Human Traces (28 page)

was careful to keep their private rooms separate from the life of the clinic, but even in the main house and the courtyard there was an atmosphere of something purposeful, something worthwhile being driven through by force of will and character. Sonia walked across the great flagged hall in the late morning and glanced at the closed doors of the twin consulting rooms, behind which the two men bent their minds to the great task they had set themselves; then she pushed open the door of the kitchen, to be greeted by a rush of steam as Frau Egger and her maids were working scarlet-faced among the clashing lids and cauldrons they were heaving from the range. Then she went beneath the stairs, through the rear doors, out along the cloister and into the tranquillity of the main courtyard, where one or two of the patients might be reading on the benches, sewing or walking up and down. She would make sure the early lunch was on time for the public patients in the North Hall, then circle the far end of the building and come round into the gardens in the west, where her favourite seat gave her a view up to the mountains. It was an old bench beneath a cedar, and the tree reminded her of Torrington, though the vista could not have been more different. At first the ground gave way, going down to meadows dotted with cows, then it rose and she could see yellow and pink wild flowers in the fields as they edged into spinneys and pale woods, then into evergreen forests that went up steeply towards the tops of the mountains with their permanently white peaks. She allowed herself twenty minutes with her book before returning to her duties, but sometimes, particularly in April and May, the prospect was so beguiling that she simply sat and stared. "I will lift up mine eyes unto the hills," she thought, settling back with a sigh of incredulity. She sometimes thought of Richard Prendergast, but it seemed long, long ago, and to have happened to someone strangely different from herself. Sonia measured time in spans of twenty-eight days. Most of the women patients, she knew, had irregularities, some of which Jacques appeared to be able to cure by placing the patient under hypnosis and suggesting to her that the next period would follow at the appointed time. Although she did not envy the women's unpredictable cycles, nor the deeper illnesses of which they might be a symptom, she did resent the clockwork arrival of her own pains, followed exactly thirty-six hours later by bleeding. She tried everything she could think of to become pregnant, once waking Jacques from a deep slumber when she thought she felt the egg drop inside the fallopian tube; but whether she tried at the most propitious time, a little before it, a little after it, once or many times, or even, perversely, when it seemed impossible, it made no difference: after twenty-eight days came bright, healthy blood as punctual and predictable as the postman who bicycled up the drive at precisely five to eight each morning. Eleven more such intervals, an autumn and a winter, went by before Jacques declared that he was ready to read his paper, which he had entitled "Psychophysical Resolution: a Proposed Curé for Hysteria and the Neuroses. A Paper read by Dr. Jacques Rebière to a Select Audience at the Schloss Seeblick, Carinthia, April 18, 1892'. He had not had time to visit Paris, but had sent a draught of his paper to his former colleague Pierre Janet at the Salpetriere who had responded in encouraging terms. They sent out invitations to the local newspapers and to medical colleagues at the hospital and in the surrounding area; they asked all the professionals and tradesmen with whom they had done business and representatives of all the institutions who had sent them patients or whom they had first approached through the register in the city public library. The patients were asked if they would like to invite members of their family and it was hinted to them that their own attendance was expected; at least, dinner would be late that night and there would be nothing else to do until the talk was given. Jacques spent the days before it going over his notes again and again, practising his delivery. He tried to model himself on Charcot, but found that his own voice was more expressive, with natural rhetorical emphases and changes of pace. He justified this to himself by thinking that his audience, unlike Charcot's, would not be comprised of medical people, but largely of laymen and their wives who would need all the help he could give them. It was a warm spring day, and at half past five he went up to his apartment to change into his best suit. Sonia looked flushed and excited when he emerged from his dressing room. She handed him a glass of water and straightened his tie. "Are you all right, my love?" He smiled. "I think so. I feel... Quite detached. I have put so much work and thought into this that now I feel resigned. It is like a bird, and either it will fly or it will not. It really needs no more help from me now. The time when I could affect it is past." She looked into his dark eyes and she saw that what he said was not true; they were filled with effortful hope and anxiety. In the bright light of the upstairs sitting room, she felt time stop for a moment to draw breath: Jacques glanced at his watch, she heard the front door open to more visitors and the crunch of horses' hooves on the gravel outside. The comic busyness of their lives rushed on all about them, but in the eyes of her husband she saw that this was the moment: there, behind the irises, was all that ambition and desire that had kept him reading through the night and now, on this soft spring evening, there could be no avoiding the fact that this was the hour on which his life's work hitherto depended and that -whatever the distracting domestic details, however much they each pretended otherwise such moments in a man's life were few. Jacques poured two glasses of Madeira from a decanter on the sideboard. He raised his own glass to Sonia, drank it off in one gulp and said, "It is time to go." They walked downstairs and Sonia took his arm as they went down the cloister, across the courtyard and into the North Hall. He had the look of a condemned man, she thought, as she released him to take her own place. There were a hundred and fifty people in the hall, perhaps two dozen with a knowledge of medicine, the rest with little more to guide them than a high school education, and some with less than that. Jacques caught Thomas's encouraging and humorous look as he showed the last of the visitors to their seats. He climbed on to a small platform that Josef had put together that morning and poured a glass of water from the jug that stood on a little table alongside. He coughed once, and began. "Ladies and gentlemen, I have a new theory to put to you tonight. It concerns the way the mind functions. I believe that by studying certain illnesses and their treatments I have been able to deduce something that may be of universal relevance to mankind and to our understanding of what it is to be human. It is the dream of all scientists to stand up and proclaim a great discovery; the greatest dream of all is to say: "I have a unified theory which explains everything, a single key that can unlock all the mysteries of being." "How do I dare make such a claim? I explain what must look like immodesty by saying that I have contributed almost nothing of originality to this discovery myself. All I have done is look at the work of others and put it together in a new way. I have read some books many books and I have observed some patients, alive and dead. That is all. "The greatest doctor of our time is Professor Charcot of the Salpetriere Hospital in Paris. As you will doubtless know, he described many complex illnesses which had previously defeated his colleagues, such as multiple sclerosis, for instance. Rightly is he viewed as the Napoleon of the medical sciences, the pre-eminent doctor of Europe. When I and my colleague Dr. Midwinter had the fortune to study under Professor Charcot some years ago, he was engaged in unravelling the mysteries of a most prevalent and distressing condition: hysteria. I do not intend to recapitulate Charcot's findings tonight. You may well look them up for yourselves; a series of his famous Tuesday Lessons was recently trans lated into German. I wish to concentrate on one aspect only of what Charcot discovered. "The classic symptoms of hysteria are of a fourfold seizure. This is seldom seen. All medical students are familiar with the problem of finding "pure" examples of diseases: even a simple affliction such as pneumonia rarely presents in a pure form because it is usually complicated, especially in elderly patients, by other ailments of the lung. This need not detain us. Symptoms of hysteria such as we generally encounter it may include paralysis, usually "hemiplegia", which is paralysis of one side of the body; contractu res in which a limb or joint becomes rigid; assorted abdominal or other muscular pains; tremors and standard neurological signs such as speech and ocular disturbance; amenorrhoea and related menstrual problems as well as headache, anxiety, sleeplessness and symptoms of what one might term a more psychological nature. "A woman is predisposed to be an hysteric by inheritance; the physiological disturbance is often activated by a malfunction of the womb or ovaries. In all these ways it is a standard neurological illness, in which a lesion which you may wish to imagine as a minute wound or blister caused by the localised death or infection of a small number of cells in the brain or spinal cord affects the nerves that radiate from that point. Thus a lesion in the part of the brain responsible for the movement of the right foot would affect that remote organ. The site of the lesion in hysteria has not yet been found, and in this case it is like Parkinson's disease, awaiting a complete description from what we might call both ends of the process: basic cause and outlying effect. "However, Charcot has proposed that the lesion in hysteria may be what is called a "dynamic" lesion. I think that some people would understand by that word that it moves; that (as in oedema, commonly known as dropsy, or in anaemia) it is an organic, or physical, lesion that proves transitory. "However, my former colleague Pierre Janet, of whom I shall speak more in a minute, a doctor at the Salpetriere, has pointed out that hysterical paralyses do not follow the proper paths of innervation. Experiments at that hospital showed that there is a fundamental difference between organic and hysterical paralyses. An hysterical paralysis of the arm is not only more acute, it is more confined; it does not spread through the connective nerve pathways. A complete organic paralysis of the arm is rare, but when a paralysis reaches that stage of severity it will naturally spread to a greater or lesser extent through the adjacent systems. "It is as though hysteria does not recognise how the body's nervous system is connected. That is why Monsieur Janet believes and so do I that the hysterical lesion exists completely independent of the standard anatomy of the nervous system. "Where? This is one of the key questions. Janet argues, and I am with him, that hysteria's apparent "ignorance" of the nervous system is not a problem but is in fact the clue to the nature of the dynamic lesion. The lesion in fact consists of a loss of the idea, of the very conception of the affected part of the body. A woman with hysterical paralysis of the arm has, at some level of her brain's consciousness, lost her idea of the arm as an integrated part of her anatomy. The reason she has done so is because of the severity of the associated trauma or memory: the greater the emotional content, the more completely will the affected part of the anatomy be removed from the normal sense of the body's integrity. And whilst in organic paralysis you would look for a lesion in the corresponding motor zone of the brain responsible for the arm, in hysterical paralysis you might look for an event whose traumatic impact was not through the complex innervation of the system but on the very arm itself. "Professor Charcot discovered that hysteria was not confined to women, but that men could suffer from it too. In their case, of course, the ovarian influence was absent, though the male body may have zones equally "hysterogenic" or capable of activating the hysterical inheritance. The English neurologists Brodie and Reynolds had written about "paralysis by idea", often following an accident and hence termed "railway spine", but were not able to show how such a process worked. That discovery was left to Charcot. Most male hysterics suffer from an accident or trauma, the impact of which they did not fully assimilate at the time. As a consequence, it was held out of the normal mental processes and lay dormant, stored as a latent energy in the brain. Eventually, when it reached a certain stage of what one might call toxicity, it released its noxious effect into the physiology of the patient's nervous system, causing contractu res and paralyses of the kind so typical of the hysteric. Again, I refer you to Professor Charcot for case studies of such men. "The influence of the womb is no longer considered as important as it once was; the influence of mental or emotional events, however, is now thought to be central in both female and male hysterics. Many doctors noticed that hysterics appeared to relive at some stage in their fits traumatic events from their past; Charcot was the first to suggest that such events might also have been the trigger in releasing their neuropathic heredity. He proved by experiments using hypnosis that there is a strong mental element in hysteria; he showed that physical paralysis or contracture can be induced by mental suggestion either that of the doctor, or, even more interestingly, that of the patient. Thus he proved conclusively that there exists a bridge between what used, in Descartes's day, to be thought of as the immaterial, thinking side of human life and the organic, physical side of it. "Charcot, however, did not conceive of it as a bridge because he did not accept Descartes's division; his explanation was to describe thought and emotion as the "physiology of the cortex", or to put it in layman's terms, the active, chemical employment of the brain. In that way, we do not need to see these two functions, the mental and the physical, as separated by a gulf. There exist neurophysiolog-ical mechanisms by which a memory or a trauma may be held out of the normal functioning of the brain. These mechanisms prevent it from being positively remembered, dealt with, laughed at or wept over. As such, it exists as an undischarged energy which may wreak havoc with the economy of the nervous system. "Charcot described it thus: "An idea, a coherent group of
associated ideas, settle themselves in the fashion of parasites, remaining isolated from the rest of the mind and expressing themselves outwardly through corresponding motor phenomena..." Only three years ago, in 1889, Pierre Janet echoed him: "The idea, like a virus, develops in a corner of the personality inaccessible to the subject, works subconsciously, and brings about all disorders of hysteria and mental disease." "We do not have as yet either the chemical knowledge or the optical instruments sufficient to describe these neuro physiological mechanisms, but that is no reason to suppose that they do not exist. When William Harvey first described the circulation of the blood, he could not identify the vessels which carried it from artery to vein and was consequently mocked by some of his contemporaries; shortly after his death, the capillaries were observed by the Italian anatomist Malpighi, and Harvey was vindicated. "Now, the precise nature of this dynamic lesion may as yet be unclear to us, but we may without fear of accident adopt the phrase used by Janet for its location: the "subconscious". That is where this bundle of unassimilated energy is held, at first dormant, then morbidly active. Some of you may be aware of the existence of something called "brain mythology", a doubtful procedure, I think, in which certain doctors have tried to explain brain functions by inventing psychological analogies of how the brain might work, then searching for such actual systems under the microscope. I do not believe this is scientific. It is one thing to say as Harvey did, "This is how the blood circulates, and a stronger lens will find the missing connection", because he started with arteries and veins and a knowledge of how they functioned. It is quite another thing to begin with nothing verifiable at all, then create hypothetical structures in one discipline and search hopefully for them in another. The reason that Monsieur Janet's idea of the subconscious is acceptable is that it is happily understood by Charcot's notion of thought as the physiology of the cortex. We are crossing no anatomical, let alone Cartesian, divide. "If Monsieur Janet is right, and I am certain that he is, then my proposition is this: that we may extrapolate from the physiology of these unfortunate hysterics the existence of certain mechanisms which may ultimately explain the way that all human minds work not just the minds of those afflicted by this hereditary disease, but the minds of all of us, every man and woman in this hall. That is the nature of my discovery, ladies and gentlemen; that is what I wish to share with you tonight." Jacques stopped for some water, and looked over the row of faces in front of him. Because the progress of his logic was so familiar to him he had been able to spare some concentration to gauge his effect, and he had noticed the gratifying silence while he spoke. However, as he looked over the rim of his glass, his eye was caught by a matron, stout and flushed in a high-necked cream dress. She could not possibly have understood, he thought, and he decided to improvise a paragraph that would re-engage her attention. He smiled at her, and at those behind her, as he put down his notes for a moment. "Sometimes patients say to me, "Doctor, is my illness real or is it all in the mind?" And do you know how I respond? I laugh. I cannot answer the question because its premises are false. It is like being asked, "Is cheese more ambitious than brick?" The fact that a question can be phrased grammatically does not mean that it can be truthfully answered. "Things which exist in the mind are real and their very existence makes them so. The love we feel for our parents and our friends is real; the grief we feel if someone dies is real. The fact that we cannot see or touch it does not make it less real. The opposite of real is not "in the mind"; the opposite of "real" is "not real". "The opposite of "in the mind" is "in the body" up to a point. This boy has a broken arm; this boy has lost his parents. Both have "real" problems, one somatic and one mental. This third boy has dementia. His symptoms are mental, but their cause is somatic: a fault in the neurones of his brain, we believe, makes him hear voices; his illness is real enough you might say it is doubly real. To take the complete opposite: this man has suffered a coronary seizure, brought on in part by overwork. Our demented patient has mental symptoms of somatic origin; our coronary patient has somatic symptoms of mental origin. Both illnesses are only too "real". "So the opposite of "all in the mind" is not quite "all in the body", is it? Because the mind is the function of the brain, a bodily organ. In fact you could say, truthfully, "the mind is all in the body"I If this all seems a little too abstract for you, let me just remind you of some homely sights with which you are familiar. When your child is nervous, she may stammer; when she is ashamed, she blushes; when she is frightened, she trembles and her hands perspire. How easily the abstract emerges in the physical! From idea, through mind, into brain, into the nervous system, through a gland and out through the skin a thought made water! A pure idea that of fear produces liquid on the child's hands that you can lick or drink. We have heard of water into wine, but idea into water... Well, is that "real", or is that "all in the mind"? Do you now see that the question is false?" Jacques smiled and picked up his notes again. He would not repeat his little diversion when he read his paper to the psychiatrists of Vienna, but he hoped it had served to rekindle the interest of the stout lady to whom he had been speaking. "Before I share with you, ladies and gentlemen, the nature of my discovery, I would like to show you that what I am proposing is in medical terms not at all revolutionary. You may think it strange for a scientist who is claiming a new theory to say that it is not particularly original, but I believe my work has a better chance of being appreciated if I show how naturally it arises as a synthesis of the innovations and discoveries already in the public domain. "Let us take the hypnotists. The function of hypnosis in this century has been far greater than merely to illustrate the mental component in hysteria. You will be familiar with the name of Franz Anton Mesmer, who proposed that humans were joined to one another and to the heavens by an invisible fluid. Good health depended on the individual's having the right balance of this fluid, which could, by magnetism, be redistributed between different people. Mesmer's successor, the Marquis de Puysegur, was able by magnetism to introduce "artificial somnambulism" in patients, with good therapeutic results. The relevant state of mind was subsequently christened "hypnotism" by a physician from England called James Braid. Well, we know that there was no Mesmeric fluid as such and we no longer think magnets are of much use; but these people had discovered something important, and that was that the certain rapport which existed between magnetiser or hypnotist on one side and patient on the other could provide a path into the patient's unconscious mind. And all this is quite old history, as you see. "Hypnotism fell into disrepute until rescued by a doctor called Hippolyte Bernheim, who worked at Nancy, developing the techniques of his master, the physician Liebeault. I have studied under Bernheim myself and have witnessed at first hand his ability to hypnotise all but the most recalcitrant of subjects and have seen the therapeutic benefits that result. Patients have been able to disclose the root causes of their symptoms, to partake in their cure and even to foretell the day of its completion. "I have touched on Charcot's immense contribution already, particularly his distinction between, on the one hand, "dynamic" paralysis caused by hysteria, trauma or hypnotism and, on the other hand, "organic" paralyses caused by a static lesion of the nervous system. Charcot also distinguished organic from dynamic amnesia. In the first, memory is utterly lost; in the second, it can be recovered under hypnosis. The mechanism of this recovery is a serious consideration for us. In his famous lecture of 1882, Charcot reestablished the respectability of hypnotism, but he went further: he showed how "fixed ideas", held outside normal mental function, could be the base of certain neuroses. "All hypnotisers have been struck by what their process reveals about the working of the human mind in general. Two years ago, in Leipzig, Max Dessoir published a book called The Double Ego, which reflected the feeling that the mind appeared to be divided into conscious and unconscious parts. The latter was accessible only under hypnosis. Others believed the split went many ways and that we are all an assemblage, or chorus, of personalities. However, it is the split into two which intrigues Janet, and on which I am relying. A long time ago, in 1846, the leading psychologist Carl Gustav Carus wrote: "The key to the knowledge of the soul's conscious life lies in the realm of the unconscious." In Carus's view, psychology is the science of the soul's development from the unconscious to the conscious. Truly, ladies and gentlemen, I offer you nothing new: Carus wrote almost half a century ago. In 1869, Eduard von Hartmann s celebrated book Philosophy of the Unconscious saw a kind of universal unconscious as the lowest stratum, then a physiological unconscious which is at work in the evolution of all beings and last, at the highest level, a psychological unconscious which underlies your mental life and mine. "For decades the truth has been all about us. The work of such men as Fechner and Bachofen is in the library in the town. You may go and read it. Even the great Wilhelm Griesinger, who is known as the "somatic" psychiatrist because he insisted that mental illness is a bodily disease of the brain, was aware of the role of the unconscious. He wrote: "Almost all fixed ideas are essentially expressions of a frustration or a gratification of one's own emotional interest." And if Griesinger is not famous enough for you, there is always Nietzsche, who wrote about the mind's quantities of dynamic energy, and how the conflicting drives within it can inhibit or suppress desires, driving them down into what Janet calls the "subconscious". "The name of Janet comes happily at this point. He is not yet as famous as I am sure he will become, but I had the pleasure of knowing him when he began his work at the Salpetriere in 1889. Before that time he had practised as a doctor at Le Havre, and it was here that he made some astounding discoveries, the details of which were published by him three years ago in Paris. A nineteen-year-old girl called Marie was brought to him, apparently raving mad. She had hysteria with severe menstrual complications. Every month, she had contractu res of the arms and the muscles between the ribs; she had partial loss of feeling; she went blind in one eye and she vomited blood. Janet discovered that on the occasion of Marie's first menstruation at the age of thirteen, she had been so ashamed that she had plunged herself into a large barrel of freezing water to stop the bleeding. She did arrest the flow, but contracted a violent fever. Under hypnosis, Janet took Marie back to the age of thirteen, convinced her by suggestion that her menstruation had not been interrupted by the cold immersion but had painlessly completed its natural course. As for the blindness in Marie's left eye, this had arisen at the age of six, when she slept with a girl who had impetigo and subsequently contracted a partial anaesthesia of the left side of her own face. Janet took her back through hypnosis to the night in question, suggested that the other girl was quite well, without infection, and that Marie had passed a pleasant night asleep close to her. All of Marie's symptoms disappeared and her menstruation returned to normal. "Janet had further successes of this kind at the Salpetriere with a young woman called Marcelle, whom he helped to walk again by removing in reverse order the fixed ideas that had lodged hysterically in her mind and, only last year, with a patient of Charcot's called Madame D, whose complete amnesia he cured by making her relive the trauma that had caused it. Janet used Madame D's dreams to unearth her hidden memories; he also asked her to indulge in "automatic talking", whereby she said anything that came into her head. This is a development of "automatic writing" done by those under hypnosis and by spirit mediums. "Janet has many other compelling cases, but my time is short tonight. The important conclusion he drew is that "in the human mind nothing ever gets lost". A subconsciously fixed idea persists because it is a kind of congealed emotion of which the patient remains unaware, but which may lead to physical symptoms as extreme as paralysis. It is our task to find what has been mislaid, or hidden. The ways of finding it are many. Some of the symptoms one thinks of the girl Marie, with the arrested menstruation, vomiting blood appear to be symbolic. In the case of Madame D, it was her dreams that allowed Janet a window on to her unconscious. "In Vienna, the great neurologist Moritz Benedikt has recently described what he calls the "second life", by which he means the important existence of a secret life in many unwell people, which contains a "pathogenic secret", almost invariably of a sexual nature. He has given many examples of patients with hysterical symptoms, almost all of them women, who have been rapidly cured by confessing their secrets. The interesting point about Benedikt is that he has always claimed, since 1864, that hysteria does not depend on organic disorders. He has presented four cases of male hysterics with no heredity and no physical trauma or accident. He contends that the root of their problem is mistreatment in childhood. This is very important. "Do you see where we are going, ladies and gentlemen? I hope so, because we have almost arrived. I hope also that I have not wearied you with the mention of so many names and the descriptions of what these men discovered or believed. They may sound strange to you, but to me they are as well-known as the names of my old classmates at school; their work is as familiar to me as the unformed handwriting of those little boys long ago. I have mentioned so many only to assure you that what I am proposing is firmly based on work already published. "Before I conclude, I would like to tell you very briefly why I believe the study and interpretation of dreams may be one of the most powerful weapons in our new cures of madness and distress. First, I must make a small confession. It was a dream of my own, a remarkable one, that first led me to wonder whether there might be some therapeutic value in the analysis of dreams. I shall of