Work Text:
Combeferre wrote, in pencil, on a fresh sheet of paper:
Saturday, 21st of April, 1832
9 o'clock in the evening
The church bells sounded at Saint-Sulpice, announcing the beginning of the Easter Vigil. Churchgoers began their observance before the Paschal Candle; Combeferre began his night rounds at Necker.
The rows of curtained beds yawned before him, curtains drawn, a name card attached to the sturdy metal frame. Frequently, he parted the bed curtains to find them empty, the patient discharged or dead. Less frequently, he parted the curtains to find a corpse. In a way, those beds seemed emptier. But for the most part, it was his job to rouse the sleeping, and for the most part, they did wake. Though it was evening, the lights burned false daylight for his sake, not the patients'. Outside, the world was black, and inside it was yellow from the gas lamps lining the walls. The light, however, did not quite reach the ceilings. It was day as long as man kept his eyes away from the heavens.
The windows had been closed against the morning's unseasonable rain, and no one had remembered to open them yet. Necker became an incubator, the fragrances of over two hundred diseased and injured bodies left to mingle in the bottle. The top note, excretions; the middle note, sweat; the base note, blood.
The students meant to shadow his evening round, including Joly, should've been here by now. He had overheard that the students preferred evenings when Combeferre's fellow senior interne, Waldman, handsome and comical and consciously ironic in his Swedenborgianism, did the rounds. They couldn't be blamed for having a preference, but Combeferre worried about their hands-on experience. He occasionally filed away one of Waldman's gestures or turns of phrase, but it seemed he didn't know how to deploy them properly; students eyed him as though he was wearing stolen clothing.
Joly's absence, however, was probably due to the dyspepsia he'd reported last night. Joly had ambitions to take the competitive exam to become an interne at the next opportunity, and the loss of valuable experience in the wards was not to his advantage. But a member of Joly's dissection group, one Joly often had over for drinks, had died of cholera last week. Combeferre had arrived to give his condolences and found Joly methodically scrubbing his flat, pockets bulging with his magnets, while Musichetta put cool cloths on his head.
His assistant for the evening, an externe whose sweat soaked through his collar, approached, bearing charts and the notes that Waldman had taken during morning rounds. "Christus resurréxit," said the externe. Combeferre couldn't place his name, but remembered his forehead bearing an ashen cross the day before, much to the disdain of every student in the lecture hall. It was a bit early for Easter greetings; Christ's body was still in its wrappings. There was a joke to be made, something about counting eggs before they hatched, but Combeferre did not have the energy to be anti-clerical, nor the desire to heap scorn upon men who had the stomach and nerve for faith.
"Resurréxit vere," Combeferre replied, and the externe beamed. Not wanting to be too encouraging, he continued, "Anything of note?" It was a more delicate way to ask if there were any new diagnoses besides cholera.
"A case of pleural effusion," said the externe. "He's a strange fellow. Waldman's scheduled him for a surgery next week, I expect the students will be thrilled."
Combeferre took the charts and notes with a nod, excusing himself to begin rounds. He made a habit of not reading Waldman's notes until the end of his round, if at all possible, though Waldman perused Combeferre's notes before he even greeted his first patient. It was flattering at best, concerning at worst. Combeferre severed his trust every night when he entered the hospital. His own judgments, his own observations, had to be his guide.
The horror of cholera was not the series of bodies falling apart, it was that no one's description of their symptoms was unique. Sometime last month, Combeferre had stopped hearing original replies to his questions. He had heard the crude, the delicate, the angry, the pious, the understating, the disbelieving, the beautiful, the delusional, the silent. Necker was one diseased body of symptoms, dry-mouthed, vomiting, sweating, putrid, incontinent, soiled. Every individual case was one dying cell, crying out its part in the requiem.
Conditions plateaued or worsened. He tried very hard not to carry these thoughts with him to the Musain, where improvement was the only tolerable outcome. But it was, at times, hard to keep his thoughts in the appropriate places. There were times when he had wounded Enjolras with an accidental moment of skepticism, or alienated a group of buoyant workers by comparing 1830 to a bloody stillbirth he had witnessed just two days ago. The world at large was within his reach: it was his job to keep it at a distance or draw it close, and his arm occasionally smarted with the suddenness of a contraction.
The wards were quiet. Some patients tried to sit up to wait for him so they could sleep through the night uninterrupted, but most had little control over whether they woke or slept. Again and again, the same reports of feeling much worse, a bit worse, or quite the same. The new admissions were always difficult, trying to get a peek at their futures by asking about their fellow patients. Combeferre maintained strict confidentiality as much as he could, speaking in low tones, offering few details. Yes, he understood their complaints about the heat; yes, he would do what he could.
He saved Waldman's pleural effusion case for last. The patient had not drawn his curtains, and was sitting up in bed. He'd been observing Combeferre for some time, his hands on his lap. He was extremely tall; the bed ended at his shins, leaving his legs to dangle over the empty space between beds. In the half-shadow of his bedclothes, his face was brutally geometrical, his hair long and lank. Combeferre glanced at the name card just visible under the man's leg. The card was blank.
"Good evening," said Combeferre. "I'm afraid I don't have your name."
"Are you the doctor?" asked the man. French was clearly not his first language, though he seemed confident in his words. The accent was strange. Perhaps he was from farther east.
"I'm the interne, acting as your physician."
"But not a doctor?"
"No, I'm in my final year as a student."
"Student!" said the man. "Everywhere I turn, more students, peering under mountains to find their origins. Where are the doctors? Where are the men who are done asking questions?"
This kind of complaint wasn't uncommon. Hundreds of patients per day, each fearing for their life, obviously all wanted personal attention from a physician. And, when the physician did show up, he did so thronged by a crowd of students, eager to hear his diagnosis. "I regret that I only have myself to offer," said Combeferre. "My name is Combeferre. What's yours?"
"I have nothing to offer you in return," said the man.
"No self, or no name?"
The man smiled. "Is there a difference?"
It was a challenging question. Combeferre was inclined to say yes, there was. Before the faculty of communicative language, there was the primordial consciousness, the idea of identity. A man with no name was himself to himself, at least, if not to others. "May I lend you one, then?"
"Oh, please."
"Very well, Monsieur Toulemonde."
The man made a quick, barking sound, as though he did not have the time to laugh longer. "You either think very highly of me, or very lowly."
Combeferre entered the name in his notes. "How old are you, sir?"
"I don't know."
"I don't need the exact date of your birth."
"Well, that's a good job."
"A rough estimate will do." Sweat beaded at Combeferre's temples, at the nape of his neck. His spectacles slipped down the bridge of his nose, and before he could move a hand to right them, the man had reached out a long, thick arm and pushed them back up.
"I knew a man who wore such spectacles," said the man, folding his hands on his lap again. "Very much like yours, in fact, and he was a student, too. Though he resemblance ends there. He was very fair, in a cool and dying manner, you must know the kind. Fair eyes, dissolved in the light, fair hair, terribly kept in its queue. Queues seem to be quite out of fashion, now. I'm not used to it, you see, the world changing around me. Perhaps it's simpler when one is inoculated into change, by virtue of being unaware of it for so long. A babe, and then a child, and then a man: and when he looks back to see that his clothes no longer fit, he is not afraid, because he has already arrived at the destination without knowing. Of course, things will change again, but he has survived that before, and without knowing."
Queues, and a distrust of students, and the terror of change. He must've been something like fifty. Combeferre settled on fifty-five. "Where are you from?"
"You mean where was I born? Ingolstadt, Germany. Do you know the university there?"
"I know of it."
"Then you know of the place I took my first steps. Though, I did not stay long enough to love it."
"You travelled?"
"Oh, I did," said the man. He leaned back against the headboard, looking up at the canopy. His long neck stretched, revealing a pale skin with veins so dark that he seemed to be an anatomist's engraving come to life. He existed in too much contrast, too much whiteness beside too much darkness. "Switzerland, England, Scotland, Ireland, Russia. I have, in fact, recently returned from the North Pole."
Even using shorthand, Combeferre found it difficult to keep up. "That's an impressive itinerary." An eccentric aristocrat-turned-loafer, perhaps, or otherwise a merchant sailor. The vocabulary spoke to the former. "Was it for leisure, or employment?"
"I miss it, the Arctic," said the man. "I could try to describe it to you, Monsieur l'étudiant, but there's no use. Especially not to someone like you, living in this writhing city, this teeming nest of carriages and their horses and their drivers and the places where the drivers must go. But I suggest you visit it, if you're ever able to do so. Imagine the roar of the ocean, or the roll of thunder, if the sound was willed with nothingness: a glorious absence. You, in this sickly beehive of a city: have you ever known any kind of quiet?"
Combeferre had paid too much money for a copy of Captain Lyon's journal, documenting the expedition to the Arctic under Captain Parry. His English was, admittedly, substandard, but even with that allowance, he didn't care for Lyon's prose, which tended to ogle more than it documented. But tucked into the center was a plate entitled "The Last Appearance of the Sun for 42 Days." It was simple, with the covered ship sitting in the frozen sea, surrounded by tiny signs of life, and a few dark figures in the foreground watching the sun dip down. What he liked about it was not any of these things: he liked the lack of everything else, the absence of buildings, the spaces where trees might go. He was drawn to its emptiness.
"I've known of it," Combeferre replied. "What are your complaints?"
"Numerous and passionate. But, as far as you are concerned, I have difficulty breathing. I am weak, I swoon like a poet. Stairs are an impossibility. I cough, often; sometimes there is blood."
"Only blood? No other manner of fluid, perhaps something white or yellow?"
"I haven't paid attention," said the man, "as I've been rather distracted by the blood."
"I understand. In what quantities?"
"I've never thought to measure it. More blood than man should lose; less than would be fatal."
"How long have you had these complaints?"
"Perhaps a year, perhaps two. I was in London before I came here, and the hospital was much better. The staff was kinder. Sisters of charity tended the beds, blessing the patients, praying for their souls. My first night, one sister held my hand until dawn, sitting vigil. I was given warm baths of vinegar and herbs. But they didn't tell me anything. At last, my physician withdrew his head from my chest and told me: if you want common decency, sir, stay here; if you want answers, go to Necker. And here I am."
"We pride ourselves on diagnostics, not therapeutics, it's true," said Combeferre. "But the physician must fully understand the nature of the sickness before it can be treated. Common decency can be found through action, not just rhetoric."
"And it would be too much to ask for both."
It was best to move on. "Your English physician listened to your lungs. Did he use any instrumentation?"
"Should he have?"
"Did my colleague, this morning, use any instrumentation?"
"Should he have?"
"If you could just part your shirt, sir, I'll perform an auscultation of the lungs."
"Of course." The man pulled at his rag of a cravat. He was missing several buttons on both his waistcoat and shirt, so his chest was already half-bare. He revealed a peculiar scar: two lines right under his collarbones, meeting at an obtuse angle in the center of his chest, running down his sternum. The scar itself was very clean, surely done by a surgeon's hand, with very little hypertrophy. The line revealed itself more by discoloration than texture. It took Combeferre a moment to place the scar, because he was used to seeing it in a very particular environment: the dissection hall.
"Thank you," said Combeferre.
It would be unwise to use his own limited experience as an unimpeachable base. It was true, the Y-incision was most commonly used in matters of autopsy, allowing broad access to the body cavity. And, yes, it was also true that he had never seen this permutation of scarring on a living man. However, overawe in the face of the unknown was the realm of poetics and not science. It was possible that this was an amalgamation of scarring: the midline incision was not unusual, although its length was perhaps excessive. A better surgeon might have kept the incision relegated to the necessary area, rather than open the entire thorax.
The subclavicular incisions, however, posed an issue. Access to the heart? Not impossible. Romero and Larrey had proven the efficacy of cardiac surgery decades ago, but that was for access to the pericardium. And incisions on both the left and right halves of the chest?
Combeferre's second assumption was that this man had endured some incredible surgery at the hands of an experimental doctor of questionable talents. Perhaps, he thought rather half-heartedly, the removal of numerous tumorous masses, or a corrective surgery following an accident.
His first assumption, which he had to double back to, was that someone had performed an autopsy on this man while he was still living.
In their first-year days, before the thick callouses of surgical apathy covered their skins, Combeferre's cohort had joked about their cadavers coming alive in the dissection halls. "He'd better pay me back my five francs," someone had said, "or otherwise, leave me an arm or a leg to pull apart." A few nervous chuckles, some playful hand-shaking with the cadavers before the demonstrator entered the room. Some students even named their corpses. It seemed to help, although Combeferre could not fully appreciate why as dozens of clumsy hands butchered cold human flesh, searching for precious organs which slipped away like fish. Ribs splintering, veins and arteries torn apart, joints wrenched into unnatural angles, in a bloody quest to understand the machine.
He'd gone into the cool, damp dissection halls at sunset and emerged when the moon was out, smelling like an abattoir, ravenously hungry, unable to eat. And then, the same thing again the next night. Mindless exploration, a worm snuffling through the dirt, unsure where he'd been or where he was going. They'd stopped naming their corpses by the next winter. Some smoked when the demonstrator was absent, not even wiping their hands before filling their pipes.
In that first year, he'd won a prize from the École pratique: free cadavers for the rest of his education, and first pick of the bodies when the time came for dissection. He became a very popular dissection partner. While his classmates argued their rank and experience, vying for his hand, Combeferre looked over the options and tried to determine the freshest. Who was only a few breaths gone? That was the ideal cadaver: someone who looked like they could open their eyes the moment they were cut into.
The man had leaned closer, his chest thrown forward and his head tilted back. The light passed over his eyes: a light brown iris and a dark yellow sclera, nearly matched in hue. A problem of the liver, perhaps, along with the pulmonary issue. The sallowness of the skin, with its dark hollows, the mention of fatigue, the implication of a poor diet during travels, the jaundice: hemolytic anemia? He refuted himself for his bad habit of sourcing all symptoms back to a singular cause, but if he was right, anemia would only worsen a pulmonary disease.
"What do you think?" asked the man.
"I beg your pardon?"
"Behold this goodly frame." The man opened his arms, a bird of prey before the dive. The skin around his scar puckered strangely.
"Your surgeon had skillful hands," said Combeferre, setting his papers aside. "For an incision of this kind to heal so cleanly, it's remarkable." He did not want to upset this man, who presented himself with such scorn, but he could hardly resist asking: "What was the purpose of the operation?"
The man's arms dropped. He looked for a moment like a schoolboy whose make-believe game had just been brushed aside, but he straightened his spine once more before replying with a curling lip, "Complications due to the nature of my birth."
He had pushed too far. Combeferre unscrewed his stethoscope.
"That looks like a telescope," said the man.
"It is," said Combeferre. "But for the ear, not the eye. I place this broad end against your chest, and the sound is funneled along here, where I can hear it properly."
"Like its brother, it makes the imperceptible known. The stars and the heart are both within reach. I am fathoms deep, Monsieur l'etudiant. Sound me."
Combeferre leans down, pressing the broad end of the stethoscope just under the man's right clavicle, avoiding the scar. "Inhale and exhale each time I move the cylinder, please."
The man breathed in, nearly choked, cleared his throat, and began again. It was imperative that Combeferre focus on the sound itself first, not its name, and not its diagnosis. Though his textbooks and lecturers supplied him with the descriptors he was to look for, it was easiest for him to entertain the sound as he would a piece of art.
The sound of this man's lung was the same as the engraving in Captain Lyon's journal. The sound was not hollow, not vacuous, but an expanse of something that was not breath. Breath itself was a shout into an open plain, with no surfaces close enough to return an echo.
Tense between the eyebrows, Combeferre moved down the intercostal spaces to the right middle lobe. Again, the expanse. The breath was also disjointed, as though momentarily lost within the lung. It was similar to the sound of the top lobe. Further down, at the lower lobe, the sound sank, aimless, until it found solid ground, but it struggled to raise itself again. He began to repeat the process on the left, on the upper and lower lobes, but was interrupted by an unusual sound: air rushing into the middle of the chest.
Now was not the time to tell himself that there was no middle lobe on the left lung, due to the space taken up by the heart. It was not the time to call to mind the engravings of lungs, or memories of lungs pulled freshly from bodies by his own bloody hands, or the feeling of the concave cardial notch between his fingers. It was the time to move back and forth between the left and right and understand that these sounds were identical.
He withdrew. The middle lobe on the left: some deformity from birth, perhaps. A gruesome surgery: a failed attempt to correct it. That the man had lived so long, and bore such a healthy heartbeat, was miraculous. And yet, the miraculous lung, like its twin, was diminished. The lung tissue within was eaten away like rusted metal. It was a sound he had heard before in a hundred more ordinary tubercular lungs.
"Well?" asked the man.
Combeferre rifled through his papers to find Waldman's notes. He had left the patient information, and most of the chart, blank. His diagnosis: pleural effusion, buildup of fluid in the lungs suspected. Recommend surgical intervention, drainage and inspection of fluid.
He second-guessed his ears, trying to understand how Waldman could mistake the creaking sound of pleural rub with this expanse of air. He stared at the note, trying to make sense of it, until he noticed that the words 'surgical intervention' were written in slightly larger letters. It had been a while since their last thoracic surgery, and a while since Waldman got to demonstrate his deft surgeon-in-training's hand.
"I believe it is pulmonary consumption."
The man did not respond.
Bedside manner was Combeferre's great challenge. He found the balance between practicality and consideration a tenuous one. The man did not seem confused, at least - merely waiting for more. "I am able to diagnose it through both the description of your symptoms," Combeferre added, "and by sounding your lungs. There is a distinct resonance which enables me to determine your condition."
"Is it fatal?" asked the man.
"Remission is possible. But the effect has reached the lower lobes of both lungs. It is- advanced."
The man laughed. Perhaps it was the after-effect of the stethoscope, but Combeferre heard a strange stopped quality in this laugh, which wanted to boom. It wasn't bawdy laughter for show, but a long series of chuckles, one that could be heard over lunch after a particularly good joke. The other patients, at least, didn't seem disturbed by it. Combeferre said nothing until the man began to cough between his bouts.
"You will have to be careful of overextending yourself."
The man waved a hand. "How did I come by this disease?"
Like a student at the podium, he gave the appropriate answer. "It is believed that pathogenic tubercles in the lungs lie dormant in the tissue until inflamed, usually by poor or humid air. Continued poor conditions lead to decline, but a change in condition can result in improvement." Cure, that would've been the more positive word. It is also a word he found difficult to say.
"And these tubercles," said the man, "where do they come from?"
"It's likely hereditary."
"These lungs," said the man, speaking very slowly, "which reside in my breast, have been blighted with disease? From the first day my creator saw to put them in me? From the first day I drew breath?"
"Did your mother or father suffer from consumption?"
The man laughed again, loud enough this time to make the bed curtains around him rustle indignantly. He swung his long legs around off the bed, so quickly that Combeferre barely managed to move out of his way. The man put his bare feet in his boots, and began to lace them. "I'd best be on my way. I have limited time."
"I recommend that you stay."
"Why?" asked the man.
Combeferre gestured to the papers. "Observation."
The man sat up straight, smiling. "I understand. You want to watch me die. You are, as you say, not a doctor. You're a student, and your subject is death. Well, that suits me very well. I've had my fill of doctors, of the study of life. How glorious, to understand the flame as it burns out! But surely, Monsieur l'etudiant, you have enough dying flames to suit your studies?" He laughed again. "There's nothing unique about my death. My lungs are, how do you say it, buggered, in the most ordinary manner. Oh, great creator, see what becomes of your clay! What mediocrity is heaped upon Prometheus, dying uninspired!"
"Sir, please, lower your voice," said Combeferre, "the others are trying to rest."
"Then you should remove me, for you will do me no good, and I will do only harm towards them. When you become a physician, you will take the oath. Primum non nocere - first, do no harm. I tell you, Hippocrates renders you a hypocrite when you say those words. Doing, itself - to have taken action - is harm. Mankind self-flagellates with every movement and calls it a kindness. You've seen death, but tell me: have you killed?"
Underneath the memories of school-sanctioned death were the deaths under the sanction of ideals. Murder and treason under one circumstance; defense and justice under another. His gun, misfiring; a brick nearby; a National Guard, reloading; the brick breaking into the skull. A figure so distant that it did not have a face; the necessity of moving through the alley; his being the steadiest hand; an unobstructed path. Hapless shots into a column of men, because there was no time to aim lethally, mercifully.
All the bedcurtains were closed, and the externes were just beginning their duties at the other end of the ward. Combeferre nodded.
The man, for the first time, gave away his surprise willingly. "What a creature you are. A man philandering before his wedding night, perhaps, or a baker glutting himself before Lent? If not, then what will you do after you take up your mantle? It is easy to resist killing before one has ever killed, but once you have a taste for it-"
"Killing is not always a matter of taste," Combeferre replied, louder than he should have spoken. "Killing is not always a crime. And, if it is, crime is not always harm."
The man considered him briefly, as though he was the examiner and Combeferre his patient. He did not like what he saw. He returned to lacing up his boots. "I am bored with you, Monsieur l'etudiant. I am bored with men who protect a humanity they do not understand, and I am bored with a humanity that does not understand itself, and I am bored with shrinking under its weight.
"I thought, once, that I would have the courage to take my life, but I found myself incapable. Not out of any reason I could give myself, but sheer will, bound into my viscera. It is not my will, but my creator's. He instilled me with his own pride, which I could not usurp. I resigned myself to living. But now, glorious news! No more dreary toil. My god is usurped by those little invasions, far greater than his intentions, and I will soon be free. The great nothing awaits me." He stood up. "Solitude, sometimes, is best delight."
"You strip the context to suit your purpose, not Milton's," said Combeferre, and he completed the phrase: "And short retirement urges sweet return."
The externes had taken notice of them now. The Catholic, in particular, was skirting along the walls, as though he would be able to do something about the situation. The man loomed over Combeferre, dissatisfaction in his face.
"There is no cure," he said.
"There are still lesser goods than cures."
"Why should I be satisfied with that?"
"You shouldn't. But you have the option to be so."
The windows groaned as the externes pried them open. A gust of cool air entered the room, and several patients gave audible sighs of relief, or thanked Jesus for the sweetness of his breath. The heat was displaced, bit by bit, and replaced with the fresh smell of dampness and mud.
The man eyed each window closely, craning his neck a bit to see beyond.
"I do not deny your right to solitude," said Combeferre. "I will discharge you, if you like. But, as your acting physician, I would remind you that life is defined by impermanence, as are its states. There is no need to linger in isolation longer than you deem fit."
The man put his hand to his chest, still bared. His fingers lingered over his heart, over that fantastical lung, now cavernous. "You are not like the student I knew," he said. "He was a man who, like me, consumed darkness-" His smile was less vicious this time. "And, like me, fell to consumption. But there was another man who entered that sunless Arctic and did not linger. Fascination and victory, for him, fell secondary to mankind. God knows if he survived his retreat into light, but he made the attempt to return. Perhaps, at least, he is survived in you."
Hand still over his heart, the man said, "Warmer climes suit lungs like these, don't they?"
"Yes," said Combeferre.
"I think I'll keep the name," said the man. "Toulemonde." He retreated down the line of drawn beds, very noiselessly, scattering the externes, and slipped into the main hall.
Outside, the clock struck midnight, signaling the pre-dawning of Easter morning. Resurréxit vere, Combeferre thought, and began the discharge notes.