Human Traces (31 page)

Twelve

In the spring of the new year Thomas became uneasily aware of one of Jacques's patients, a fair-haired young woman, fashionably dressed, with a healthy, trim physique but a weary, troubled manner. He saw her walk rapidly from her room on the first floor above the courtyard through the cloister to the dining room and exchanged pleasantries with her as she passed by; she smiled and returned his greetings in a clear, soft voice, but there was something about her demeanour that troubled him. She appeared feverish, he thought; there were sometimes spots of colour in her cheeks. He noticed these when he saw her emerging from Jacques's room after a protracted consultation, but he was inclined to ascribe it to the rig ours of the interview: hysterical or neurotic patients were frequently embarrassed or upset by the content of what they had revealed. Thomas's misgivings, however, would not leave him. He found himself fascinated by this woman, with her agile movements that seemed to mask pain, her loose fair curls neatly held back from the skin of her face and the reading glasses she removed if she felt she was being watched in the courtyard or in the dining-room; he was intrigued by the way her expensive clothes seemed at odds with a rather studious manner. He was also anxious that she might be seriously unwell, and one morning brought up her case with Jacques. "Ah yes," he said. "Fraulein Katharina. She is a very fascinating problem, I think. She has made good progress and she will shortly be leaving us. I am writing up her case notes because I am hoping to read a paper to the autumn meeting of the Psychiatric Association in Vienna. I shall have to ask her permission of course and find another name for her. Why do you want to know?" "She intrigues me." "She is an intriguing woman. In some ways a textbook case of hysteria, I think, but with interesting complications." "I don't suppose you would allow me to read your case history?" "I was trying to pluck up the courage to ask you to do just that. I would value your opinion very much indeed. As soon as I have finished it, I shall pass it over." Thomas decided to ask Sonia if she knew any more about this Fraulein Katharina, but when he went up her apartment he could find no trace of her. Sonia was sitting in her favourite seat beneath the cedar tree, looking up to the mountains. The previous afternoon, she had gone into town on the pretext of visiting some tradesmen, but had made a secret visit to the gynaecologist, who had confirmed what she believed: that she was three months pregnant. At the age of thirty-seven, she felt it might be her last chance. The doctor assured her that he could see no reason why she should miscarry a second time, but did urge her to rest each morning for as long as she could. Sheepishly, because she was worried that Jacques might think her idle, she explained to him what the gynaecologist had said. "And the reason I must rest, my love," she said, 'is that I am expecting a child." She watched his dark eyes carefully as she broke the news, and she saw tears rise up the iris, tremble on the lower lid, then run in two unchecked lines down his cheeks. He reached out his arms and held her close to his chest, with a comically exaggerated care, as though already aware of a third person between them. He made her undress and lie down on the bed, so that he could run his hand over her belly and kiss it. Sonia looked down from the pillows. "How big is he now, do you think?" Jacques bent his thumb in half and pointed to the top joint. "About this long, I think. He has a head and limbs. A large head, small arms and legs." "Does he have a brain?" "Not much yet." "Oh dear, do you think he is a simpleton?" "No, I think he will take after his mother." "Stop it. What else can you tell me about him?" "He is sleeping a lot. He is very warm and happy in there." "Oh, I love him so much, don't you?" Jacques laughed. "I mean it," said Sonia. "He is a perfect sweetheart." "Will he be English or French?" "I don't know. Ask him." Jacques placed his lips on Sonia's belly and spoke in German, then French, then English; then he put his ear to the skin, where a thin brown pigmentation was already starting to make a line. "He says he is an Englishman because he loves his mother best." "Good boy. What a charmer. And what does he like doing?" "He likes sleeping. Wait a minute. I'll ask him. He says he would like to play cricket." "I feel I know him already' said Sonia. She grew suddenly serious. "I have known him all my life, since I was a child. He has been there since before I was born." She began at once to cry, the sobs taking over her body, as she came to see the enormity of what she said, of this life about to happen, something eternal, returning from a land unknown. Thomas had to be told the news, so that he would know why Sonia was resting on her bed in the morning rather than working in the office. He was moved by her happiness, and his own; he felt that Sonia's life might now move on towards its appointed purpose and fulfilment. That evening, when his last consultation was over, he swivelled his desk chair round and put his feet up on the windowsill, so that he could look out over the lawn. It was a pity his father was not alive to see Sonia's child, he thought, to see how she had redeemed her fortunes. There was a knock on the door. "There you are, Thomas," said Jacques. "I have been looking for you. My paper on Fraulein Katharina. I finished it last night and I need to send it off before the end of the week. Do you think you might have ten minutes to glance through it?" "I shall do it now." "Bear in mind that it's only a draught. I have written it in German and have tried to give it a fairly authoritative tone for the benefit of the audience." "I understand," said Thomas. "I shall not expect to hear your own Breton voice in it." "No. Though the science and the resolution are certainly mine. It's on the blotter on my desk. It is held together with a pin." Jacques's consulting room had a faint odour of cigars from the indulgence he allowed himself each evening when the last patient had gone. There was a large blue and white pot full of hydrangeas on a windowsill and a vase of cut flowers on the desk. The bookshelves were lined with the astonishing extent of his German and French reading, much of it in cheap or second-hand editions, but the shredding rug on the oak boards managed to give the room a homely rather than intimidating feel. Thomas took the pinned papers from the desk, went over to the window and pushed back the folded wooden shutter so the light fell across his shoulder as he began to read.

FRAULEIN KATHARINA VON A

In the early summer of 189, a patient was referred to me by a physician in private practice in Vienna. A young woman, aged twenty-five years, Fraulein Katharina von A had been complaining for some time of severe lower abdominal pain, accompanied by infrequent vomiting. She had been wrongly diagnosed by a doctor in Vienna as suffering from uterine fibroids, when she was too young for such a condition typically to have developed and had experienced no increase in menstrual flow; in fact, as later became apparent under more careful examination, she had suffered an intermittent amenorrhoea. Fraulein Katharina gave the impression on first meeting of being a young person of outstanding character. Her father was a businessman of considerable means, and Katharina had passed an apparently uneventful childhood in the company of her younger brother and sister, to whom she appeared tenderly devoted; indeed, in speaking of her family, and in particular of her father, she invariably displayed a most natural and pleasing affection. Her mother was English, though had spent a great deal of her own youth in Ceylon, where her father worked as a tea planter; she had met and married Herr von A in London in 1869, and Katharina was born the following year in Vienna, where the family retained a house even when the father's work necessitated their temporary removal to Hanover and to the Baltic states. Of a little above average height and with a fair colouring characteristic of her Prussian and English descent, on her first visit to my consulting rooms Fraulein Katharina in many ways presented a picture of youthful vigour. On a close visual examination, I found the epidermis to be fine, with a scattering of reddish-brown maculae on legs, arms and lower back, typical in one of such colouring; the areolae were unusually thin, barely discrete in texture from the surrounding skin. She informed me that she had practised archery as a hobby, and the effects of the sport were visible in a somewhat enlarged brachialis of the right arm and a firmness of the extensor and flexor muscles. She had recently been on a walking holiday in the Eastern Alps, where she had climbed in the Hohe Tauern range, at heights of more than two thousand metres. There was a minor development in the adduct or and quadriceps; the pelvis appeared fairly narrow and there was no excess tissue on the gluteus maximus. The patient spoke with a soft but clear voice; it was apparent from the first consultation that she was a person of considerable education and self-possession. However, in addition to lower abdominal pain, she reported chronic joint pain in the shoulders, elbows and fingers. She had also suffered a form of spasm in the shoulders, and, on infrequent occasions, in the hips and face: the symptoms she described were similar to those found in Sydenham's chorea, though she said they recurred less and less often and was inclined to treat them as a closed episode. The pains in her joints had been attributed by her family physician to an excess of secretarial work undertaken for her father, whose failing health had obliged him to work more and more from the family house in an affluent part of Vienna instead of going into his company's office. I was not initially in a position to confirm or reject this diagnosis, but I did note that she reported that the pains recurred regardless of whether or not she had been working at her desk; and that the amount of secretarial work she was obliged to do had dramatically diminished, for the simple reason that her father had recently died of an infection of the heart. Since the age of seventeen, Fraulein Katharina had suffered from right-sided occipital headaches, though she had been largely cured of these by an oculist in Vienna, who diagnosed a moderately severe astigmatism, a common abnormality of vision from which her father also suffered. Katharina wore small, silver-rimmed glasses for close work of any kind. She assured me that she only needed them if she was required to concentrate her eyesight for any length of time; indeed, she exhibited some aversion to wearing them, but I attributed this to feminine vanity, she being in other respects a manifestly modest and serious-minded young woman. She still suffered from stinging in the eyes if she was tired or upset, regardless of whether or not she had been using her reading-glasses. Her eyes in other respects appeared normal when I tested for diplopia and the Argyll Robertson sign. Her health as a child had generally been good, though she had had a tendency to infections of the throat, which had caused her to lose many weeks at school. At the time of our first consultation, she had a minor irregularity of the pulse and her temperature was elevated a degree above normal. This she attributed to a mild chill she had caught in the coach on the way to the sanatorium, and since the pyrex ia was absent on our second meeting, I was inclined to accept her own diagnosis. The patient seemed bemused by her symptoms, particularly the degree and variety of abdominal and joint pain from which she was suffering. I have frequently observed that patients with organic illness are able to give, according to their powers of self-expression, a more or less coherent and consistent account of the sensation of pain they are experiencing; they can say, for instance, whether it is throbbing or stabbing, twisting or dull. Neurasthenic patients, on the other hand, often devote many minutes to trying to describe the discomfort and generally seem dissatisfied with their own efforts, even when they are people of superior lucidity. The present patient fell into neither category, but, while clearly distressed by her pain, spoke of it in a detached and cool manner which made me suspect that her attention was in fact more passionately engaged elsewhere, on issues of which the pains in her joints and lower abdomen might be little more than representations. There was no obvious neuropathic heredity in Fraulein Katharina's family, though she seemed to know little about her mother's English relations beyond her maternal grandmother, a healthy old woman who had occasionally travelled from her home in London to visit them. Though German was her first language, Katharina spoke fluent English, with no accent, so far as I could judge; she also demonstrated competence in French when I asked her to speak in that language. The reason for my doing so was that she had complained of complete aphonia on two occasions in the last two years, the first time when she was visiting her brother in Paris, and I was interested in establishing whether her temporary loss of speech might have had some connection with a lack of confidence in a foreign language. The most intriguing aspect of Fraulein Katharina was the contrast between, on the one hand, the range of symptoms she presented and the very real distress that they occasioned her and, on the other, a kind of rational detachment. It was becoming clear to me that the initial impression that this evidently thoughtful young woman gave to the world concealed an extremely troubled interior life, and I was inclined to attribute the stoical air with which she bore her considerable troubles to what Charcot called the belle indifference of the hysteric. The clinical picture was further complicated by what one might term superficial anxiety states, expressed in a chronic insomnia, a tendency to low spirits, and a somewhat morbid fear of animals1. It was, at our first consultation, impossible for me to investigate fully these symptoms or to assign them their proper places in the hierarchy of her illness. My initial reaction was to see these relatively common and not particularly severe symptoms as with one exception a kind of diversion or displacement of more serious concerns and not in themselves particularly significant; and I am happy to say that my subsequent investigations were to prove me right. Having arranged for Fraulein Katharina's admission to the sanatorium, I concluded our first consultation by assuring her I was confident we should shortly get to the root of her troubles. Privately, I was inclining to a mixed diagnosis, in which it was possible that while some organic disorder might originally have been present, it was hysteria that was now, as it were, conducting the orchestra.2 I told her that we would begin with some massage and electrotherapy and that her diet and exercise regimen would be closely supervised by the staff between her consultations with me. I had a most arresting example of this zoophobia when one of the stray cats occasionally found in the gardens pressed itself against the windowpane of the consulting room, causing Katharina to jump in exaggerated fright. She explained that as the creature turned sideways to rub itself against the glass, she felt as though a single eye was watching her. 2 Hysterical symptoms regularly become attached to what were originally manifestations of an organic disorder. Neck and arm cramps, for instance, can be employed for the purpose of hysterical attacks, where the patient does not have the typical symptomatology of hysteria at her disposal. She appeared happy to think that positive steps were being taken and made no resistance when I told her that, in addition to these measures, I might wish to enquire into her personal history in considerably more depth in the course of the following days. To tell the truth, I was somewhat daunted by the thought of how the techniques of psycho physical resolution might be applied to such a wide variety of symptoms in the case of a patient with an apparently well developed self-understanding. It was difficult, on the other hand, not to feel sympathy for the evident suffering of a transparently affectionate and well-meaning young woman, so the prospect of resolution also held out considerable therapeutic allure. April 19 [morning] Fraulein Katharina said she had passed a very disturbed night. She was at pains to stress that the fault did not lie with her accommodation, which evidently pleased her and which she was quick to praise, but with the acute discomfort from her joints. I examined her again and applied the faradic brush to a part of her arm she reported as having lost sensation; I then massaged her back and shoulders and told her she could expect a consequent relief in the pains of the joints. She appeared to enjoy the experience and was happy for me to stroke the parts of the lower abdomen that had most troubled her, though I applied only a limited pressure. I said I would arrange for twice-daily massage to become part of her regime, but she seemed alarmed that it might not be I who administered it on each occasion, so I agreed to postpone any firm decision. By now I had decided to try to hypnotise the patient to see if somnambulism could provide a route into her unconscious, there being in my view a degree of urgency about the case. She readily agreed to the procedure and, when she was fully dressed again, lay down on the couch. After several attempts to put her into a hypnotic sleep, I had to confess that she was an extremely resistant subject; for all that I have studied Bernheim's methods at close quarters, I have concluded that his own skill with hypnosis is as much responsible for his remarkable results as the innate suggestibility of his patients. With Fraulein Katharina, I had to be content with a state of co-operative relaxation, from which, I told her, she would be able to remember more at key moments suggested by the pressure of my hand on her forehead. Using this technique, I was soon able to establish the moment at which she had first been aware of her abdominal troubles. Her father had first fallen ill when Katharina or Kitty, as she was known to her family was twenty-one years old. They had enjoyed a relationship of unusual closeness throughout her life; he treated her more as a sister than a daughter and appeared to rely on her for a level-headedness and equanimity sometimes absent in the mother. He used to take Katharina to the theatre and discussed his work with her in detail, sometimes joking with her that he wished he could take her into the gentlemen's clubs he frequented for supper, since she was 'as good as any man'. He was a generous and loyal father; he enjoyed buying her dresses and small pieces of jewellery. On many occasions he told her how much he loved her and that she was a 'blessing sent to him as a sign of love from God'. By her own account, Katharina had been a tomboy, who much enjoyed playing with the local youths on a farm near Hanover where they had passed the summers of her early childhood. In the course of these she had become acquainted with the rudiments of animal reproduction; she had watched a bull being put to the cows and one spring had helped with lambing. Her mother appeared to have been an indolent and rather foolish woman who, while remaining undoubtedly good-looking and possessed of considerable charm, had not made the most of her gifts. Katharina had a brother called Gustav, two years younger than herself, and a sister called Anna, three years younger than Gustav. It naturally fell to Kitty to help nurse them, particularly when her mother was going out for the evening. These tasks she performed with good grace and devotion, dressing up dolls for Anna and allowing Gustav to share her room and even her bed when he was frightened of the dark. The ebullience of her temperament doubtless made such duties easy for her to perform, but at the same time she told me she was anxious that she was likely to be used both as a substitute mother for her siblings and to some extent as a surrogate wife by her father; she was clearly a high-spirited and determined girl who felt there was a possibility that she would be denied the time to develop her own talents, which her father had convinced her were the 'equal of any boys'. At the age of fifteen, Fraulein Katharina was sent to a girls' boarding school nearWolfsburg and for a time felt extremely disconsolate about being parted from her family, particularly from her father and from little Gustav, with whom she had been accustomed to share her secrets. At school, her anxieties about being used by the needs of others, and thus somehow finding herself overlooked, began to take a sexual form. As I applied mild pressure to her forehead, she confessed that she craved attention and had enjoyed sapphic fantasies about the older girls at school and had occasionally masturbated at night in her bed. She further volunteered that when she was about twelve, she and her friend Maria had been playing in the woods when both found it necessary to hoist up their skirts to squat down and micturate; they discovered later that Gustav had been spying on them, and Kitty confessed that she had enjoyed being exposed to her brother's gaze in this way and had wanted to touch Maria's genitals while they were wet, 'to lure something warm out of