctor Marie would just . . . Thank you. The larger pattern. That’s it.’
The assistants replaced all the different charts with a single sequence. From left to right, the blackened footprints of a human being tr
ailed life-size across the lit stage, their image preserved in ink and lit by the spotlights that Charcot’s white-aproned men trained on them. While Jacques was thrilled by the diagnostic brilliance of his older colleagues and the way that the described patterns repeated themselves so unfailingly in character, he was moved by the sense of something more profound. In the clangorous wards around them the epileptics frothed and screamed, thrashing their heads on the soiled floor; the hysterics mounted their bizarre performances, bending their bodies into rigid hoops while torrents of verbal filth poured from their mouth; but there in the quiet of the amphitheatre, the footprints of the wretched beings, abandoned by life and the world, left traces of their passage – a claim in ink that they had been something more than transients – and with it some fragile plea that those who followed after them were bound to try to understand their compromised existence.
Charcot resumed his position beneath the spotlight while two of his pupils set up a projector to show slides of examinations done in the pathology laboratory. It was whispered by critics among the sandy pathways of the Salpêtrière that Charcot’s ability in the lab (a dingy little room at the end of the cancer ward) was limited, and that most of the work was done by his intern Victor Cornil, who had studied in Berlin. However, Charcot was generous in acknowledging his assistant, while his own early drawings of the spinal cord in multiple sclerosis remained, in the eyes of Jacques and many other pupils, articles of absolute beauty. To the less knowledgeable of his amphitheatre audience, the very function of the new slide projector was a source of quite sufficient wonder.
In any event, the proof of the teacher’s greatness lay, beyond debate, in his siting of the lesions he now demonstrated. Whatever his shortcomings in histology, it was he who had unriddled the mysteries of the multiple sclerosis, amyotrophic sclerosis (now, indeed, known as Charcot’s disease) and other complicated afflictions, images of whose actual seat in the brain or spinal cord were projected on to a screen behind him.
There was nothing triumphant in Charcot’s manner of speaking, which remained clipped, reluctant and packed with meaning. No word escaped him that did not bend each syllable to work. ‘In Parkinson’s disease, long-established,’ he said, ‘we have a complete clinical picture of the symptom, but our microscopes and our best endeavours have yet to locate its lesion. Other conditions in this pregnant state include Huntington’s disease, epilepsy and hysteria. I have no doubt that in time we shall discover the lesion that initially affects the nerves in all these conditions. Science will provide more powerful means. Young men will supply a keener gaze. For the moment they remain what we might call a bridesmaid illness, one looking for a husband. This is not in any sense a less severe or less organic condition – a morning walk through the epileptic or hysteric ward will leave you in no doubt as to that. My procedure in this hospital, as most of you will know, is the clinical-anatomical method. The clinical part is provided by close observation of the patient’s symptoms, the anatomical by the subsequent inspection at post-mortem. Bridesmaid conditions, such as Parkinson’s and hysteria, are as yet lacking anatomical completion – though that completion is imminent.’
After Charcot had compared the symptoms of his outpatients and dismissed them, he progressed to the second part of the lecture, in which a variety of inpatients, previously selected by his heads of clinic and senior interns, were produced for the audience’s edification. Doctors Bournville and Richer left the stage to bring them in one by one, with the help of the faithful Mademoiselle Cottard, who had been at the Salpêtrière, it was said, since she was sixteen.
The patients came and went, Charcot demonstrating with their help the difference between pure and partial forms of a disease. Jacques settled himself on the hard bench and turned the pages of his notebook. The final patient to sidle into the spotlight was a woman unfamiliar to him. Since there were more than five thousand in the hospital, this was not in itself surprising; yet there were some patients who were known to offer such pure forms of their particular ailments, that it made them ideal for repeated teaching purposes. They tended to be younger, because older women developed complications from germs, habit and degeneration.
‘And finally,’ said Charcot, ‘we examine a case of one of the most commonly encountered diseases at the hospital: hysteria.’
The patient chosen to demonstrate hysteria was often a young woman with tumbling brown hair and large eyes called Blanche Wittmann; this patient was skinnier and paler than Blanche, with a focused, narrow gaze. Jacques felt a slight disappointment.
‘Hysteria, as you know,’ said Charcot, ‘was once thought of as an ailment only of the uterus. Indeed, that is how it gained its name, from the Greek word for the womb. I am not going to detain you with a history of the illness, however. Let us be content to state where our understanding currently sits. Hysteria is a bridesmaid, like Parkinson’s, though one of my distinguished colleagues will doubtless find its lesion within the next few years – or months. Hysterics suffer from fits similar to, but less severe than, those endured by epileptics. The classic attack has four parts which we shall shortly demonstrate to you. A predisposition to hysteria is inherited. In this respect, as in almost all the others, it is a standard neurological disorder. The fascination of hysteria, the aspect that makes it sui generis, is the way that it offers a bridge between the physical and mental functions of the patient.
‘Let me recap: a standard neurological illness. Lesion, nervous malfunction, motor disorder with hereditary predisposition. Yet we note also the persistence of some ovarian element. An hysterical attack can be arrested by a doctor applying pressure to the ovaries. An epileptic seizure cannot.’ Charcot held up his wooden pointer in a rare flourish. ‘Second distinction. In mid-seizure, many of these women appear to relive a traumatic event from their past. Third distinction: I believe it is possible that such a mental element may be not only retrospective but causal. It may in fact be a precipitating factor in the unlocking of the hereditary neural disposition.’
There was silence in the amphitheatre. Charcot spoke softly, yet abruptly. ‘Not quite such a standard illness, then. But we have more. In the course of an experiment with metallotherapy on hysterical patients, I became aware that the sites of pain and contracture could be moved about the body. This led me to experiment with hypnosis, from which I discovered that all hysterical patients can be hypnotised, whereas those who do not suffer from this condition can under no circumstances be hypnotised. When hysterics are under the influence of hypnosis, they can be made to act out a full and pure form of the hysterical attack, as my staff will now demonstrate.’
Charcot nodded to one of the aproned interns, who approached the hysterical woman and laid his hands on her eyes. A gong was sounded a few inches from her ear, and she quickly began to show signs of distress, clutching her throat, as though something was choking her. Dr Gilles de la Tourette stood to one side of her and Mlle Cottard to the other.
‘After the aura,’ said Charcot, ‘the premonition of the rising attack, comes the globus hystericus, the patient’s sensation that her uterus has risen in her abdomen and threatens to choke her. Next will come a sub-epileptic seizure. This is the first phase proper.’
The woman fell to the stage, tearing her blouse as she did so and beating her head on the boards. The doctors watched over her intently as she writhed and thrashed. Jacques noticed Richer, an artist as well as a neurologist, making rapid sketches. The woman stopped her writhing and raised herself on her back, supporting her weight on her feet and hands only.
‘The second phase,’ said Charcot. The woman held the position, her body in an arc with her belly thrust up at the peak of the semicircle, her breasts moving backwards and sideways over her thorax.
‘This acrobatic clownism,’ said Charcot, ‘requires considerable strength of the wrists and feet, far more than she would normally have. It will be followed by the striking of impassioned poses, as though the patient has seen someone she fears or hates. I should warn you that th
is is sometimes accompanied by profane language.’
At once the woman stood up, and held her arm over her eyes, as though scanning the horizon in terror. Then she rushed from one side of the stage to the other, pausing to hold a position of horror and dismay. Jacques was aware of a burbling vocalisation as she moved, which eventually became audible in a sort of masochism of the gutter, using language familiar to Jacques from his ward rounds but causing gasps from the audience. This finally gave way to a protracted delirium in which meaning was lost and the woman reverted to thrashing back and forth on the floor.
‘The final stage,’ said Charcot. He nodded to two of the interns who awoke the woman from hypnosis by rubbing her eyes and banging the gong loudly again in her ear. They then guided her to a chair, where she sat looking quietly bewildered.
‘And what do we deduce from this?’ said Charcot. ‘That this illness not only has a mental element, as I described before, but also an auto-suggestive element, as we have seen. Yet this woman is not mentally unwell; on the contrary, hysteria remains a classic neurological illness with a somatic base. Our main task is to locate its cerebro-spinal lesion, but I may say to you that the auxiliary task may turn out to be more challenging. And it is this: to determine the neural mechanisms by which trauma, thought and memory take over the motor functions of a patient to produce such symptoms of ataxia, contractures and so on. Hypnosis allows us to examine the course of an hystero-epileptic attack with the clarity normally reserved to the other end of our work – beneath the lights of the post-mortem laboratory. However, let us not forget that hysteria remains also an affliction of the ovaries.’
Charcot nodded to Richer and Bournville. ‘An attack may be triggered without hypnosis by a neurologist who knows the hysterogenic points.’ Bournville placed his hand on the woman’s naked ribs below her left breast and squeezed. At once, she began the first part of the cycle again, going into sub-epileptic seizure.
Human Traces Page 20