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Home arrow Language & Literature arrow Syphilis in Victorian Literature and Culture: Medicine, Knowledge and the Spectacle of Victorian Invisibility

The Indexicality of Pain in Medical Casebooks

In "The Cruel Madness of Love”: Sex, Syphilis and Psychiatry in Scotland, 1880-1930 (2008), Gayle Davis delineates the importance of clinical case records to the understanding of the schemes of local care provision in the treatment of tertiary syphilis. Her complementary reading of medical writings and clinical notes helps her establish the complex realities of Victorian asylumdom. Davis also shows the epistemological and hermeneutic problems posed by clinical case studies. She points out their local idiosyncrasies and inconsistencies, their multi-authorial, makeshift and pragmatic character. She also underscores their fundamental eclecticism, polyvocality and their intrinsic interpretative nature (2008: 25-30). These characteristics alone are suggestive of the tensions between the communication, recording and interpretation of pain and suffering. Even though the rise of asylumdom in the second half of the nineteenth century was instrumental in making the syphilitic insane invisible in public, medical records provided a counter-site of their visibility. Despite their highly provisional character, case records offered a space where the disease itself left undeletable traces, which, although difficult to decipher, are at the same time indexical testimonies to the (physical) ravages brought about by syphilis and other ailments.

As the circumstances of record-taking often contributed to the fragmentariness of case notes, the peculiar symptomatology of the disease, rather than the mundane realities of patients’ suffering, took pride of place in clinical accounts and in medical writing. In his overview of the clinical aspects of the disease, Charles A. Mercier, Physician for Mental Disease to Charing Cross Hospital, describes the progressive character of the disease, which brings with itself epileptic-like seizures, temporal loss of consciousness, sudden rises of temperature and vomiting along with recurring lethargic and comatose states. With each “crisis,” the health of the patient deteriorates further so that he never manages to regain the state of health from before the seizure (Mercier 1914: 86-7). Changes in bodily reflexes and affections of musculature begin to affect the speech and the motility of the patient, leading to a gradual loss of the ability to independently perform any actions. The progress of the disease is evinced by the sinusoid of the patient’s body. Exhaustion, sepsis, an epileptic attack or pneumonia are the most frequent causes of death (Mercier 1914: 100-3).

In his detailed clinical description, Mercier pays particular attention to the non-normative behaviour of GPI patients. Comparing the early GPI symptoms to the state of intoxication, he highlights the “increased energy” of the sufferer who, in the initial stages of the disease, can now work longer hours, becomes less cautious and more speculative in his actions and exhibits a degree of excess (Mercier 1914: 93):

He entertains more; he shows more inclination for society; [... ]. He talks more, more loudly, more imperiously, and more egoistically. He becomes lavish. [... ] He associates familiarity with his social inferiors. He is apt to become loose in his sexual relations. He is often irascible and excitable. Combined with these mental characters there is usually an elation, a buoyancy of mind and high spirits. (93)

This description links the progress of the disease with a gradual transgression of social rules. Whatever its exact course, it imminently brings with itself physical and mental debilitation: “It is loss; it is defect; it is the removal of ability, of competence, of efficiency, of power of mind, and adaptability in conduct. [... ] until nothing remains. Not the simplest reactions betray the existence of consciousness” (Mercier 1914: 95). These changes are accompanied by a transformation in the affective states of the patient so that, while some experience a high degree of joy and wellbeing, others sink into states of continuous misery. To these states are also related various types of delusions, from the delusions of grandeur and wealth to those of inconsequence and incapacity (Mercier 1914: 96-7). Overall, medical textbooks of the late nineteenth century devote a comparatively large amount of space to the enumeration of extraordinary behavioural patterns of GPI patients. Mercier focuses on the convictions characteristically voiced by the exalted/classical type of general paralytics: “The patient attributed to himself ability, worthiness, and wealth in unspeakable degree. There is nothing he cannot do, no honour great enough for his merits [... ]. He can kill people and bring them to life again. He has a hundred bodies. [ ...] He is Lord, Duke, King, Emperor, Saviour, God” (105). The classical exalted type believes in his high social status, promises to achieve the impossible and busies himself with writing directions and orders concerning grand transactions and initiatives. At the same time, he is easily influenced and can quickly be diverted from his actions. In its exuberance, his clothing reflects this mental state as the patient assumes fantastic, “grotesque ornaments” such as “a sunflower the size of a cheese-plate” in his button-hole (Mercier 1914: 106).12 Other potential behavioural scenarios take up another three pages. The discrepancy between the length of these descriptions and the attention given to other symptoms makes the contemporary reader ask whether the author is driven by the desire to offer a comprehensive depiction of the disease symptomatology or by more sensationalist urges.

Clinical case notes are characterized by an equally detailed record of non-normative behaviour, which raises similar questions. The Bethlem male casebooks from the period 1884-1900 scrupulously document patients’ delusions. Ernst Colquhoun Woodward is noted to believe that he is “Emperor of Russia” and that he can run a mile in five seconds.13 James Adamson Taylor told the interviewer that “Christ and he were to teach the Gospel” and that “he is King” and “Christ.”14 William Henry Harris Bolton “imagines that he has a number of tubes inside him” and that a part of his skull has been removed and thrown into the sewage.15 Cecil Stuart Miller relates he “is married to the Princess of Wales, most of the royal family are his children.” He has seen “the devil in Australia” and is invincible, as “no poison in the world is strong enough to kill him.”16 These comments reference the most common types of delusions attributed to GPI.17

Clinical notes also offer iconotextual records of the gradual mental and physical impairment of GPI patients. They document, often in a very succinct manner, the gradual loss of speech and memory, and, with that, the growing inability to communicate. The patient “answers questions put to him in monosyllables [... ] his talk beyond the answer to any questions is without sense,” “memory bad/ideas much confused” - these are some of the descriptions frequently found in the case notes.18 James Adamson Taylor “[r]efuses to speak or make any reply to questions.” With the progression of the disease, his speech becomes “unintelligible” as the patient is noted to be “in the condition described [... ] as ‘silent excitement’ [and] is always pulling at or pushing at whatever is in reach without speaking.”19 An attendant notes in Alice Campion’s records that, shortly after admission, she “became quite quiet, and now does not seem to object to being here at all. When spoken to, answered promptly, clearly and reasonably for about a minute, then walked away and could not be induced to utter a single word.” “Affection of speech is very marked, and the patient herself feels that this is so, [... ] she only uses one or two words at a time like ‘Jingle’ in Pickwick Papers. For example, this morning pointing to her mouth, she said ‘Teeth Beautiful’. Which is indeed the case.”20 These comments not only document the progress of the disease but also mark a growing difficulty in doctor/attendant-patient communication. They highlight the ineffability of pain due to the disease itself.

As they are composed of attendants’ observations, these records offer a testimony to the patients’ inexpressible suffering in the reactions of the caregivers. Woodward’s death notice records his gradual deterioration along with the attendant’s response to his suffering: “the disease has steadily progressed and lately he had been attacked by fits and had become bedridden” [... ].21 “June 19th. Patient had a fit in which he was unconscious, the left side was paralysed. [... ] Sept. 20th. Rubs his head violently and moans as if in pain, crunches his teeth, seems to suffer very much.”22 It is the empathic observations of the attendants that articulate the agony of the patients who have lost the ability to verbally communicate their pain. Although these fragments can in no way be regarded as ‘objective’ testimonies of suffering, they evoke, in the succinct record of the patients’ physical and mental changes, and in the testimony of the attendants, traces of otherwise inarticulable suffering.

Although the validity of clinical notes as sites for the articulation of patients’ personal narratives has been criticized, they certainly offer invaluable glances, however scant and mediated, at the (self-)perception of asylum inmates. Patients’ opinions, the phrases they uttered, noted both in direct and indirect speech, and letters that had been tucked among the pages of the casebooks draw attention to their thought processes. A letter by John Stevenson, dated 13 November 1891, addressed to one Dr Percy Smith, offers such a unique testimony:

Dear Dr Percy Smith,

I told you that I was affected from head to foot. - Have for a long time before [... ] - being kept within doors not only by my lungs but my abdomen [... ]. I was out of doors in early Summer occasionally but [... my] bowels kept me indoors for sometime after mid-summer. A short time before Mr. Haskell left I began to have headache along with pain in my eyes. My bowels have begun to disturb me [... ] so that I was obliged to cease writing to a great extent, and only did very little at a short time.23

In the remainder of the letter, the patient notes his life circumstances and comments on the debilitating powers of his disease. Even if an unreliable testimony to the actual developments of the disease, this is a record of Stevenson’s deteriorating mental powers, a testimony to his feelings of discomfort and to the ways in which his body and his illness encumber his existence.

The letter is also an indexical record of his physical deterioration. Stevenson’s attendants note that “[t]here has been a great change in his writing of late, it is now untidy, very shaky.”24 Mercier describes the gradual loss of the ability to write in GPI patients: peculiar formation of words, duplication or omission of letters and syllables, changing mechanics of writing, with flawed, interrupted lines, changing size of letters, “[b]lots, smudges and erasures”:

The letter usually begins pretty well, as the conversation does; but as in the spoken word, so in the written, the later part of the word is worse executed than the beginning, and as the articulation fails more and more the longer the conversation is continued, so the calligraphy becomes worse and worse the longer the effort of writing endures. (1914: 101)

These letters are indices of the disease itself, of pain and gradual loss of identity. In the same way, Stevenson’s note serves as an index to the progress of his disease, even if only indirectly addressing the pain that he must have felt. If its content eludes the evocation of his inner struggle, his handwriting inadvertently testifies to the changes in his bodily abilities. Like the occasional photographic portraits of the patients, the letter is a corollary of the otherwise ineffable suffering. Like these letters, the photographs invoke the pain without describing it directly. It is the difference and the metamorphosis evoked by the juxtaposition of the admission and deathbed photographs that instantiates the amount of suffering that the patient has undergone. It is in the non-existence and non-appearance of visual recording - in the absence between the first and the second photograph - that its intensity is registered.

The gradual loss of memory, speech and writing skills in GPI patients impaired their capacity to verbally communicate their suffering. Admittedly, it must have affected medical records and care provision. While evincing numerous levels of erasure, clinical records capture the suffering of GPI patients, be it in the empathic observations of the attendants, occasional personal narratives of the patients, or in the indexicality of their writing and in the photographic record of their changing bodies. At the same time, however, they are sad reminders of the encumbrances of the doctor-patient communication and highlight the problems of care provision.

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