And crown thy good with brotherhood
From sea to shining sea!
14.
Alice James and Rheumatic Gout
. . . a lump I have had in one of my breasts for three months is a tumor. . . . This with a delicate embroidery of “the most distressing case of nervous hyperasthenia,” added to spinal neurosis that has taken me off my legs for seven years, with attacks of rheumatic gout in my stomach for the last twenty, ought to satisfy the most inflated pathologic vanity.
—Alice James (June 1, 1891)
IN NOVEMBER 1882, AFTER ONE OF MANY “NERVOUS” ATTACKS, Alice James (1850–1892) took to her bed in the Boston home of her father, Henry James, Sr. On the advice of her brother, Dr. William James, and after ten days of bed-ridden solitude, she agreed to consult one of her brother’s colleagues at Harvard Medical School, Dr. Henry Harris Aubrey Beach. Dr. Beach suspected that there was “something lying in back of her nervousness,” which coincided with her father’s terminal illness. After three weeks of investigations, he informed his patient that her malady was “gout, rheumatic gout!”
The diagnosis was relatively new on this side of the Atlantic, having been put on the medical map by A. B. Garrod of London in 1859. Beach, however, was a very up-to-date physician; he had taught anatomy under Dr. Oliver Wendell Holmes, held an appointment at Massachusetts General Hospital, and was an assistant editor of the Boston Medical and Surgical Journal (now the New England Journal of Medicine). Beach promised relief to his patient and, indeed, she was relieved to hear that her symptoms were due to something as physical as gout and not simply one more “fight between my body and my will.” But in December her father died; she again relapsed into general debility, muscle weakness, and depression. Eventually she placed herself in the Adams Nervine Asylum, where for several months she was treated with electrical stimulators, vapors, and the rest cure of Dr. S. Weir Mitchell. These measures were of little avail and, after a variety of other treatments for symptoms attributed to “spinal neurosis,” “nervous hyperaesthesia,” “neurasthenia,” or “suppressed gout,” she crossed the ocean to join her brother Henry in England.
In London Alice encountered one of the few physicians who could explain to her that rheumatic gout had little to do with her lifelong infirmity. Dr. Beach had arranged the consultation, assuring the Jameses that Sir Alfred Baring Garrod (1819–1907) was the only man who knew anything about “suppressed gout.” Beach was somewhat off the mark. Garrod, unquestionably the British authority on rheumatic complaints, thought that the term “suppressed gout” was gibberish. Today, Garrod is credited with turning the study of arthritis into the protoscience of rheumatology. At a public lecture on February 8, 1848, Garrod demonstrated that gout was due to a pile-up of uric acid in the blood and urine of the gouty, whereas there was no such increase in acute rheumatism (rheumatic fever). At the time, he was assistant physician at University College Hospital. Later, in 1854, he observed that linen strings dipped into the blood or urine of gouty patients became coated with visible crystals of uric acid. Garrod’s “string sign” was a milestone in clinical biochemistry; similar deposits of crystals in the joints are the direct cause of gouty inflammation. Garrod went on to distinguish gout from rheumatic fever and, by the time he saw Alice James, he had just plucked a new diagnostic entity, rheumatoid arthritis, from the vague grab bag of conditions called “rheumatic gout.” He wrote in his Treatise on Gout:
Although unwilling to add to the number of names, I cannot help expressing a desire that one may be found for the disease under consideration, not implying any necessary relation to gout or rheumatism. . . . I propose the term rheumatoid arthritis, by which name I wish to imply an inflammatory affection of the joints, not unlike rheumatism in some of its characters, but differing materially from it in its pathology.
Alice James reported that she had “spent the most affable hour of my life” with Garrod, who told her in 1885 that the weakness in her legs and her digestive complaints were functional and not “organic” in origin. But—as usual with her doctors—she soon became disenchanted. At the dawn of the Freudian age she complained:
I could get nothing out of him & he slipped thro’ my cramped & clinging grasp as skillfully as if his physical conformation had been that of an eel instead of a Dutch cheese—The gout he looks upon as a small part of my trouble, “it being complicated with an excessive nervous sensibility” but I could get no suggestions of any sort as to climate, baths, or diet from him. The truth was he was entirely puzzled about me and had not the manliness to say so.
Whether like an eel or a Dutch cheese in manly conformation, Garrod was sensible enough not to suggest changes in “climate, baths, or diet.” His patient suffered from no sort of gout known to him. Garrod was one of the first to draw clear distinctions between the common, heritable, and lead-induced varieties of gout. The lead-induced form, saturnine gout, had been rampant in the ruling classes of Europe since the sixteenth century and is caused by consumption of lead-contaminated spirits such as fortified wine or brandy. The disease took its greatest toll among the middle and upper classes, for the poor drank mainly gin and beer. Its epidemiology accounted for the notion of “the Honor of the Gout.” Since saturnine gout was due to nurture, not nature, Garrod and his contemporaries had a good notion of what to do for other forms of rheumatic complaints such as “rheumatic gout”: change nurture. Their well-off patients were packed off to take the cure at Bath or Leamington in England, or on the Continent, where a few weeks of lead-free water were expected to flush lead and uric acid out of their systems. Garrod so often prescribed hydrotherapy in Aix-les-Bains that today a street in the spa is named rue Sir Alfred Garrod. Garrod had seen enough patients like Alice James to conjecture that in the potpourri of conditions called rheumatic gout “there is much to show in its etiology and the distribution of the affected joints that is intimately connected with the nervous system.”
Garrod and Alice James had a familiar sort of doctor–patient tussle over her symptoms. He believed that her muscle aches and cramps were caused by the galvanic stimulator she had used for several years; she believed that the Indian hemp (cannabis) prescribed by Garrod had made her sick. She sought refuge with a Dr. Townsend, who informed her that she had a “gouty diathesis complicated by an abnormally sensitive nervous organization.” Finally, accompanied by her companion and a nurse, she took herself off to Royal Leamington Spa in 1889. She prepared to settle into the long, sessile routine of the invalid: Alice in Bed as legend (and the titles of two modern works) would have it. Clinging to the belief that while some of her symptoms might be those of rheumatic gout, she blamed the others on her own nervous temperament. “How well one had to be—to be ill!” she wrote in July 1890.
Nine months later, cancer struck, and by the spring of 1892, she was terminally ill:
I am being ground slowly on the grim grindstone of physical pain and on two nights I had almost asked for K’s lethal dose, but one steps hesitatingly along unaccustomed ways and endures from second to second.
The lethal dose would have been laudanum, and the K who dispensed it would have been Alice James’s faithful companion, Katharine Peabody Loring. A few days after that entry, Alice James was dead from metastatic cancer, killed by what she called “this unholy granite substance in my breast.”
She had known full well that this was something palpably different from the afflictions that brought her to Leamington:
To him who waits, all things come! My aspirations have been eccentric, but I cannot complain now that they have not been brilliantly fulfilled. Ever since I have been ill, I have longed and longed for some palpable disease, no matter how conventionally dreadful a label it might have. . . . It is entirely indecent to catalogue one’s self in this way, but I put it down in a scientific spirit to show that though I have no productive worth, I have a certain value as an indestructible quantity.
Indestructible she was not, but nevertheless she continued to produce in her journal an ind
estructible work of literature that ranks with those of her brothers. Discretion dictated that it appear eighteen years after Henry James’s death (1934) after passing in the family to the daughter of Robertson, youngest and frailest of the James brothers. The journal is a record of daily events, an almanac that condenses a decade, and a sharp text of self-knowledge. It had begun simply enough: “I think that if I get into the habit of writing a bit about what happens, or rather doesn’t happen, I may lose a little of the sense of loneliness and despair which abides by me.”
But soon she found her own style, in which social insight, cutting wit, and a good nose for literature mixed well with a bent for reform and a tendency to what her brother Henry called “passionate radicalism.” She was a sharp critic of conservative politics, a fan of Irish Home Rule and of Parnell. Hypocrisy outraged her:
What a spectacle, the Anglo-Saxon races addressing remonstrances to the Czar against expelling the Jews from Russia, at the very moment when their own governments are making laws to forbid their immigration.
She was also ahead of her time in sniffing out the cost of empire. She worried about an English class structure in which:
. . . the working man allows himself to be patted and legislated out of all independence; thus the profound ineradicables in the bone and the sinew conviction that outlying regions are their preserves, that they alone of human races massacre savages out of pure virtue. It would ill-become an American to reflect upon the treatment of aboriginal races; but I never heard it suggested that our hideous dealings with the Indians was brotherly love under the guise of pure cussedness.
After her tumor was diagnosed, the tone of her journal turned darker and the entries more confessional. She permitted herself at last to express openly her love for Katharine Loring. Loring was a competent, educated woman of Brahmin stock, of whom Alice James had written to Sara Darwin (Charles Darwin’s American daughter-in-law),
She has all the mere brute superiority which distinguishes man from woman combined with all the distinctively feminine virtues. There is nothing she cannot do from hewing wood and drawing water to driving run-away horses & educating all the women in North America.
Photographs show Katharine Loring as a tidy, angular woman: Alice B. Toklas as nurse and confidante. Loring had given up an active life to be with Alice James, shuttling between her own consumptive sister and the intermittently paralyzed Alice. In her last few months of life, the journal was no longer written by Alice James herself, but dictated to K. Alice James’s tribute at what she called “this mortuary moment” is therefore perhaps the more poignant:
. . . is it not wonderful that this unholy granite substance in my breast should be the soil propitious for the perfect flowering of Katharine’s unexampled genius for friendship and devotion. The story of her watchfulness, patience, and untiring resource, cannot be told by my feeble pen, but the pain and discomfort seem a feeble price to pay for all the happiness and peace with which she fills my days.
Reading Alice’s journal of disease and despair, a tableau comes to mind. It is set in a Kensington drawing room that might have been painted by John Singer Sargent, but the feeling is pure Edvard Munch. It is January 6, 1892, two months before her death, and Alice is racked by the jaundice of liver metastases. A photograph of the time shows Alice in her daybed; she is drawn and gaunt but has been dressed up and beribboned for the photographer. She sits stiffly propped on her cushions and appears pain-free for a while on morphine: the poppy is singing its song. She can no longer concentrate enough to write and dictates her journal entries to the beloved K. But K is by no means the only reader for whom these pensées are intended; she is also leaving a record for her brothers William and Henry.
Alice James contrasts the warm devotion of Katharine with the clinical cool of her doctors. Sir Andrew Clarke, who diagnosed that granite lump, is reprimanded for never quite being on time: he is of course the late Sir Andrew. But that eminent cancer specialist cannot help her; she is afraid that he is gripped by “impotent paralysis” and “talking by the hour without saying anything, while the longing, pallid victim stretches out a sickly tendril, hoping for some excrescence, a human wart, to catch on to . . . ” Alice James utters a cry from what John Keats called a “world of pains and troubles” to the world of her loftier brothers:
When will men pass from the illusion of the intellectual, limited to sapless reason, and bow to the intelligent, juicy with the succulent science of life?
Some day the science of life, biology, should be able to explain not only how tumor suppressor genes and hormones influence breast cancer, but also the lifelong affliction of souls as fragile as Alice James. The most convenient biological explanation is the genetic, and keepers of the Jamesian flame point to a striking cluster of nervous pathology in two generations of the family. Deep depression, hysterical paralyses, and sexual ambiguity seemed to run in the clan: father Henry suffered from a Swedenborgian “midnight vastation”; Henry, Jr., was accused by William of “coddled sensibilities” and “dorsal anguish”; William was paralyzed by “quivering fear.” Mental homes provided refuge for the “incommunicable sadness” of the youngest brother, Rob, and the “madness” of cousin Kitty.
William James, the loftiest of the brood, believed that the family carried a genetic load on its back. Using the spinal imagery of his day, he wrote to Rob, “I account it as a true crime against humanity for any one to run the probable risk of generating unhealthy offspring. For myself I have long since fully determined never to marry with any one . . . for this dorsal trouble is evidently s’thing in the blood.” Alice also alluded to a family serpent motif, writing for publication:
Dr. Tuckey [a mesmeric doctor, recommended by William] asked me the other day whether I had written for the press, I vehemently denied the imputation. How sad it is that the purely innocuous should always be supposed to have the trail of the family serpent upon them.
The family serpent was, of course, the double helix of depression and inspiration that ran through the James family, that “dorsal trouble . . . in the blood.” The dying Alice James dictated to K an account of a visit paid her years before by Charles Darwin’s daughter, Henrietta Litchfield. When Alice James told Mrs. Litchfield that her invalidism had for years been called “latent gout,” Mrs. Litchfield exclaimed, “Oh! that’s what we have [in our family], does it come from drink in your parents?” The Darwins, like the Jameses, were a clan of morose geniuses, scholars, and medics who seemed also to have had a family serpent in their blood. The Darwin biographies document a strong family history of depression, somatization reactions, and wives who took to their beds for decades; sure enough, much of this pathology was blamed on a “gouty diathesis.” Depression and inspiration were closely intertwined in the Darwin line, as closely—one might say—as the two dancing serpents on the crest of Darwin College, Cambridge.
While social explanations rival the genetic, biography can describe, but not explain, the flight into sickness. Jean Strouse’s authoritative biography was written before paired lives like those of Alice James and Katharine Loring were explored in the context of legal constraints and homophobia. Treating that subject by elision, Strouse argued plausibly that Alice James’s flight into disease was at least in part a not uncommon female strategy for coping with oppressive male society in general and her father’s expectations specifically. Strouse attributes some of Alice’s symptoms to a daughter’s reaction to a “kind father who had so blithely stimulated and thwarted her.” She quotes Alice James’s recollection of an acute early episode:
As I used to sit immovable reading in the library with waves of violent inclination suddenly invading my muscles taking some one of their myriad forms such as throwing myself out of the window, or knocking off the head of the benignant pater as he sat with his silver locks, writing at his table, it used to seem to me that the only difference between me and the insane was that I had not only all the horrors and suffering of insanity but the duties of doctor, nurse and strait-jack
et imposed upon me, too.
In retrospect, no one can blame with confidence either nature or nurture for Alice James’s life of infirmity and her unasked-for crucifixion, to use a phrase of Oliver Sacks’s. Nurture in the form of nineteenth-century medical practice was clearly responsible for the diagnoses pinned on Alice James in her lifetime: spinal irritation, neurasthenia, hysteria, suppressed gout, and so on. Medical practice also subjected her to electric prods, Indian hemp, spinal manipulation, and all those buckets of tepid spa water . . . “as if to be singed and scalded were a costly privilege and leeches were a luxury,” a phrase of Dr. Oliver Wendell Holmes.
Alice was one of many poor spirits who were flogged from pillar to post on the premise that their paralyses and palpitations were due to rebel humors in the spine; the tale of their prodding, buzzing, and poking has been told by the historian of our psychosomatic era, Edward Shorter. Those treatments were not simply an assault of male doctors on their spinally challenged female patients. The male version of hysteria was called hypochondriasis, and the paralyses it produced were also, willy-nilly, attributed to spinal irritation. Fresh from Harvard Medical School, Dr. William James advised Rob, the most nervous of the James brothers, to take iron, to exercise, and to apply iodine to his back until his skin peeled. The doctrine of counterirritation demanded the show of wounded flesh on the part of male and female patient alike. That doctrine remains a major feature of folk medicine the world over; Western medicine abandoned it when we gave up cupping.
In the end, her mother, Mary, knew what was wrong with Alice James: “It is a case of genuine hysteria for which no cause as yet can be discovered.” Alice herself awaited a new science of the mind. In her last letter to William, whose Principles of Psychology had just been published, she pleaded, “ . . . so when I’m gone, pray don’t think of me simply as a creature who might have been something else, had neurotic science been born.”
The Fevers of Reason Page 12