Category Archives: Medicine

The Making of the Eye

By Ken · Posted in Life, Medicine, Nature, People, Science

by Sir Charles Sherrington

This is the finest description I’ve read of the wonder of life. It’s long, but oh-so worth it. I’ve included this extract in full because it’s a story everyone should read at least once, just to taste the sheer miraculousness of it. The English physiologist Sir Charles Sherrington (1857-1952) won a Nobel Prize in 1932 for his work on the nervous system of mammals. Experimenting on cats, dogs, monkeys and apes that had had their cerebral hemispheres removed, he showed that reflexes must be regarded as integrated activities of the whole organism. He coined the words ‘neuron’ and ‘synapse’ to mean the nerve cell and the point at which the nervous impulse is transmitted from one cell to another. His book Man and His Nature (1940) presents man – both mind and body – as the product of natural forces acting upon the materials of our planet. This extract is from the second edition, 1951.

The eye
Can then physics and chemistry out of themselves explain that a pin’s-head ball of cells in the course of so many weeks becomes a child? They more than hint that they can. A highly competent observer, after watching a motion-film photo-record taken with the microscope of a cell-mass in the process of making bone, writes: ‘Team-work by the cell-masses. Chalky spicules of bone-in-the-making shot across the screen, as if labourers were raising scaffold-poles. The scene suggested purposive behaviour by individual cells, and still more by colonies of cells arranged as tissues and organs.’[1] That impression of concerted endeavour comes, it is no exaggeration to say, with the force of a self-evident truth. The story of the making of the eye carries a like inference.

The eye’s parts are familiar even apart from technical knowledge and have evident fitness for their special uses. The likeness to an optical camera is plain beyond seeking. If a craftsman sought to construct an optical camera, let us say for photography, he would turn for his materials to wood and metal and glass. He would not expect to have to provide the actual motor power adjusting the focal length or the size of the aperture admitting light. He would leave the motor power out. If told to relinquish wood and metal and glass and to use instead some albumen, salt and water, he certainly would not proceed even to begin. Yet this is what that little pin’s-head bud of multiplying cells, the starting embryo, proceeds to do. And in a number of weeks it will have all ready. I call it a bud, but it is a system separate from that of its parent, although feeding itself on juices from its mother. And the eye it is going to make will be made out of those juices. Its whole self is at its setting out not one ten-thousandth part the size of the eye-ball it sets about to produce. Indeed it will make two eyeballs built and finished to one standard so that the mind can read their two pictures together as one. The magic in those juices goes by the chemical names, protein, sugar, fat, salts, water. Of them 80 per cent is water.

Water is the great menstruum of ‘life’. It makes life possible. It was part of the plot by which our planet engendered life. Every egg-cell is mostly water, and water is its first habitat. Water it turns to endless purposes; mechanical support and bed for its membranous sheets as they form and shape and fold. The early embryo is largely membranes. Here a particular piece grows fast because its cells do so. There it bulges or dips, to do this or that or simply to find room for itself. At some other centre of special activity the sheet will thicken. Again at some other place it will thin and form a hole. That is how the mouth, which at first leads nowhere, presently opens into the stomach. In the doing of all this, water is a main means.

Dragonfly eye2 Dragonfly’s eyes.
The eye-ball is a little camera. Its smallness is part of its perfection. A spheroid camera. There are not many anatomical organs where exact shape counts for so much as with the eye. Light which will enter the eye will traverse a lens placed in the right position there. Will traverse; all this making of the eye which will see in the light is carried out in the dark. It is a preparing in darkness for use in light. The lens required is biconvex and to be shaped truly enough to focus its pencil of light at the particular distance of the sheet of photosensitive cells at the back, the retina. The biconvex lens is made of cells, like those of the skin but modified to be glass-clear. It is delicately slung with accurate centring across the path of the light which will in due time some months later enter the eye. In front of it a circular screen controls, like the iris-stop of a camera or microscope, the width of the beam and is adjustable, so that in a poor light more is taken for the image. In microscope, or photographic camera, this adjustment is made by the observer working the instrument. In the eye this adjustment is automatic, worked by the image itself!

The lens and screen cut the chamber of the eye into a front half and a back half, both filled with clear humour, practically water, kept under a certain pressure maintaining the eye-ball’s right shape. The front chamber is completed by a layer of skin specialised to be glass clear and free from blood-vessels which if present would with their blood throw shadows within the eye. This living glass-clear sheet is covered with a layer of tear-water constantly renewed. This tear-water has the special chemical power of killing germs which might inflame the eye. This glass-clear bit of skin has only one of the fourfold set of the skin-senses; its touch is always ‘pain’, for it should not be touched. The skin above and below this window grows into movable flaps, dry outside like ordinary skin, but moist inside so as to wipe the window clean every minute or so from any specks of dust, by painting over it fresh tear-water.

The light-sensitive screen at the back is the key-structure. It registers a continually changing picture. It receives, takes and records a moving picture life-long without change of ‘plate’, through every waking day. It signals its shifting exposures to the brain.

This camera also focuses itself automatically, according to the distance of the picture interesting it. It makes its lens ‘stronger’ or ‘weaker’ as required. This camera also turns itself in the direction of the view required. It is moreover contrived as though with forethought of self-preservation. Should danger threaten, in a moment its skin shutters close protecting its transparent window. And the whole structure, with its prescience and all its efficiency, is produced by and out of specks of granular slime arranging themselves as of their own accord in sheets and layers and acting seemingly on an agreed plan. That done, and their organ complete, they abide by what they have accomplished. They lapse into relative quietude and change no more. It all sounds an unskilful overstated tale which challenges belief. But to faithful observation so it is. There is more yet.

The little hollow bladder of the embryo-brain, narrowing itself at two points so as to be triple, thrusts from its foremost chamber to either side a hollow bud. This bud pushes toward the overlying skin. That skin, as though it knew and sympathized, then dips down forming a cuplike hollow to meet the hollow brain-stalk growing outward. They meet. The round end of the hollow brain-bud dimples inward and becomes a cup. Concurrently, the ingrowth from the skin nips itself free from its original skin. It rounds itself into a hollow ball, lying in the mouth of the brain-cup. Of this stalked cup, the optic cup, the stalk becomes in a few weeks a cable of a million nerve-fibres connecting the nerve-cells within the eye-ball itself with the brain. The optic cup, at first just a two-deep layer of somewhat simple-looking cells, multiplies its layers at the bottom of the cup where, when light enters the eye – which will not be for some weeks yet – the photo-image will in due course lie. There the layer becomes a fourfold layer of great complexity. It is strictly speaking a piece of the brain lying within the eye-ball. Indeed the whole brain itself, traced back to its embryonic beginning, is found to be all of a piece with the primordial skin – a primordial gesture as if to inculcate Aristotle’s maxim about sense and mind.

The deepest cells at the bottom of the cup become a photo-sensitive layer – the sensitive film of the camera. If light is to act on the retina – and it is from the retina that light’s visual effect is known to start – it must be absorbed there. In the retina a delicate purplish pigment absorbs incident light and is bleached by it, giving a light-picture. The photo-chemical effect generates nerve-currents running to the brain.

The nerve-lines connecting the photo-sensitive layer with the brain are not simple. They are in series of relays. It is the primitive cells of the optic cup, they and their progeny, which become in a few weeks these relays resembling a little brain, and each and all so shaped and connected as to transmit duly to the right points of the brain itself each light-picture momentarily formed and ‘taken’. On the sense-cell layer the ‘image’ has, picture-like, two dimensions. These space-relations ‘reappear’ in the mind; hence we may think their data in the picture are in some way preserved in the electrical patterning of the resultant disturbance in the brain. But reminding us that the step from electrical disturbance in the brain to the mental experience is the mystery it is, the mind adds the third dimension when interpreting the two dimensional picture! Also it adds colour; in short it makes a three dimensional visual scene out of an electrical disturbance.

All this the cells lining the primitive optic cup have, so to say, to bear in mind, when laying these lines down. They lay them down by becoming them themselves.

Cajal, the gifted Spanish neurologist, gave special study to the retina and its nerve- lines to the brain. He turned to the insect-eye thinking the nerve-lines there ‘in relative simplicity’ might display schematically, and therefore more readably, some general plan which Nature adopts when furnishing animal kind with sight. After studying it for two years this is what he wrote:

The complexity of the nerve-structures for vision is even in the insect something incredibly stupendous. From the insect’s faceted eye proceeds an inextricable criss-cross of excessively slender nerve-fibres. These then plunge into a cell-labyrinth which doubtless serves to integrate what comes from the retinal layers. Next follow a countless host of amacrine cells and with them again numberless centrifugal fibres. All these elements are moreover so small the highest powers of the modern microscope hardly avail for following them. The intricacy of the connexions defies description, before it the mind halts, abased. In tenuis labor. Peering through the microscope into this Lilliputian life one wonders whether what we disdainfully term ‘instinct’ (Bergson’s ‘intuition’) is not, as Jules Fabre claims, life’s crowning mental gift. Mind with instant and decisive action, the mind which in these tiny and ancient beings reached its blossom ages ago and earliest of all.

Fly's eye Fly’s eyes.
... The human eye has about 137 million separate ‘seeing’ elements spread out in the sheet of the retina. The number of nerve-lines leading from them to the brain gradually condenses down to little over a million. Each of these has in the brain, we must think, to find its right nerve-exchanges. Those nerve-exchanges lie far apart, and are but stations on the way to further stations. The whole crust of the brain is one thick tangled jungle of exchanges and of branching lines going thither and coming thence. As the eye’s cup develops into the nervous retina all this intricate orientation to locality is provided for by corresponding growth in the brain. To compass what is needed adjacent cells, although sister and sister, have to shape themselves quite differently the one from the other. Most become patterned filaments, set lengthwise in the general direction of the current of travel. But some thrust out arms laterally as if to embrace together whole cables of the conducting system.

Nervous ‘conduction’ is transmission of nervous signals, in this case to the brain. There is also another nervous process, which physiology was slower to discover. Activity at this or that point in the conducting system, where relays are introduced, can be decreased even to suppression. This lessening is called inhibition; it occurs in the retina as elsewhere. All this is arranged for by the developing eye-cup when preparing and carrying out its million-fold connections with the brain for the making of a seeing eye. Obviously there are almost illimitable opportunities for a false step. Such a false step need not count at the time because all that we have been considering is done months or weeks before the eye can be used. Time after time so perfectly is all performed that the infant eye is a good and fitting eye, and the mind soon is instructing itself and gathering knowledge through it. And the child’s eye is not only an eye true to the human type, but an eye with personal likeness to its individual parent’s. The many cells which made it have executed correctly a multitudinous dance engaging millions of performers in hundreds of sequences of particular different steps, differing for each performer according to his part. To picture the complexity and the precision beggars any imagery I have. But it may help us to think further.

There is too that other layer of those embryonic cells at the back of the eye. They act as the dead black lining of the camera; they with their black pigment kill any stray light which would blur the optical image. They can shift their pigment. In full daylight they screen, and at night they unscreen, as wanted, the special seeing elements which serve for seeing in dim light. These are the cells which manufacture the purple pigment, ‘visual purple’, which sensitizes the eye for seeing in low light.

Then there is that little ball of cells which migrated from the skin and thrust itself into the mouth of the eye-stalk from the brain. It makes a lens there; it changes into glass-clear fibres, grouped with geometrical truth, locking together by toothed edges. The pencil of light let through must come to a point at the right distance for the length of the eye-ball which is to be. Not only must the lens be glass-clear but its shape must be optically right, and its substance must have the right optical refractive index. That index is higher than that of anything else which transmits light in the body. Its two curved surfaces back and front must be truly centred on one and the right axis, and each of the sub-spherical curvatures must be curved to the right degree, so that, the refractive index being right, light is brought to a focus on the retina and gives there a shaped image. The optician obtains glass of the desired refractive index and skilfully grinds its curvatures in accordance with the mathematical formulae required. With the lens of the eye, a batch of granular skin-cells are told off to travel from the skin to which they strictly belong, to settle down in the mouth of the optic cup, to arrange themselves in a compact and suitable ball, to turn into transparent fibres, to assume the right refractive index, and to make themselves into a subsphere with two correct curvatures truly centred on a certain axis. Thus it is they make a lens of the right size, set in the right place, that is, at the right distance behind the transparent window of the eye in front and the sensitive seeing screen of the retina behind. In short they behave as if fairly possessed.

I would not give a wrong impression. The optical apparatus of the eye is not all turned out with a precision equal to that of a first-rate optical workshop. It has defects which disarm the envy of the optician. It is rather as though the planet, producing all this as it does, worked under limitations. Regarded as a planet which ‘would’, we yet find it no less a planet whose products lie open to criticism. On the other hand, in this very matter of the eye the process of its construction seems to seize opportunities offered by the peculiarity in some ways adverse of the material it is condemned to use. It extracts from the untoward situation practical advantages for its instrument which human craftsmanship could never in that way provide. Thus the cells composing the core of this living lens are denser than those at the edge. This corrects a focussing defect inherent in ordinary glass-lenses. Again, the lens of the eye, compassing what no glass-lens can, changes its curvature to focus near objects as well as distant when wanted for instance, when we read. An elastic capsule is spun over it and is arranged to be eased by a special muscle. Further, the pupil – the camera stop – is self-adjusting. All this without our having even to wish it; without even our knowing anything about it, beyond that we are seeing satisfactorily.

The making of this eye out of self-actuated specks which draw together and multiply and move as if obsessed with one desire namely to make the eye-ball. In a few weeks they have done so. Then, their madness over, they sit down and rest, satisfied to be life-long what they have made themselves, and, so to say, wait for death.

The chief wonder of all we have not touched on yet. Wonder of wonders, though familiar even to boredom. So much with us that we forget it all our time. The eye sends, as we saw, in to the cell-and-fibre forest of the brain throughout the waking day continual rhythmic streams of tiny, individually evanescent, electrical potentials. This throbbing streaming crowd of electrified shifting points in the spongework of the brain bears no obvious semblance in space-pattern, and even in temporal relation resembles but a little remotely the tiny two dimensional upside-down picture of the outside world which the eyeball paints on the beginnings of its nerve-fibres to the brain. But that little picture sets up an electrical storm. And that electrical storm so set up is one which affects a whole population of brain-cells, Electrical charges having in themselves not the faintest elements of the visual – having, for instance, nothing of ‘distance’, ‘right-side-upness”, nor ‘vertical’, nor ‘horizontal’, nor ‘colour’, nor ‘brightness’, nor ‘shadow’, nor ‘roundness’, nor ‘squareness”, nor contour’, nor ‘transparency’, nor ‘opacity’, nor ‘near’, nor ‘far’, nor visual anything – conjure up all these. A shower of little electrical leaks conjures up for me, when I look, the landscape; the castle on the height, or, when I look at him, my friend’s face, and how distant he is from me they tell me. Taking their word for it, I go forward and my other senses confirm that he is there.

It is a case of ‘the world is too much with us’; too banal to wonder at. Those other things we paused over, the building and shaping of the eye-ball, and the establishing of its nerve connections with the right points of the brain, all those other things and the rest pertaining to them we called in chemistry and physics and final causes to explain to us. And they did so, with promise of more help to come.

But this last, not the eye, but the ‘seeing’ by the brain behind the eye? Physics and chemistry there are silent to our every question. All they say to us is that the brain is theirs, that without the brain which is theirs the seeing is not. But as to how? They vouchsafe us not a word.

Source: Sir Charles Sherrington, Man on His Nature, 2nd edition, Cambridge, Cambridge University Press, 1951. Taken from the Faber Book of Science, edited by John Carey.

[1] E.G.Drury, Psyche and the Physiologists and other Essays on Sensation (London 1938), p.4.

Two avoidable deaths, one sad, the other…well, less so

By Ken · Posted in Drama, Enterprise, Exploration, Human spirit, Life, Medicine, Science

The story of Robert Scott of the Antarctic
and Anna Bågenholm, from Norway.

This story borders on unbelievable. It shows unambiguously the dividends made possible thanks to advances in research usually funded through small, seemingly insignificant gifts made by private individuals acting alone.

Though, try telling Anna Bågenholm they’re insignificant.

I’ve included it because Scott was a childhood hero of mine, because such stories as Anna’s are rare and thrilling and because I like endings to be happy, at least some of the time.
Scott of the Antarctic

It’s 29th March, 1912. Trapped in his hut deep in the Antarctic wastelands at the bottom of the world a 43-year-old British adventurer is slowly freezing to death. The weather outside is dreadful. He’s been marooned for days, slowly starving. The last of his companions has already died and he is now alone. Frostbite has taken hold. Skin ulcers cover his emaciated body. As his body’s temperature falls, one after another its normal functions cease. Heartbeat, breathing rate and blood pressure all drop catastrophically. Speech becomes difficult. Shivering grows uncontrollable. Mental confusion steadily increases, amnesia too. Exposed skin stands blue and puffy. Muscles fail. Even his hair stands on end in a hopeless, involuntary action to preserve vanishing heat.  Clinical death will occur soon after, though due to the extreme cold, brain death might be postponed for some time. It is a fearsome end.

Skiers Fast forward 87 years, to 1999. In the northern Norwegian wilderness an intrepid 29-year-old skier falls, twists onto her back and, out of control, slides into a ravine. In seconds she’s careened into a fast-flowing stream that sweeps her to where the flow vanishes under thick ice. She can’t move as her body is wedged tightly beneath the ice by the water’s fierce flow. Two friends racing behind catch her skis just in the nick of time to stop her from being swept away, but in the snow and the wild terrain they can’t haul her out from that icy mountain stream. Little by little she’s sucked ever more under. Now she too is slowly freezing to death.

Forty minutes after being trapped in the icy water her struggles slowly ceased. Minutes later her heart stopped beating. Her body now was completely still. By the time the rescue helicopter arrived her heart hadn’t beaten for nearly an hour and a half. By then, she was technically dead. Still paramedics in the rescue helicopter worked tirelessly against the odds, trying to revive her. By the time her body was handed into the care of Dr Mats Gilbert on the roof of Tromso University Hospital her heart had been stopped for well over two hours.

Both Anna Bågenholm and Robert Falcon Scott froze to death. But unlike Scott and untold thousands before him, more than three hours after her heart stopped beating, Anna Bågenholm was brought back to life.

How could this miracle happen?

Well, in part at least, because of you.

Here is Anna’s incredible story. As you read it, please say aloud to yourself, at the appropriate moment, ‘We did this. When in the past I supported medical research, I helped make this miracle possible. That’s what I, and others like me, that’s what we did.’

Say it now. Say it with pride.

Because it’s true. When you and thousands like you supported the development of those high-risk new research initiatives, this is the kind of thing you were making possible.

Amazingly, the very thing that was killing Anna also helped save her life.

The cold.

In that extreme cold Anna’s body, including her brain and all her life functions, effectively shut down.

How incredible is that?

But the cold alone wasn’t the only thing that saved her. This is the bit where you come in.

Three more modern miracles combined to bring Anna back to life. They’re all available now, even in the frozen north of Norway. Sadly, none of them were there for Robert Falcon Scott of the Antarctic, nor for thousands of others who died like him.

But they are there now.

The first of these advances has it roots in the makeshift ambulance wagon that appeared in 1795, during the Napoleonic wars, when medics first realized the value of getting to wounded soldiers quickly, before trauma and blood loss reduce survival chances. Anna’s equivalent though was very up-to-date – the flying air ambulance helicopter.

The second life-saver goes back to the last days of World War II, to pioneering experiments on the human heart that led to invention of the heart bypass machine which temporarily takes over the task of circulating blood so that surgeons are free to work on the no-longer-beating heart. In Anna’s case it was circulating her blood – all of it – through a gentle warming process via one of these machines that brought her lifeless carcass back to viability.

The third miracle owes its origins to the fight against polio; to the development of the iron lung and the ‘life support’ system which today routinely saves so many premature babies and others whose fragile bodies struggle just to survive.

Of course other qualities came together to play important parts in the saving of Anna’s life. Persistence, stick-ability, determination, courage, optimism in the face of hopeless odds. Not to mention professional skills that money can’t buy and the best medical facilities that money can.

But as Captain Scott and his colleagues showed such a short time before, in such circumstances human qualities alone, admirable though they are, are not enough. That’s why we promote the research that you support, that day in, day out is saving lives like Anna’s, even as you read this incredible story.

Robert Falcon Scott is presumed to have died on 29 March 1912, or possibly a day later. The positions of the bodies in the tent when it was discovered eight months later suggested that Scott was the last of the three to die. From the Antarctic wastes Scott’s last words echo down the ages with a pathos and resignation that moves us still.

‘We took risks, we knew we took them; things have come out against us, and therefore we have no cause for complaint, but bow to the will of Providence, determined still to do our best to the last…

‘Had we lived, I should have had a tale to tell of the hardihood, endurance, and courage of my companions which would have stirred the heart of every Englishman. These rough notes and our dead bodies must tell the tale…’

Anna Bågenholm
Anna Bågenholm was very much more fortunate. Thanks to good luck, some brave and brilliant friends, some dedicated, wonderful medical staff and some quite extraordinary advances in medical science, she can tell that tale herself, in the flesh. It’s a triumph made not just possible, but effective, by all who have worked to properly fund research.

That includes you. Yes, you.

Anna has survived that ordeal now for more than 5,000 days. If Anna were able to, I’m sure she’d want to say to everyone who played a part in this modern miracle, ‘thank you for the days’.

Well done, you! Thank you for the days.

Fanny Burney endures a mastectomy, 30 September 1811

By Ken · Posted in Drama, Human spirit, Medicine

This story is so graphically detailed it will make you squirm. It’s included because it’s so simply and courageously told. And though you may wriggle, writhe, weep and wonder, it might touch you powerfully too.

by Fanny Burney

Frances (Fanny) Burney was an admired friend of Dr Samuel Johnson. She served five years at the court of George III and Queen Charlotte as Second Keeper of the Royal Robes (1786-1791). Fanny Burney married Alexandre d’Arblay in 1793 after he had fled to England to escape the Revolution. They lived for ten years in France, from 1802-1812.

This rare patient narrative describes a mastectomy performed before the introduction of anesthesia. Madame d’Arblay first felt pain in her breast in August 1810. Cancer was diagnosed and Baron Larrey, Napoleon’s surgeon, agreed to perform the operation. To spare her suspense, she was given very little notice. The ‘M. d’A’ of her account is her husband. Alexander is her son.

Fanny Burney

Before the operation M. d’Arblay arranged for linen and bandages as his wife made her will and wrote farewell letters to him and her son. Her doctor gave her a wine cordial, the only anesthetic she received. Waiting for all the doctors to arrive must have been agony. The image of Fanny Burney is from a 1772 painting by Edward Francisco Burney.

One morning – the last of September, 1811, while I was in Bed & M. d’ A. was arranging some papers for his office, I received a  letter written by M. de Lally to a Journalist, in vindication of the honoured memory of his Father against the assertions of Mme Deffand. I read it aloud to My Alexanders, with tears of admiration & sympathy, & then sent it by Alex: to its excellent Author, as I had promised the preceding evening. I then dressed, aided, as usual for many months, by my maid, my right arm being condemned to total inaction; but not yet was the grand business over, when another Letter was delivered to me – another. indeed! – ‘twas from M. Larrey, to acquaint me that at 10 o’clock he should be with me, properly accompanied, & to exhort me to rely as much upon his sensibility & his prudence, as upon his dexterity & his experience; he charged to secure the absence of M. d’ A: & told me that the young Physician who would deliver me his announce would prepare for the operation, in which he must lend his aid: & also that it had been the decision of the consultation to allow me but two hours’ notice. – Judge, my Esther, if I read this unmoved! – yet I had to disguise my sensations & intentions from M. d’ A! – Dr Aumont, the Messenger & terrible Herald, was in waiting; M. d’ A stood by my bedside; I affected to be long reading the Note, to gain time for forming some plan, & such was my terror of involving M. d’A. in the unavailing wretchedness of witnessing what I must go through, that it conquered every other, & gave me the force to act as if I were directing some third person. The detail would be too Wordy, as James says, but the wholesale is – I called Alex to my Bedside, & sent him to inform M. Barbier Neuville, chef du division du Bureau de M. d’A. that the moment was come, & I entreated him to write a summons upon urgent business for M. d’A. & to detain him till all should be over. Speechless & appalled, off went Alex, &, as I have since heard, was forced to sit down & sob in executing his commission. I then, by the maid, sent word to the young Dr Aumont that I could not be ready till one o’clock: & I finished my breakfast, & – not with much appetite, you will believe! forced down a crust of bread, & hurried off, under various pretences, M. d’ A. He was scarcely gone, when M Du Bois arrived: I renewed my request for one o’clock: the rest came; all were fain to consent to the delay, for I had an apartment to prepare for my banished Mate. This arrangement, & those for myself, occupied me completely. Two engaged nurses were out of the way – I had a bed, Curtains, & heaven knows what to prepare – but business was good for my nerves. I was obliged to quit my room to have it put in order: – Dr Aumont would not leave the house; he remained in the Sallon, folding linen! – He had demanded 4 or 5 old & fine left off under Garments – I glided to our Book Cabinet: sundry necessary works    & orders filled up my time entirely till One o’dock, When all was ready – but Dr Moreau then arrived, with news that M. Dubois could not attend till three. Dr Aumont went away – & the Coast was clear. This, indeed, was a dreadful interval. I had no longer anything to do – I had only to think – TWO HOURS thus spent seemed never-ending. I would fain have written to my dearest Father – to You, my Esther – to Charlotte James – Charles – Amelia Lock – but my arm prohibited me: I strolled to the Sallon – I saw it fitted with preparations, & I recoiled – But I soon returned; to what effect disguise from myself what I must so soon know? – yet the sight of the immense quantity of bandages, compresses, spunges, Lint – made me a little sick: – I walked backwards & forwards till I quieted all emotion, & became, by degrees, nearly stupid – torpid, without sentiment or consciousness; – & thus I remained till the Clock struck three. A sudden spirit of exertion then returned, – I defied my poor arm, no longer worth sparing, & took my long banished pen to write a few words to M. d’ A – & a few more for Alex, in case of a fatal result. These short billets I could only deposit safely, when the Cabriolets – one – two – three – four – succeeded rapidly to each other in stopping at the door. Dr Moreau instantly entered my room, to see if I were alive. He gave me a wine cordial, & went to the Sallon. I rang for my Maid & Nurses, – but before I could speak to them, my room, without previous message, was entered by 7 Men in black, Dr Larry, M. Dubois, Dr Moreau, Dr Aumont, Dr Ribe, & a pupil of Dr Larry, & another of M. Dubois. I was now awakened from my stupor – & by a sort of indignation – Why so many? & without leave? – But I could not utter a syllable. M. Dubois acted as Commander in Chief. Dr Larry kept out of sight; M. Dubois ordered a Bed stead into the middle of the room. Astonished, I turned to Dr Larry, who had promised that an Arm Chair would suffice; but he hung his head, & would not look at me. Two old mattrasses M. Dubois then demanded, & an old Sheet. I now began to tremble violently, more with distaste & horror of the preparations even than of the pain. These arranged to his liking, he desired me to mount the Bed stead. I stood suspended, for a moment, whether I should not abruptly escape – I looked at the door, the windows – I felt desperate – but it was only for a moment, my reason then took the command, & my fears & feelings struggled vainly against it. I called to my maid – she was crying, & the two Nurses stood transfixed at the door. Let those women all go! cried M. Dubois. This order recovered me my Voice – No, I cried, let them stay! qu’elles restent! This occasioned a little dispute, that re-animated me – The maid, however & one of the nurses ran off – I charged the other to approach, & she obeyed. M. Dubois now tried to issue his commands en militaire, but I resisted all that were resistable – I was compelled, however, to submit to taking off my long robe de Chambre, which I had meant to retain – Ah, then, how did I think of my Sisters! – not one, at so dreadful an instant, at hand, to protect – adjust – guard me _ I regretted that I had refused Mlle de Maisonneuve – Mlle Chastel _ no one upon whom I could rely – my departed Angel! _ how did I think of her! – how did I long -long for my Esther _ my Charlotte! – My distress was, I suppose, apparent, though not my Wishes, for M. Dubois himself now softened, & spoke soothingly. Can You, I cried, feel for an operation that, to You, must seem so trivial? _ Trivial? he repeated – taking up a bit of paper, which he tore unconsciously, into a million of pieces, oui – c’est peu de chose, mais – ‘ he stammered, & could not go on. No one else attempted to speak, but I was softened myself, when I saw even M. Dubois grow agitated, while Dr Larry kept always aloof, yet a glance showed me he was pale as ashes. I knew not, positively, then, the immediate danger, but every thing convinced me danger was hovering about me, & that this experiment could alone save me from its jaws. I mounted, therefore, unbidden, the Bed stead & M. Dubois placed me upon the mattress. & spread a cambric handkerchief upon my face. It was transparent, however, & I saw, through it, that the Bed stead was instantly surrounded by the 7 men & my nurse. I refused to be held; but when, Bright through the cambric, I saw the glitter of polished Steel – I closed my Eyes. I would not trust to convulsive fear the sight of the terrible incision. A silence the most profound ensued, which lasted for some minutes, during which, I imagine, they took their orders by signs, so made their examination – Oh what a horrible suspension! – I did not breathe – & M. Dubois tried vainly to find any pulse. This pause, at length, was broken by Dr Larry, who, in a voice of solemn melancholy, said ‘Qui me tiendra ce sein? -’ .

No one answered; at least not verbally; but this aroused me from my passively submissive state, for I feared they imagined the whole breast infected – feared it too justly, – for, again through the Cambric, I saw the hand of M. Dubois held up, while his forefinger first described a straight line from top to bottom of the breast, secondly a Cross, & thirdly a Circle; intimating that the WHOLE was to be taken off. Excited by this idea, I started up, threw off my veil, &, in answer to the demand ‘Qui me tiendra ce sein?’ cried ‘C’est moi, Monsieur!’ & I held my hand under it, & explained the nature of my sufferings, which all sprang from one point, though they darted into every part. I was heard attentively, but in utter silence, & M. Dubois then replaced me as before, &, as before, spread my veil over my face. How vain. alas, my representation! immediately again I saw the fatal finger describe the Cross – & the circle _ Hopeless, then, desperate, & self-given up, I closed once more my Eyes, relinquishing all watching, all resistance, and interference, & sadly resolute to be wholly resigned.

My dearest Esther, – & all my dears to whom she communicated this doleful ditty, will rejoice to hear that this resolution once taken. was firmly adhered to, in defiance of a terror that surpasses description, & the most torturing pain. Yet – when the dreadful steel was plunged into the breast – cutting through veins – arteries –  flesh – nerves – I needed no injunctions not to restrain my cries, – began a scream that lasted unintermittingly during the whole time of the incision & I almost marvel that it rings not in my Ears still, so excruciating was the agony. When the wound was made, & the instrument was withdrawn, the pain seemed undiminished, for the air that suddenly rushed into those delicate parts felt like a mass of minute but sharp & forked poniards, that were tearing the edges of the wound – but when again I felt the instrument – describing a curve, cutting against the grain, if I may so say, while the flesh resisted in a manner so forcible as to oppose & tire the hand of the operator, who was forced to change from the right to the left – then, indeed, I thought I must have expired. I attempted no more to open my Eyes – they felt as if hermetically shut, & so firmly closed that the Eyelids seemed indented into the Cheeks. The instrument this second time withdrawn, I concluded the operation over – Oh no! presently the terrible cutting was renewed – & worse than ever, to separate the bottom, the foundation of this dreadful gland, the parts to which it adhered – Again all description would be baffled – yet again all was not over, – Dr Larry rested but his own hand & – Oh Heaven! – I then felt the Knife rackling against the breast bone – scraping it! – This performed, while I yet remained in utterly speechless torture, I heard the Voice of Mr Larry, – (all others guarded a dead silence) in a tone nearly tragic, desire everyone present to pronounce if anything more remained to, be done; The general voice was Yes, – but the finger of Mr Dubois – which I literally felt elevated over the wound, though I saw nothing, & though he touched nothing, so indescribably sensitive was the spot – pointed to some further requisition – & again began the scraping! – and, after this, Dr Moreau thought he discerned a peccant attom – and still, & still, M. Dubois demanded attom after attom – My dearest Esther, not for days, not for Weeks, but for Months I could not speak of this terrible business without nearly again going through it! I could not think of it with impunity! I was sick, I was disordered by a single question – even now, 9 months after it is over, I have a headache from going on with the account! & this miserable account, which I began 3 Months ago, at least, I dare not revise, nor read, the recollection is still so painful.

To conclude, the evil was so profound, the case so delicate, & the precautions necessary for preventing a return so numerous, that the operation, including the treatment & the dressing, lasted 20 minutes! a time, for sufferings so acute, that was hardly supportable – However, I bore it with all the courage I could exert, & never moved, nor stopt them, nor resisted, nor remonstrated, nor spoke except once or twice, during the dressings, to say ‘Ah Messieurs! que je vous plains! -’ for indeed I was sensible to the feeling concern with which they all saw what I endured, though my speech was principally – very principally meant for Dr Larry. Except this, I uttered not a syllable, save, when so often they recommended, calling out ‘Avertissez moi, Messieurs! avertissez moi!’ Twice, I believe, I fainted; at least, I have two total chasms in my memory of this transaction, that impede my tying together what passed. When all was done, & they lifted me up that I might be put to bed, my strength was so totally annihilated, that I was obliged to be carried, & could not even sustain my hands & arms, which hung as if I had been lifeless; while my face, as the Nurse has told me, was utterly colourless. This removal made me open my Eyes – & I then saw my good Dr Larry, pale nearly as myself, his face streaked with blood & its expression depicting grief, apprehension, & almost horror.’

When I was in bed, – my poor M. d’Arblay – who ought to write you himself his own history of this Morning – was called to me – & afterwards our Alex.