Paul Davenant was preoccupied by a number of thoughts before he at last fell asleep. He did not, however, pass any time in reflection upon the fate of the little blue jar which bore his name in capitals on the label, and in which he had expectorated early that morning. Indeed, had it been possible for him never to have heard of the matter again, it is probable that he would have forgotten it completely.
But this act of expectoration was—though Paul could not have known it—of infinite significance. New rules of conduct, new standards of behaviour, new systems of rewards and punishments, new concepts of virtue and vice, of character and its lack, of wisdom and its absence, would be formulated according to the result of the analysis of the matter hygienically sealed within the small blue container.
If Paul gave little thought to analyses, he nevertheless showed a marked interest in the flat glass tube which twice each day he was required to hold between his lips: it provided the only verifiable evidence of his condition from one day to the next. The previous evening at six o’clock precisely he had retained his thermometer in his mouth for the regulation period of ten minutes, at the end of which time the mercury had risen several divisions above the red line which indicates normal; a rapid calculation had shown this to be under 100° Fahrenheit, and with confused memories of boyhood temperatures he felt that it could have been considerably worse.
On waking the following morning he had instinctively stretched out his hand for his thermometer case; probably as a consequence of a whole day’s rest, his temperature would be lower than it had been twenty-four hours previously. At the end of five minutes (he was too impatient to wait the whole ten) he saw that it was actually two divisions higher. Irrationally he felt that this was a confirmation of his worst fears, and he speculated gloomily upon his condition and its implications. Dr. Vernet had spoken about treatment. But what other treatment was there, he wondered uneasily, apart from prolonged rest in bed? Stray words and phrases of his comrades had provided hints so horrible that at the time he assumed that they must have been joking. But now he searched his memory for every detail, attempting hopelessly to distinguish the truth from the total mass of fanciful exaggeration.
An hour later a waiter brought in his breakfast on a tray. John Cotterell, who had been sleeping until this moment, got up and dressed hastily and went to share the communal breakfast in the salle à manger.
Whilst John Cotterell was still away, Paul decided to get up and wash. His image in the mirror above the basin arrested his attention; familiar but impersonal, he could not wholly associate it with his own person. With the detachment of a lecturer identifying a condition to medical students, he said to himself: “This is the face of a man who is chronically ill.” The traditional details—the pallor of the cheeks merging into burning apices, the encircled eyes, themselves moistly bright, the drops of sweat where his hair-line joined with his forehead—for the first time since the diagnosis of his illness he recognised and acknowledged what he saw. With difficulty he withdrew his attention from the details in order to study the whole; he saw then a face mask-like in its lack of mobility, a coloured plate from a medical book on toxicology, the sort that one opens at hazard and instantly regrets.
As he began his toilet he was seized by so violent an attack of coughing that he was forced by breathlessness to sit on the end of John Cotterell’s bed. His throat was blocked and in order to free it he gulped and expelled air, producing a primitive and hollow croaking, the cry of the very disease within him, a sound which Paul had never heard before and which he could not believe proceeded from himself. His efforts provoked a fresh series of coughs which seemed to have their beginning in the extremities of his toes and which dragged a raucous and eerie progress up the length of his whole body. Then suddenly the sputum lodging in his throat was expelled, and he spat it into the crachoir at the side of his bed. Instantly his breathing returned to normal, his throat felt splendidly clear, and the silence in the room seemed by contrast even more astonishing than the dreadful noises which he had been producing a few minutes earlier. He dried his eyes, which had been secreting freely, and continued with his wash; the spasm being over, it seemed unthinkable that it should ever start again.
But during the course of the morning it happened only too frequently that Paul’s arm serpented from his bed to grasp the white enamel crachoir. And he noted with melancholy interest that, now that he had taken to his bed, the disease was declaring itself with far greater intensity than formerly.
The only visitor during the morning was Emile, the concierge. Twice a day he delivered letters to the patients in the sanatorium, and this morning he had nearly half a dozen for John Cotterell.
This Emile was a small, solid man in his middle fifties. He had silvery hair and a red face; protruding blue eyes sheltered under tufted eyebrows; his white cropped moustache showed yellow at the extremities. He was a prominent character both in the sanatorium and in the village of Brisset; his laugh, unmirthful and insinuating, was well known and, in certain quarters, not a little feared. Several times during the day he would descend to the station, either to collect letters or to meet passengers, and on the way he would call at a little bistro where a fine always awaited him, which he would swallow in a single gulp. Progressively through the day his eyes would become moister, his gestures more expansive, and his laugh lose any inhibiting restraint.
Just before lunch the British students assembled in Paul’s room in order that they might all go together to the salle à manger. The last of them had received his medical examination, and the results for the party as a whole were good. No one, apart from Paul, was sufficiently ill to be confined to bed. With this reassurance all attention could now be directed to the new arrivals, and to speculation about the future.
Greetings had already been exchanged with the French contingent. It was thought that greetings had been exchanged with the Hungarians (or were they Czecho-slovaks?), who had only spoken German, of which language not one of the British party had even a superficial knowledge. In consequence the Brisset Esperanto had been employed, a sort of basic French mixed freely with the words of any other language known to the speaker, which depended for direction and edge more upon intonation than eloquence.
Paul only gave part of his attention to what his friends were saying. All morning he had speculated upon the nature of T.B. treatment. He knew that John Cotterell could have answered most of his questions, but he feared that the latter’s account would be over-circumspect. It seemed to him that John MacAllister would probably be the person least likely either to exaggerate or to spare him.
Accordingly, he had decided during the morning that when John MacAllister came in with the others before lunch, he would ask him directly for the information which he sought. But now that all the students were assembled, he shrank from carrying out his intention; a number of times he was on the point of speaking, but he hesitated and then the opportunity was lost. He wanted to say: “Look, I know that I am pretty ill. I am a moral coward. I think that I am not frightened by the prospect of death, but I am frightened by the scope of my imagination. Tell me what I must expect, tell me the worst that can happen to me, and then certainty, however bad, must bring relief.”
But how, how could he ask? John Cotterell was now giving a demonstration of how a Hungarian ballet master whose second language was German would instruct a French class to dance czardas, whilst Angus Gray and William Davis as his pupils scampered across the floor and jumped over the beds. Then some French students hearing the noise opened the door, and, without hesitation, they too joined in the dancing. John Cotterell jumped on to a chair and started to sing in improvised Hungarian; everyone either pranced about wildly or clapped his hands to the rhythm. The uproar came to an end with a furious knocking on the floor of the room above. And then, because it was now lunchtime, the students, breathless with their exertions and with laughter, filed out of the door and left Paul to his introspection.
But in a sanatorium there is one topic of conversation to which everyone, sooner or later, always returns. William Davis had appointed himself treasurer for the British party, and he had purchased a packet of cakes, which he shared out at the end of the cure de silence. Whilst everyone was eating, John MacAllister made a passing reference to the X-ray apparatus in use in Les Alpes, and David Bean, swallowing quickly, seized the opportunity for expressing his views. Long before X-ray apparatus had ever been thought of, he observed, there had been doctors who, with a simple wooden stethoscope, had been capable of making a far more accurate diagnosis than a modern specialist with all his streamlined equipment. Perhaps in the future doctors would do better to rely a little more on the evidence of their ears than of their eyes. And, for what his opinion was worth, he believed that it would have been no loss to medicine if X-ray machines had never been invented, and one day he intended to write a thesis on the mistakes in diagnosis arising from their use. The majority of operations for appendicitis, he insisted, were quite unnecessary, being based on the erroneous interpretations of X-ray plates. And in T.B. it was notorious that every doctor interpreted the shadows in X-rays as he wished, and he could quote cases where X-ray plates, and even tomograms (a series of X-rays in depth), had shown nothing to indicate the existence of disease, though subsequently a P.-M. had revealed extensive damage.
Angus Gray congratulated David Bean on so lucid an exposition of his views, but suggested that they did not go quite far enough. Discard all X-ray apparatus, of course, but on what grounds retain the stethoscope? Had there not been doctors capable of recognising consumption long before stethoscopes had been invented? And then again what doctor of real integrity would ever care to make a diagnosis of a patient’s condition before having attended his post-mortem?
As everyone laughed, David Bean said sarcastically:
“Oh, we all know that the information provided by any little gadget or magic box is worth its weight in gold to the modern practitioner so long as it saves him the trouble of thinking. I must say, Angus, that I envy your future patients.”
“And quite frankly I envy yours—for the tonic effect your personality will have on them,” replied Angus Gray.
“And talking about tonic effects, gentlemen, I think that we might do well to remember from time to time that Paul here is still awaiting a decision about treatment,” added John MacAllister.
Everyone was astonished, everyone had quite forgotten.
“You mean to say that you still don’t know what they’re going to do to you?” said Angus Gray.
“No.”
“Give them time. He only had his medical yesterday,” said William Davis.
“It’s true. But it seems as if we’ve been here weeks already.”
“What do you think they’ll do to me?” asked Paul, trying to make the question sound quite casual, though he addressed it pointedly at John MacAllister.
“I can’t say—it will depend on all sorts of things. Are both your lungs affected or only the one?”
“Both; but I gather that there’s not much wrong with my right lung.”
“Well, it’s always possible that they’ll try to give you a pneumo on your left lung, and then if it’s not too badly damaged the right could clear up by itself. But don’t take that as official, they may do something quite different. Besides, it’s not really possible to express any opinion without much more knowledge of your case.”
“I’m afraid I don’t even know what a pneumothorax is.”
Briefly John MacAllister explained the nature and the function of the pneumothorax. The basis of all treatment for T.B. was rest, which gave the affected tissues a chance to heal. The pneumothorax, which artificially reduced the function of either (and if necessary of both) lungs, brought the principle of rest directly to bear on the affected part.
It was accomplished in this way. Air was pumped between the exterior of the lung and the interior of the chest wall, which had the effect of compressing the lung to a fraction of its original size. Although it continued to breathe, its activity was greatly restricted, and healing could start to take place.
Because the air so introduced was absorbed during a certain period of time into the bloodstream, it was necessary to maintain the pneumothorax by reintroducing fresh supplies of air at regular intervals. Both refills of air and the initial induction were made in the same manner: a hollow needle was passed between the ribs, and the air was pumped directly into the pleural cavity. This was effected with a minimum of trouble, and did not take more than a few minutes.
Was it necessary to remain in bed all the time that one had a pneumothorax? John MacAllister shook his head; complete bedrest was only required during the initial stages, after which it was possible to lead a semi-normal life. To the question of how long it was necessary to maintain the pneumothorax, John replied that it depended on the individual case, and that the time varied usually between two and six years.
“Well,” said Paul, “it appears to me to be a good solution. I think I shall ask for one.”
“You are splendidly naïve about all this,” commented David Bean. “It will be more a question of what Vernet decides for you than what you want. Besides, John has given the impression that a pneumothorax always works, whereas in point of fact it quite often can’t even be induced. Then again it occurs not infrequently that there are adhesions, and if these can’t be cut, then the pneumothorax has to be abandoned.”
“I see,” said Paul. “Does that mean that no further treatment can be carried out?”
David Bean laughed. “Something in the tone of your voice tells me that you wouldn’t be wholly disappointed if I told you that that was the case. No, there are still quite a few specialities. The enthusiastic fish, for example, can always be filleted.”
“Filleted?”
“Have his ribs out. An intricate and engaging little process performed without the benefit of a general anæsthetic.”
“Without a general anæsthetic?” exclaimed Paul, now thoroughly startled.
“David’s putting it ridiculously,” said John MacAllister. “The operation is performed under a very powerful local anæsthetic. The object in removing the ribs is to obtain a permanent collapse of the ill part of the lung.”
“A method which might be compared to cracking a walnut with a steam-roller,” commented David Bean.
“And of course there’s no question of feeling the ribs coming out,” added Angus Gray quickly.
“One may not feel them coming out, but one certainly hears them,” said David Bean. “I’ve been present at a number of thoracoplasties and I’ve never found the sound particularly stimulating, quite apart from how it must strike the person who is actually undergoing the operation. I certainly would not propose myself as a candidate.”
“Obviously nobody volunteers for one,” said John MacAllister, “but at least it can usually be looked upon as a permanent job, and you don’t run the same danger of fluid which so often wrecks a pneumothorax.”
“What do you mean by ‘danger of fluid’?” asked Paul, his voice sounding strained.
“Well, it can happen that a pneumothorax provokes an irritation of the pleura, which then results in an effusion. Sometimes it clears up by itself, but if not it can always be aspirated.”
“And as the aspiration often re-irritates the pleura, you then get a fresh secretion, which in due course is followed by another aspiration. It can, in time, become quite tedious,” said David Bean.
“David’s putting the wind up you,” said John MacAllister. “You needn’t think that complications are inevitable or even likely—a tremendous number of people have had a pneumothorax with very satisfactory results. There’s no reason in the world why you should be unlucky, if it proves possible to induce one. And if it doesn’t work, there’s always the second line of defence.”
“And when the thoracoplasty turns out not to work, what’s the third line of defence?” asked David Bean.
“Stop blethering, man,” cried Angus Gray. “You might have the decency to keep all your pessimistic drivel to yourself. I’ve heard of people like you amongst the patients, but for a medical student to speak as you do is a damned disgrace.”
“The damned disgrace is to pay lip service to a whole system of treatment which doesn’t repay its existence by its results,” replied David Bean, slightly raising his voice. “I would advocate any method, however radical, if I could see that it served its purpose. But how many times have we all seen examples of treatment producing clinically satisfactory results, and then the whole thing breaking down for some inexplicable reason at a later stage? Why does no one start to reflect that there is something infinitely mysterious and subtle about tuberculosis? Why, for example, should we, from our comfortable middle-class homes, well-nourished, well-developed, fall victims to a deficiency disease? And why, if we have got it, should we expect to overcome it by suppressing its symptoms?”
“It’s probably all a lot less mysterious and subtle than you’re trying to make out,” said John MacAllister. “If you’ve had a primary infection when you were a child, you’ve been able to build up a resistance against it. But if for some reason you haven’t, down you go the first time you come into contact with a big dose.”
“You’re over-simplifying. I don’t believe that a person in a state of mental and physical equilibrium could catch the bug even if he hadn’t had a primary infection.”
“No, and probably one wouldn’t have caught it before the Fall of Man. What’s the use of speaking of mental and physical equilibrium in the abstract? The question is, Man having fallen, what methods have you to substitute for the treatment which you find so unsatisfactory?”
“I haven’t said that I have anything to substitute, but, because a specific is lacking, I don’t believe in resorting to witchcraft. If Man has fallen, then the thing is to try and get him up again. Once one can re-establish mental and physical equilibrium in a patient, I am positive that the disease will disappear of its own accord. There are various fairly obvious methods of going about this, depending on the case. Congenial surroundings, good food and plenty of rest will help. Then what? Analysis? The priests? The almoners? I don’t know. The patient is disequilibriated and the reason must be found; each is an individual case and must be treated individually. The doctor who does not acknowledge this is criminally negligent, and will never succeed in producing permanent results.”
“You’re talking absolute nonsense,” said John MacAllister. “I’ve seen the most appalling cases completely cleared up by treatment.”
“I don’t doubt it. But I’ll tell you with every confidence that the cases, however appalling, of which you speak, would have got equally well if no treatment whatever had been administered. Either the body produces its own resistance against the disease, or it collapses. Yesterday someone was citing Gide and Somerset Maugham as examples of people who recovered from tuberculosis. Does it occur to you that both got better without any form of treatment whatever? Now, if they’d fallen ill today, what would have happened? Pneumothoraxes, ribs out, God knows what. And all the resistance which they needed to combat their disease would probably have been employed in trying to combat the effects of the treatment. Gide would have done well with a double pneumothorax with probably a double purulent pleurisy to follow.” David Bean turned towards Paul: “It’s no use being depressed through hearing the facts, and it’s far worse learning the truth afterwards, when the miracle which you were expecting doesn’t happen. You may be lucky and you may come out of this all right—I hope you do. But at least you ought to know at the outset a few of the issues which are involved.”
The discussion was interrupted by the entry of Sœur Jeanne, who was carrying a number of prints in her hand.
“These are the copies of your X-rays,” she said, distributing one to each of the students. But the copy which was due to Paul she put inside a folder affixed to his temperature chart.
“What is mine like?” he asked.
“Ce n’est pas très joli, mon pauvre garçon. Do not look at it.”
The other students were occupied in examining the copies of their own X-rays, when there was a knock at the door, and the young Dr. Florent peered into the room, a look of embarrassment on his face.
“Monsieur Cotterell, pouvez-vous venir un moment? J’ai quelque chose à vous dire.” Dr. Florent had no English.
John went out into the passage, and returned a few minutes later. “It’s the result of the sputum analysis,” he said briefly. “We’re all negative, except for Paul, and …” he broke off, realising too late that he would have done better not to have hesitated.
“Well?” asked Paul.
“Well, I’m afraid I’ve got to move, that’s all. As far as I’m concerned, I wouldn’t do so, but Florent says that it’s an order; I’m sorry, Paul. Florent says that there’s a Pole who’s been ill a long time, and he’s going to have him put in here with you.”
And as the day was already advanced, and as John had been told that he must move before the evening, he started on the removal of those of his possessions which two days previously he had stored in cupboards and drawers.