# The Elephant Man and other reminiscences/A Case of "Heart Failure"

VII
A CASE OF "HEART FAILURE"
WHAT a strange company they are, these old patients who crowd into the surgeon's memory after a lifetime of busy practice! There they stand, a confused, impersonal assembly, so illusive and indistinct as to be little more than shadows. Behind them is a dim background of the past—a long building with many windows that I recognize as my old hospital, a consulting room with familiar furniture, an operating theatre, certain indefinite sick-rooms as well as a ward in which are marshalled a double row of beds with blue and white coverlets.
Turning over the pages of old case books, as one would idle with the sheets of an inventory, some of these long departed folk appear clearly enough, both as to their faces and the details of their histories; but the majority are mere ghosts with neither remembered names nor features, neither age nor sex. They are just fragments of anatomy, the last visible portions of figures that are fading out of sight. Here, among the crowd, ​are the cheeks of a pretty girl encircled by white bandages and the visage of a toothless old man with only one ear. I can recollect nothing but their looks. They belong to people I have known, somewhere and somehow, in the consulting room or the ward. Here a light falls upon "that knee," "that curious skull," "that puzzling growth." Here is a much distorted back, bare and pitiable, surmounted by coils of beautiful brown hair. If the lady turned round I should probably not recognize her face; but I remember the back and the coils of hair.
This is a gathering, indeed, not of people, but of "cases" recalled by portions of their bodies. The collection is not unlike a medley of fragments of stained glass with isolated pieces of the human figure painted upon them, or it may be comparable to a faded fresco in a cloister, where the portions that survive, although complete in themselves, fail to recall the story they once have told.
It is curious, when so much is indefinite, how vividly certain trivial items stand forth as the sole remains of a once complete personality. All I can recall of one lady—elderly but sane—was the fact that she always received me, during a long illness, sitting up in bed with a large hat on her head trimmed with red poppies. She also wore ​a veil, which she had to lift in order that I might see her tongue. She was further distinguished by a rose pinned to her nightdress, but I recall with relief that she did not wear gloves.
Of one jolly boy the only particular that survives in my mind is a hare's foot which was found under his pillow when he was awaiting an operation. It had been a talisman to coax him to sleep in his baby days, when his small hand would close upon it as the world faded. His old "nanny" had brought it to the nursing home, and had placed it secretly under his pillow, knowing that he would search for it in the unhappy daze of awakening from chloroform. He wept with shame when it was discovered, but I am sure it was put back again under the pillow, although he called his "nanny" "a silly old thing."
Then, again, there was the whistling girl. She was about sixteen, and had recently learnt whistling from a brother. Her operation had been serious, but she was evidently determined to face it sturdily and never to give way. She expressed herself by whistling, and the expression was even more realistic than speech. Thus as I came upstairs the tone of her whistling was defiant and was intended to show that she was not the least afraid. During the dressing of the wound ​the whistling was subdued and uncertain, a rippling accompaniment that conveyed content when she was not hurt, but that was interrupted by a staccato "whoo" when there was a dart of pain. As soon as my visit was over the music became debonair and triumphant, so that I often left the room to the tune of Mendelssohn's "Wedding March."
On the other hand, among the phantoms of the case book are some who are remembered with a completeness which appears never to have grown dim. The figures are entire, while the inscription that records their story is as clear as it was when it was written.
In the company of these well remembered people is the lady whose story is here set forth. More than thirty years have passed since I saw her, and yet I can recall her features almost as well as if I had met her yesterday, can note again her little tricks of manner and the very words she uttered in our brief conferences. She was a woman of about twenty-eight, small and fragile, and very pretty. Her face was oval, her complexion exquisite, while her grey-blue eyes had in them the look of solemn wonder so often seen in the eyes of a child. Her hair came down low on either side of her face, and was so arranged ​as to remind me of the face of some solemn lady in an old Italian picture. Her mouth was small and sensitive, but determined, and she kept her lips a little apart when listening. She was quiet and self-possessed, while her movements and her speech were slow, as if she were weary.
She was shown into my room at an hour when I did not, as a rule, receive patients. She came without appointment and without any letter of introduction from her doctor. She said that she had no doctor, that she came from a remote place in the north of England, that she had an idea what was the matter with her, and that she wanted me to carry out the necessary operation. On investigation I found that she had an internal growth which would soon imperil her life. I explained to her that an operation would be dangerous and possibly uncertain, but that if it proved successful her cure would be complete. She said she would have the operation carried out at once, and asked me to direct her to a nursing home. She displayed neither anxiety nor reasonable interest. Her mind was made up. As to any danger to her life, the point was not worth discussing.
She had informed me that she was married, but had no children. I inquired as to her parents, but she replied that she was an orphan. I told ​her that I must write fully both to her doctor and to her husband. She replied, as before, that she had no doctor, and that it seemed a pity to worry a strange medical man with details about a patient who was not under his care. As to her husband, she asked if I had told her all and if there would be anything in my letter to him that I had not communicated to her. I said that she knew the utmost I had to tell. "In that case," she replied, "a note from you is unnecessary." I said, "Of course, your husband will come up to London?"
To which she remarked, "I cannot see the need. He has his own affairs to attend to. Why should any fuss be made? The operation concerns no one but myself."
I asked her then what relative or friend would look after her during the operation. She said, "No one. I have no relatives I care about; and as to friends, I do not propose to make my operation a subject for gossip." I explained to her that under such circumstances no surgeon would undertake the operation. It was a hazardous measure, and it was essential that she should have someone near her during a period of such anxiety. She finally agreed to ask an elderly lady—a remote connexion of hers—to be with her during her stay in the nursing home.
​Still, there was some mystery about the lady that I could not fathom, something evidently that I did not know. There was a suggestion of recklessness and even of desperation in her attitude that it was difficult to account for. As she sat in the chair by the side of my desk, with her hands folded in her lap and her very dainty feet crossed in front of her, her appearance of indifference was so pronounced that no onlooker would imagine that the purport of our converse was a matter of life and death. One little movement of hers during our unemotional talk was recalled to my mind some days later. She now and then put her hand to her neck to finger a brooch in the collar of her dress. It was a simple gold brooch, but she appeared to derive some comfort, or it may be some confidence, from the mere touching of it.
The operation was effected without untoward incident of any kind. It was entirely successful. The wound healed by what is known as "first intention," there was no rise of temperature and no surgical complication. But the condition of the patient caused an uneasiness that deepened day by day. She became restless and apathetic and at the same time very silent, answering questions only in monosyllables. She resisted no ​detail of treatment, but accepted everything with a lethargic complacency impossible to overcome.
That, however, was not all. She appeared to be possessed by an indefinite anxiety which was partly expressed by an intense attitude of expectation. She was expecting a letter, looking out for it day after day and hour after hour. She listened to the door and to any sound on the stair as an imprisoned dog might listen for the steps of its master. This terrible vigil began on the second or third day after the operation. When I made my visit about that time she asked me if I had given orders that she was to have no letters. I assured her I had not done so and that she should have every letter the moment it arrived. But no letter came.
Whenever I made my appearance her first question was, "Did you see a letter for me in the hall?" I could only answer "No." Then she would press me with other inquiries: "How often does the postman come? Is he not sometimes late? Has there been any accident on the railway? Do letters get occasionally lost in the post?" and so on interminably. If anyone came into the room there was always a look of expectation on her face, an eager searching for a letter in the hand or on a tray. If a knock was heard at ​the front door, she at once inquired if it was the postman, and very usually asked me to go to the top of the stair to ascertain.
The sisters, the nurses and the patient's friend could tell me nothing. No letter of any kind arrived. The poor, tormented creature's yearning for a letter had become a possession. I inquired if she had written any letters herself. The sister said that, as far as was known, she had written but one, and that was on the eve of her operation. Although she should have been in bed at the time, she insisted on going out for the purpose of posting the letter herself.
She rapidly became weaker, more restless, more harassed by despair. She was unable to sleep without drugs and took scarcely any food. Feeble and failing as she was, her anxiety about the coming of a letter never abated. I asked a physician versed in nervous disorders to see her, but he had little to propose. She was evidently dying—but of what?
She was now a pitiable spectacle, emaciated and hollow-eyed, with a spot of red on her cheek, an ever-wrinkled brow and ever-muttering lips. I can see to this day the profile of her lamentable features against the white background of the pillow. Pinned to the pillow was the brooch that ​I had noticed at her neck when I saw her in my consulting room. She would never allow it to be removed, but gave no reason for her insistence. I have seen her hand now and then move up to touch it, just as she had done during our first interview.
I was with her when she died. As I entered the room there was still the same expectant glance at the door. Her lips, dry and brown, appeared to be shaping the question, "A letter for me?" There was no need to answer "No." At the very last—with a display of strength that amazed me—she turned over with her face to the wall as if she wished to be alone; then, in a voice louder than I had known her to be capable of for days, she cried out," Oh, Frank! Frank!" and in a moment later she was dead.
Her death was certified, with unconscious accuracy, as due to "heart failure."
Here was a mystery, and with it a realization of how little we knew of this lady who had died because she wished to die. I was aware that her husband's christian name was William, but beyond that I knew practically nothing of him. The sister of the nursing home had both written and telegraphed to the husband, but no reply had been received. It was afterwards ascertained that he ​was away at the time and that the house was shut up.
I was determined to find out the meaning of the tragedy, but it was some months before I was possessed of the whole of the story. The poor lady's marriage had been unhappy. Her husband had neglected her, and they were completely estranged. She formed a friendship with a man of middle age who lived near by. This is he whose christian name was Frank and who was, I imagine, the giver of the brooch. The friendship grew into something more emotional. She became, indeed, desperately attached to him, and he to her. Their intimacy was soon so conspicuous as to lead to gossip in the neighbourhood, while the state of the two lovers themselves was one of blank despair. She looked to him as Pompillia looked to Caponsacchi. He was her saviour, her "soldier saint, the lover of her life." To him she could repeat Pompillia's words: "You are ordained to call and I to come."
It became evident in time that the only course the two could adopt was to run away together. She, on her part, counted no cost and would have followed him blindly to the world's end. He, on the other hand, hesitated. He did count the cost and found it crushing. His means were small. ​His future depended on himself. An elopement would involve ruin, poverty and squalor as well as, in time, a fretful awakening from a glorious dream.
He did the only thing possible. He told her that they must part, that he must give her up, that he must not see her again, that he must not even write to her. It was a wise and, indeed, inevitable decision; but to her it seemed to foretell the end of her life. He kept the compact, but she had not the strength to accept it. It was something that was impossible. She endeavoured to get in touch with him again and again, and in many ways, but without success. Hard as it was, he had kept to his resolve.
Then came the episode of the operation. Now, she thought, if she wrote to him to say that she was in London and alone and that she was about to undergo an operation that might cause her death, he must come to see her or he must at least reply to her letter. She felt assured that she would hear from him at last, for, after all that had passed between them, he could not deny her one little word of comfort in this tragic moment.
She wrote to him on the eve of her operation. The rest of the story I have told.