3—
"But What If She Should Die?"
She won't die. People don't die in childbirth nowadays. . . . Yes, but what if she should die?
—Hemingway
Case History
It is Memorial Day on the medical wards. By late afternoon I have already had four admissions, two to the I.C.U. I have hardly been able to leave I.C.U. all day and have had nothing to eat since early this morning. But the medical resident comes to tell me that I have a transfer patient from obstetrics. He nods toward a bed.
Around 8:00 p.m. I finally get to her, my fifth admission. I go to read her chart. Another instance of a service dumping a difficult case onto the medical service, I think. Today is a holiday. We are
shorthanded. Why do they have to transfer her today? I pick up her bright blue chart and begin to read her history Suddenly, I have a fearful premonition: this is not going to be an ordinary case; it is going to be a terrible one. I wish I could close the chart and walk away The words become frightening. Is there no escaping them?
Mrs. S, twenty-nine years old, had been in perfect medical health. About nine months ago, she became pregnant with her first child. The first four months of pregnancy were uneventful.
About halfway through her pregnancy, she began to develop dyspnea (difficulty in breathing) on exertion. When her dyspnea progressed, she was admitted to a small community hospital near her hometown for a workup. Routine studies—chest X-rays and chest tomograms—were unremarkable, but her doctors found that her blood oxygen (PO2 ) was in the mid-60s. (For a young person who is a nonsmoker, the PO2 should be about 95.) After several days, her doctors discharged her with conservative treatment, without knowing the etiology of her shortness of breath.
Over the next months, Mrs. S's pregnancy progressed and her condition worsened: more shortness of breath and exhaustion, without any obvious explanation. In the eighth month of her pregnancy, Mrs. S was readmitted to the community hospital. Her PO2 was now in the high 50s. Again, no explanation for her symptoms was found. Soon Mrs. S was almost ready to go into labor. What was more and more urgent, she was beginning to look acutely ill because of her respiratory problems.
It was then that she was transferred to the obstetrical unit of our hospital, a large university medical center. On admission, Mrs. S was already in the early stages of labor. Within twenty-four hours she gave birth to a somewhat premature but healthy infant. The actual delivery went rather smoothly. But just before, during, and immediately after delivery, Mrs. S's respiratory status deteriorated until she was short of breath even while at complete bedrest. Her every inhalation was a gasp.
Once the baby was born, an aggressive workup of the mother was begun. Because the chest X rays revealed nothing, a cardiologist was called in for a catheterization. To everyone's surprise and dismay, the cardiac catheterization revealed the diagnosis: primary pulmonary hypertension. The pulmonary pressures mea-
sured about six times greater than normal, indicating that Mrs. S was probably in an advanced stage of the disease.
Now the diagnosis is on her chart. It cannot be erased from her history or from her life. Dark thoughts burn through my brain. I am no longer tired. I search feverishly for facts remembered, ideas gleaned from medical textbooks which now come chillingly to life: a birth from the words on the page into the actuality of Mrs. S's disease; a birth, like her baby's, that erupts into reality and into pain. The facts I recall are these:
1. The cause of primary pulmonary hypertension is unknown.
2. The disease is uniformly fatal.
3. The most aggressive form of the disease occurs in women who are pregnant, who carry a child to full term and deliver.
Now it is well into Memorial Day night. For the first time I approach the young woman lying on the bed in the corner of the I.C.U. I can see what her chart has already told me: she is in great distress. Because talking tires her out, she can barely communicate with me. She wears an oxygen face mask.
The history I take is very brief. Already, I can tell there will not be the bond that exists, or begins to be nurtured, between a patient and the attending doctor—a bond often built of warmth or trust or caring. It is sometimes a bond of hate but it is a bonding nevertheless, a joining through touch and through mental, emotional, and even spiritual rapport. Now I rush through the physical examination, afraid that Mrs. S will see in my actions, words, and expression the truth about her condition. I try to comfort and reassure her, but I do not think I can be very effective. What am I supposed to do? What can I do?
Certainly, death on the medical wards is not new to me. Throughout medical school and this internship I have seen a number of patients in tragic and terminal situations. Yet in all my past experiences, I had always felt that I had been able to offer my patients something —some sort of relief or help, if not from a medical standpoint, at least from an emotional or supportive one. But now I can offer nothing.
The first night I consult briefly with a cardiologist, a pulmonary specialist, and the medical resident with whom I am working
on this rotation. No one really has anything more to offer. The diagnosis has precluded that. Although we attempt to assist Mrs. S with oxygen and medication to dilate her blood vessels and lower her pressures, my impression is that there is little we can do, even for her pain.
From that night on, almost nobody talks to me about the case. Yet if I feel isolated, how much more isolated Mrs. S must feel, for no one ever visits her: not her husband or a relative. Surrounded by all the people bustling around in a six-hundred-bed hospital—doctors, nurses, technicians, other patients, other patients' visitors—Mrs. S is, except for her baby, virtually alone.
For thirty minutes every day the nurses bring the infant up from the newborn special care unit to spend time with her mother. Thirty minutes is all the time Mrs. S can be with her baby without becoming totally exhausted. It hurts and angers me to see the nurses laugh when they carry the infant, when they place her in her mother's arms. Their joyful—and what seems to me frivolous—attitude makes even more tragic what I know is to come. Even though I explain Mrs. S's condition to them, they do not seem to understand. Or do they? At least there will be thirty minutes a day of happiness.
Several times I watch the mother with her child. She appears to get a great deal of pleasure from being with her baby For a moment she reminds me of other new mothers I have seen on the obstetrical services: smiling, enchanted with the beauty of the new life they have created, enchanted and somewhat bewildered by their new roles as mothers. As I watch Mrs. S playing with her infant, I ponder the irony of it all. The baby to whom she has given life will be the cause of her death.
Two or three days go by The patient's PO2 is now in the mid-40s. Mrs. S is worn out just trying to breathe. She is slowly suffocating. Consciously, I have tried to hold off the decision to put her on a respirator because it will hinder her interaction with her child. But finally I have no choice. She must be put on a respirator to survive. On the day I can no longer delay the decision, nobody can be reached—not the cardiologist, not the pulmonary specialist, not Mrs. S's husband. Intubated and hooked up to the respirator, Mrs. S becomes an orifice plugged with a pipeline into her lungs, a lifeline that is the symbol of her impending death. Before
her intubation Mrs. could barely speak Now, with her mouth forever gagged by that fateful tube, she cannot talk at all. No longer can she whisper to her baby or even smile at her. She can communicate now only with her hands or her eyes.
It is the night of the fourth day after Mrs. S's delivery. Once again, the cardiologist is trying to put a catheter into her heart. He is trying to do something . During the procedure, Mrs. S has a cardiac arrest and cannot be revived.
As the cardiologist fills out the death certificate, he reads each word as if this were the first time he had ever seen such a document, though he has filled out perhaps scores of them before. And, in a somewhat shaky hand, he writes his own name on the line calling for the name of the deceased.
I tear up that death certificate and write out another one.
The next morning I go downstairs to the newborn special care unit. I want to see Mrs. S's baby. As I stand near the incubator, I am flooded with feelings, images, and desires, with memories that will never leave me. I try to sort out—to master—my thoughts. First, I realize I want to take the infant home with me. As far as I know, her father had abandoned her mother. Would he abandon their child as well? Then I try to imagine how this little girl will grow up. I hope she will never know the truth about her mother's death: if she had not been born, her mother might have lived, perhaps for many years. And somehow I begin to hope—it's not impossible, is it?—that those visits the infant had had for thirty minutes a day during the first three days of her life would permit her, in some mysterious and miraculous way, to know her mother. A few moments of love cannot be meaningless, can they?
Literary Parallels
Mrs. S's doctors had given her virtually no emotional support. Because we wondered how some other doctors had reacted when one of their patients died as a result of childbirth, we turned to literature. But literature, which is so lavish in examples of loves licit and illicit, of passions healing and destroying, and in its depictions of other rites de pas-
sage, is strangely stingy in its depictions of mothers dying as a result of pregnancy or childbirth. Why? For centuries, after all, every pregnancy ran a certain risk of maternal mortality. Then why does so little imaginative literature describe it? Is it because so much literature is written by men, and no man can fully understand the physical, emotional, and spiritual states relating to childbearing and parturition? Yet books are written by women, too. Is it because women writers are more concerned with other matters, not with what they might consider the merely mundane task of bearing babies and expelling them from the womb? These suggestions are possible. But might there be a more compelling reason: that of a taboo that has been promulgated and perpetuated in Western culture, a taboo that says one does not speak about childbirth—except in purely clinical terms or in sentimentalized, romanticized language? Still, despite this taboo, there exist some examples in literature. No taboo remains unviolated. Three nineteenth- and twentieth-century depictions are particularly apropos.
War and Peace
In Tolstoy's War and Peace , it is two months after the battle of Austerlitz. Prince Andrew Bolkónski, who was wounded in the battle, is presumed dead. His pregnant wife, the little princess Lise, lives at the Bolkónski country estate with her crotchety old father-in-law, Nicholas, and her sister-in-law, Princess Mary.
Immediately after breakfast one March morning, Lise's labor begins. A midwife comes. Although the family had sent for a doctor from Moscow, he has not arrived yet. An old nurse, who comes to sit with Princess Mary, tries to reassure her. "'God is merciful, doctors are never needed,' she said."[1]
Night falls. The house is hushed but no one sleeps. Suddenly there are noises and voices. Prince Andrew has come home, and with him has come the doctor: "(they had met at the last post station)," Tolstoy interpolates.[2] How impor-
tant is the doctor? As described here, his arrival is incidental.
Prince Andrew enters his wife's room. We perceive Lise through her husband's eyes and conscience:
The little princess lay supported by pillows, with a white cap on her head (the pains had just left her). Strands of black hair lay round her inflamed and perspiring cheeks. . . . Her glittering eyes, filled with childlike fear and excitement, rested on him without changing their expression. "I love you all and have done no harm to anyone; why must I suffer so? Help me!" her look seemed to say. . . . Prince Andrew . . . kissed her forehead. . . .
"I expected help from you and I get none from you either!" said her eyes.
When Lise's contractions resume, the midwife tells Prince Andrew to leave the room. Within minutes there are moans, cries, and a horrible shriek.
Piteous, helpless, animal moans came through the door. Prince Andrew got up, went to the door, and tried to open it. Someone was holding it shut. . . . He began pacing the room. The screaming ceased, and a few more seconds went by. Then suddenly a terrible shriek—it could not be hers, she could not scream like that—came from the bedroom. Prince Andrew ran to the door; the scream ceased and he heard the wail of an infant.
"What have they taken a baby in there for?" thought Prince Andrew. . . .
Then suddenly he realized the joyful significance of that wail; tears choked him, and leaning his elbows on the window sill he began to cry, sobbing like a child.[3]
His "sobbing like a child" is at once endearing and condemning. It suggests his childlike surrender to the wonder he feels but also his egotistical self-absorption. For he has not thought about the infant's mother.
The door opened. The doctor with his short sleeves tucked up, without a coat, pale and with a trembling jaw, came out of the room. Prince Andrew turned to him, but the doctor gave him a bewildered look and passed by without a word. A woman rushed out and seeing Prince Andrew stopped, hesitating on the threshold. He went into his wife's room. She was lying dead, in the same position he had seen her in five minutes before. . . .
"I love you all, and have done no harm to anyone; and what have you done to me?"—said her charming, pathetic dead face.[4]
How does the reader feel about the doctor who offers no help to the man who has simultaneously become a father and a widower? Do we feel angry with him? Or do we understand and sympathize with his pale and "bewildered look, his trembling jaws," and his speechless state?
Throughout his depiction of Lise's labor, Tolstoy has made us feel her fear, exhaustion, and pain. Above all, he has made us aware of her isolation, which comes to weigh heavily and guiltily on us. Several times we perceive her uncomprehending and accusing words, "What have you done to me?" For example, when Prince Andrew goes to her coffin "to give her the farewell kiss," there "in the coffin was the same face, though with closed eyes. 'Ah, what have you done to me?' it still seemed to say." And Prince Andrew "felt that something gave way in his soul and that he was guilty of a sin he could neither remedy nor forget."[5] Lise's father-in-law, too, is affected but in a different way. When Nicholas Bolkónski approaches her coffin, "her face seemed to say: 'Ah, what have you done to me, and why?' And at the sight the old man turned angrily away."[6] How can this old man be angry at the dead young woman? Is he so despicable, so inhuman? His anger might also be interpreted, however, as another manifestation of guilt or as an expression of the fury and frustration one feels in the face of one's own helplessness. Were not guilt and anger some of the emotions that Mrs. S's doctors experienced but dared not voice?
A Farewell to Arms
A detached, almost clinical depiction of a woman's death in childbirth occurs at the end of Hemingway's A Farewell to Arms . Or at least so it appears.
Frederic Henry, the narrator, is an American who has joined the Italian army during the First World War. A lieutenant in the ambulance corps, Frederic is basically unsentimental, detached, and ironic. Rather indifferently, partly to escape from the monotony of going to whorehouses every night, he begins an affair with Catherine Barkley, an English nurse's aide he meets in Italy. When he is severely wounded, she nurses him in a hospital, continues their affair, and becomes pregnant. By then, Frederic has fallen in love with her.
When Catherine's labor begins at around 3 o'clock one morning, she and Frederic go to the local hospital. (They are living in exile in Switzerland because Frederic has deserted from the Italian army.) Although they have not married, she gives her name as Catherine Henry.
About twelve hours go by. Frederic goes out for a rather long breakfast and lunch. Catherine is wheeled into the delivery room so that the doctor can give her gas for her pains. The labor is not going well. Catherine is worrying about dying, and Frederic tries to calm her.
When Frederic is sent out of her room for a while his mind meanders into a meditation that is at once restrained and impassioned, for it opens the floodgates of his fear.
Poor, poor, dear Cat. And this was the price you paid for sleeping together. . . . And what if she should die? She won't die. People don't die in childbirth nowadays. That was what all husbands thought. Yes, but what if she should die? She won't die. She's just having a bad time. The initial labor is usually protracted. She's only having a bad time. . . . But what if she should die? She can't die. Yes, but what if she should die? She can't, I tell you. Don't be a fool. It's just a bad time. . . . Yes, but what if she should die? She can't die. What reason is there for her to die? There's just a child that has to be born. . . .
But what if she should die? She won't die. But what if she should die? She won't. She's all right. But what if she should die? She can't die. But what if she should die? Hey, what about that? What if she should die?[7]
The terrifying and obsessive question "What if she should die?" is sounded ten times, with ever-increasing frequency. As Frederic's terror mounts, even as he tries to control it, the doctor breaks in on his reveries. Might the doctor's meditations be similar to Frederic's? For he says that he ought to perform a Cesarean.
When the doctor leaves to prepare for surgery, Frederic is left with Catherine. Because she is begging for more and more relief, Frederic, who wants to do something , disregards the doctor's directions about how to administer gas and turns the dial on full force. He knows what he is doing is dangerous, even potentially lethal, but he does it anyway. He tells her, '"You be brave, because I can't do that all the time. It might kill you'"[8]
Although he decides not to watch the operation, Frederic does go into the gallery to watch the doctors close the incision.
I thought Catherine was dead. She looked dead. Her face was gray, the part of it that I could see. Down below under the light, the doctor was sewing up the great long forcep-spread, thick-edged, wound. Another doctor in a mask gave the anaesthetic. Two nurses in masks handed things. It looked like a drawing of the Inquisition. I knew as I watched it I could have watched it all, but I was glad I hadn't. I do not think I could have watched them cut, but I watched the wound closed into a high welted ridge with quick skillful-looking stitches like a cobbler's, and was glad.[9]
Filled with fear, thinking that Catherine looked dead, Frederic immediately defends himself against his terror with his talent for clinical observation, which is also his compulsion. Then his poetic imagination takes over, revealing his horror, anger, and rather ironical view of life. For the birth scene
does not suggest to him a sacred or transcendent experience, such as a Nativity, perhaps, or the reverential awe one feels at the biological burgeoning of new life. Instead, the scene suggests, with all its concomitant intimations of torture, injustice, and probable death, "a drawing of the Inquisition." Frederic's thoughts reveal, too, the conflicts between his machismo and his gentler side: he says he could have watched "all" of the surgery but was "glad" that he "hadn't." Then he admits that he probably could not have watched the doctors "cut."
Frederic talks with Catherine after the surgery. He does not realize, and nobody has told him yet, that their infant was stillborn. A nurse later calls him out of the room and tells him what has happened.
Soon after, Frederic goes out for supper. He stays out for a very long time. It is as though something is driving him to eat and eat and drink and drink, to concentrate compulsively on what he is eating and drinking and, in so doing, not think about what has occurred and what might yet occur. The meal scene seems boringly protracted, eerie, and compelled. For Frederic it is a form of flight—from the hospital, from Catherine, and from himself.
I ate the ham and eggs and drank the beer. The ham and eggs were in a round dish—the ham underneath and the eggs on top. It was very hot and at the first mouthful I had to take a drink of beer to cool my mouth. I was hungry and I asked the waiter for another order. I drank several glasses of beer. I was not thinking at all but read the paper of the man opposite me. . . . When he realized I was reading the back of his paper he folded it over. I thought of asking the waiter for a paper, but I could not concentrate. . . . I ordered another beer. I was not ready to leave yet. It was too soon to go back to the hospital. I tried not to think and to be perfectly calm. . . . I drank another beer. There was quite a pile of saucers now on the table in front of me. . . . Suddenly I knew I had to get back. . . .
Upstairs I met the nurse coming down the hall.
"I just called you at the hotel," she said. Something dropped inside me.
"What is wrong?"
"Mrs. Henry has had a hemorrhage."[10]
Terrors race through Frederic's mind. "Everything was gone inside of me. I did not think. I could not think. I knew she was going to die and I prayed that she would not.[11]
When Frederic enters Catherine's room, he bursts into tears at her bedside. Now, by his presence and his words, he offers Catherine whatever comfort he can. As they talk, Catherine expresses her fears, her anger about what happened, and her love. Finally, the doctor tells Frederic that he must leave the room. Catherine needs her rest.
For a long time Frederic waits in the hallway. When he is finally permitted back in, Catherine has "had one hemorrhage after another" and is unconscious. Frederic remains with her. "She was unconscious all the time, and it did not take her very long to die."[12]
A final dialogue between Frederic and the doctor takes place in the hall outside of Catherine's room. The exchange, brief and broken, is based almost entirely around negatives. In the following excerpt, the doctor speaks first:
"I know there is nothing to say. I cannot tell you—"
"No," I said. There's nothing to say. . . ."
"It was the only thing to do," he said. "The operation proved—"
"I do not want to talk about it," I said.[13]
Immediately after this dialogue, Frederic's repressed anger translates itself into aggressive action. When a nurse tells him that he cannot go into Catherine's room, he says defiantly, "Yes, I can. . . . You get out. . . . The other one too."[14]
In Catherine's room silence reigns, as over a morgue. Now Frederic's objective, almost detached tone returns. "But after I had got them out and shut the door and turned off
the light it wasn't any good. It was like saying good-by to a statue. After a while I went out and left the hospital and walked back to the hotel in the rain." These words close the novel. They seem clinical and cold. But could any words vent what Frederic is feeling now? His pain is beyond the verbal. And like his wordlessness, his apparent aloofness, calmness, and control may be understood as his attempts to keep himself from falling apart emotionally.
Still, we wonder, can literature offer more than this—a mirror in words of our own wordlessness, fears, and flights? Can a doctor-writer offer further insights or help?
Liza of Lambeth
W. Somerset Maugham, who received his medical degree in 1897, actually came to grips with his art by grappling with a tale about a girl dying as a result of a miscarriage. His first novel, Liza of Lambeth , written when he was a medical student, was published in 1897. Its success led him to pursue writing instead of medicine as a career. This novel is also particularly poignant in terms of Maugham's own life because when he was eight, his mother died one week after giving birth to a baby who lived only one day. When he was a mature man, Maugham said that he never really recovered from the trauma of his mother's death. "When I was a small boy and unhappy I used to dream night after night that my life at school was all a dream and that I should wake to find myself at home again with my mother. Her death was a wound that fifty years have not entirely healed."[15]
Liza of Lambeth portrays the cockney-speaking slum of Lambeth, a borough of London, where girls marry young, have babies, are beaten up by their drunken husbands, and keep on having babies. Liza Kemp's mother has had thirteen children. But Liza is slightly different. A "young girl of about eighteen,"[16] she has an affair with Jim Blakeston, a married
man of around forty, who is already the father of five. And Jim's wife is pregnant again.
Whenever she can, Liza slips off with Jim, even after he blackens her eye one time. Finally, Jim's wife corners Liza in the street and beats her up. Liza goes home, gets drunk with her mother, and by the next day is in the throes of a miscarriage. "Liza began to have frightful pains all over her. . . and at last, about six o'clock in the morning, she could bear it no longer, and in the anguish of labour screamed out, and woke her mother."[17]
Mrs. Kemp rushes upstairs to get help from a neighbor, Mrs. Hodges, a (self-taught) midwife, who tells Liza's mother that her daughter has had a miscarriage. She also sends someone to the hospital to get a doctor. The news shocks Mrs. Kemp, who did not even know her daughter was pregnant. She is distressed, too, because Liza is not married.
When the doctor arrives, he offers little help or hope. His brief first visit to Liza and the cockney women is barely described.
The doctor came.
"D'you think she's bad, doctor?" asked Mrs. Hodges.
"I'm afraid she is rather," he answered. "I'll come in again this evening."
"Oh, doctor," said Mrs. Kemp, as he was going, "could yer give me somethin' for my rheumatics? I'm a martyr to rheumatism, an' these cold days I 'ardly knows wot ter do with myself."[18]
Why is the doctor so inarticulate? Could he not offer some help to Liza or the women—if not medical, then at least emotional? Liza is conscious now and in pain. Might not a doctor's word soothe or strengthen her?
If the doctor seems uncaring in this scene, another character seems even more insensitive: Liza's mother. After all, her daughter lies dying and all Mrs. Kemp does is complain to the doctor about her own ailments. Is her brain so addled
by alcohol that she is unaware of, or unmoved by. Liza's situation? Is she so wholly despicable?
By the time the doctor arrives that night, Liza is unconscious. Once again, the physician does not offer much help. In fact, his dialogue with the midwife is almost wordless. In his extreme brevity, however, the doctor conveys—to those who are listening carefully—not coldness but sadness and agitation. As in his earlier response to the midwife ("'D'you think she's bad, doctor?' . . . 'I'm afraid she is rather,' he answered"), the doctor uses the expression "I'm afraid." This phrase, an apparent politeness, also reveals his genuine anxiety.
"Wot do yer think of 'er, doctor?" said Mrs. Hodges. . . .
"I'm afraid she's very bad."
"D'yer think she's goin' ter die?" she asked, dropping her voice to a whisper.
"I'm afraid so!"[19]
The doctor sits down by Liza's side. Suddenly, Mrs. Kemp shows some emotion for her daughter: "she put her handkerchief to her eyes."[20]
Liza's mother and the midwife then talk. Although they speak about Liza a bit, they seem to concentrate on their own lives and problems. Yet their dialogue is very revealing about the defenses that people, especially paramedical or medical people, use; for the midwife, the paramedical person here (although unlicensed), discloses her need for them. Like a doctor or a nurse, she must face pain, suffering, and sometimes death in her work. And confronting these, she acknowledges, hurts "a very kind 'eart" and disturbs one's "peace of mind."
"I've been very unfortunate of lite," remarked Mrs. Hodges, as she licked her lips [from the brandy they were drinking], "this mikes the second death I've 'ad in the last ten days—women, I mean, of course I don't count bibies."
"Yer don't sy so."
"Of course the other one—well, she was only a prostitute, so it didn't so much matter. It ain't like another woman, is it?"
"Na, you're right."
"Still, one don't like 'em ter die, even if they are thet. One mustn't be too 'ard on 'em."
"Strikes me you've got a very kind 'eart, Mrs. 'odges," said Mrs. Kemp.
"I 'ave thet; an' I often says it 'ud be better for my peace of mind an' my business if I 'adn't. I 'ave ter go through a lot, I do; but I can say this for myself, I always gives satisfaction, an' thet's somethin' as all lidies in my line can't say."[21]
The atmosphere seems strangely, inappropriately, unemotional. But is it, realty? For are not the women's words attempts to block out, by not mentioning it, the imminent tragedy? And are not their words attempts to carve out some "peace of mind" because they "'ave ter go through a lot"?
Suddenly, Liza's lover bursts in. "Jim took the girl's head in his hands, and the tears burst from his eyes. . . . They all remained silent: Liza lying stiller than ever, her breast unmoved by the feeble respiration, Jim looking at her very mournfully; the doctor grave, with his fingers on the pulse."[22] Once again, the doctor is barely responsive. His sole medical act, symbolic at once of his usefulness—and uselessness—as a doctor, for he can do nothing here to save Liza, is to keep taking her pulse.
Because she can "bear the silence no longer," the midwife speaks.
"You 'ave got 'er insured, Mrs. Kemp? . . ."
"Trust me fur thet!" replied the good lady "I've "ad 'er insured ever since she was born. Why, only the other dy I was sayin' ter myself thet all thet money 'ad been wisted, but you see it wasn't; yer never know yer luck you see!"[23]
The word "luck" seems horrifying, outrageous. But it turns out that what Mrs. Kemp means is that with the insurance money she will be able to give Liza "a good funeral." Her
words, which seem incredibly callous or crazy, actually hide, and are meant to reveal, a real caring.
Mrs. Kemp and Mrs. Hodges then talk about funeral directors, types of caskets, and how Mrs. Kemp's husband, swollen with dropsy when he died, had had to be stuffed into his casket. Their dialogue is grotesque, comical—and pitiful.
"Suddenly a sound was heard—a loud rattle. It was from the bed and rang through the room, piercing the stillness."[24] Liza has just died. The doctor, who had been taking her pulse, places her hand on her breast. Now the women's emotions, against which they had been defending themselves until this moment, erupt: "the two women began weeping silently."
We note some similarities between the defenses used by these two illiterate women and the defenses that Mrs. S's doctors used: silence about the impending death; busyness with other things; preoccupation with the objective, nonemotional, technical, and practical. All these defenses are attempts to stay in control—or to appear to stay in control—of an uncontrollable and wrenchingly emotional situation.
Literature and Life
Comparing these literary cases with Mrs. S's, we see her virtual isolation mirrored in Lise's and Liza's fearful isolation. Only Catherine in A Farewell to Arms does not seem so terribly forsaken, and that is because her lover remained with her and talked with her.
When we turn to the families in the literary examples, we note that Lise's husband and father-in-law were no help to her during her labor and death, but their reactions afterward—guilt and anger—provide insights into her husband's mind and her father-in-law's defenses. Frederic Henry, who was helpful to Catherine, used powerful defenses to steel himself during her ordeal, which was also his ordeal. Liza Kemp's mother was also full of defenses that
made her appear cold and unfeeling, but little things revealed that Mrs. Kemp did care and was suffering deeply in her own way. She wanted to give Liza "a good funeral," and she wept silently at the end.
The doctors in the literary selections offer several parallels to Mrs. S's doctors. In War and Peace and A Farewell to Arms , the doctors were visibly unnerved by their experiences. In Liza of Lambeth , however, the doctor did not seem particularly shaken by his patient's death. Was that because Liza was so poor? Or was it because Maugham chose not to portray much of the doctor's reaction? Or did Maugham—with his medical background and the terrible memory of his own mother's death as a result of childbirth—actually portray the doctor's pain? It is true that Liza's doctor did not offer Liza or her family much help, either medical or emotional. He therefore resembled the doctors portrayed by Tolstoy and Hemingway, for those doctors, like Liza's doctor, were almost speechless. But speechlessness, as Tolstoy and Hemingway illustrated, might not be a sign of callousness; it might actually be a sign of caring. It is possible, then, that the doctor in Liza of Lambeth might have been suffering more than it appeared. Maugham's final words about him certainly suggest that. The doctor had kept taking her pulse. When she died, "The doctor opened one of Liza's eyes and touched it, then he laid on her breast the hand he had been holding, and drew the sheet over her head."[25] He had been holding her hand, not her wrist or her pulse. The words "breast" and "hand" suggest that for this doctor Liza was not just a patient or a body to be monitored but someone much closer to him—like a friend or a relative or a lover. She was someone whose breast he might have wanted to touch, someone whose hand he might have wanted to hold. Maugham's words suggest that for this almost inarticulate doctor, Liza was not just a patient but a person for whom, and about whom, he cared.
We think back to Mrs. S's doctors. Whenever possible, they had avoided being present. They had preferred flight to facing the patient. When they were at her bedside, they
could not really talk with her. What could they say—they and she, who could barely breathe? They were continually preoccupied with doing technical things—drawing blood, checking laboratory values, measuring pulmonary pressures. They were trying to do something . And like the doctors in at least two of the literary histories (and perhaps in Maugham's case as well), Mrs. S's physicians had been shaken, stunned, numbed, and speechless. They had felt helpless, angry, and guilty, perhaps, because they could do nothing to save their patients. Their wordlessness expressed, and tried to suppress, their sadness and frustration. For wordlessness is at times the most eloquent expression of grief.
The reactions of family members in the literary parallels help explain to some extent the doctors' reactions to Mrs. S. Was it because Mrs. S had no family visibly present that her doctors reacted, in a sense, like family? Or was it because the reactions of family members in the three literary selections are the reactions of doctors as well? Because in taking care of such a case, doctors become as intimately involved as family.
Literature, therefore, does offer something that is not at all negligible: the comfort of companionship. In their defenses and deeds, Mrs. S's physicians did not act like monsters but like men—like other human beings, like other doctors, and like the women's families as portrayed in literature. They acted like other people in similar circumstances. Such knowledge is calming, even reassuring in a way. But is it possible to find a better, more helpful way to react, a more positive, more constructive way to cope? Can a doctor find something more active than the quiet consolation of companionship?
Mauriceau"s Case History
A moving example comes not from literature this time but from life and the history of medicine. It is a case history
recounted by François Mauriceau (1637–1709), the French physician whose Treatise on the Diseases of Pregnancy and Childbirth , first published in 1668, was "a milestone in the history of obstetrics."[26] Mauriceau, whose name is immortalized in the "Mauriceau maneuver," was able to turn the tragedy of his twenty-year-old sister's death in childbirth into a driving force to understand, to create, and to continue caring—about the woman, her baby, and his own role as a doctor.
It was very difficult for Mauriceau to relate this history. In fact, some twenty-nine years after it happened, he wrote, "the memory [of my sister's death] is so painful to me, that the ink I am using to write it down now . . . seems to me to be made of blood."[27] But he decided to tell the story "so that the public . . . might profit from it."
His sister, "who was not yet twenty-one, was eight-and-one-half months pregnant, with her fifth child." Some three days after a fall, she began bleeding profusely. A midwife was called. After the patient had bled heavily for about five hours, the midwife sent for a famous surgeon, "the most skillful of all Surgeons, who was practicing childbirth in Paris."[28] When the surgeon arrived and saw his prospective patient in that state, "he merely said that she was a dead woman" for whom "nothing could be done but to have her receive the Sacraments." Then he left, abandoning "in that deplorable condition, and without any help at all, this woman whose life and whose child's life he would undoubtedly have saved, had he delivered her at that time."
About two hours later, Mauriceau learned what had happened and rushed over to his sister's apartment. She was still bleeding abundantly. He sent a messenger to the famous surgeon begging him to return; the surgeon refused. Since Mauriceau hesitated to deliver his own sister, he then sent for another surgeon. That doctor was not at home. Finally, Mauriceau had to perform the delivery himself. But because his sister "had previously lost all her blood," she died an hour after her baby was born.[29]
Mauriceau wants the reader to draw several conclusions from this "lamentable history."[30] First, he says, a doctor should do all that he can, as soon as he can, to deliver the infant. Second, he reasons that the famous surgeon fled from this difficult case out of fear—fear that the woman might die and fear that if she did die when in his care, other women might not use him as their accoucheur. Third, Mauriceau wants the story of "this bloodstained death" to serve as a lesson and an inspiration to other doctors, to teach them what they should and should not do and what they should and should not fear.
Reflections
On the night that Mrs. S died, all of her doctors felt something give way within them, too. They never said it; they could not. They barely spoke to Mrs. S or to each other. But the cardiologist voiced, silently but fully, their feelings of frenzy, sorrow, and despair when, without realizing it, he signed his own name on the line of the death certificate calling for the name of the deceased. That name could have been, and in a sense was, all of their names—and all of our names. For anyone who so much as observes such a case cannot help but become emotionally involved in it. Even observers are as participants. Further, when doctors can do nothing medical to save or even help a patient, they become, in a way, like all other people.
The literary histories have afforded some helpful and reassuring insights. They provide what all of us, who are so fearfully isolated in time of tragedy, really need and crave: the consolation of companionship. And Mauriceau's case history, written in an "ink . . . of blood," gives us—doctors and lay people alike—a fierce and forceful impetus to action: to face, and not to flee from, a woman who may be doomed to die in the act of creating new life; to face, and not to flee from, ourselves.