Madame Bovary

Don K. Nakayama, MD, MBA

The author (AΩA, University of California, San Francisco, 1977) is the Milford B. Hatcher Professor and Chair of the Department of Surgery at Mercer University School of Medicine in Macon, Georgia.

n Madame Bovary author Gustave Flaubert described two medical conditions that are key episodes in the novel. The first is a surgical complication, accurate in every detail: iat- Irogenic lower extremity gangrene from a too-tight brace that an orthopedist today would recognize as compartment syndrome with subsequent gangrene. The progression of symptoms and the vivid description of ascending gangrene attest to

French novelist, Gustave Flaubert (1821–1880). From a portrait by Paul Baudoin. Photo by Hulton Archive/Getty Images.

28 The Pharos/Winter 2013 the author’s upbringing as the son of the chief surgeon living on the grounds of a hospital where amputations routinely took place. The second is Emma Bovary’s suicide from arsenic ingestion. To describe her gruesome death Flaubert took descriptions of arsenic poisoning directly from the medical texts belonging to his father and brother, both surgeons, and his closest friend, a former medical student. Beyond the clinical descriptions are his characterizations of the practitioners and how they react to the tragic events portrayed. His characters possess both professional and human qualities that he likely observed while growing up in a hospital wing. Passages quoted here are from Lydia Davis’s critically well- received translation of Madame Bovary, the most recent of many English versions of Flaubert’s masterpiece.1 Literary criticism, in both French and English, of Madame Bovary is vast. Two compendia of Flaubert scholarship, compiled by Laurence Porter,2 and Porter and colleague Eugene Gray,3 provide useful surveys for the neophyte on relevant criticism on the novelist and his work. The discussion that follows is based on these sources.

Flaubert’s exposure to medical scenes In Porter’s words, Flaubert aspired to complete “stylistic and structural perfection” through attention to detail and masterful treatment of the psychology of his characters.2vii–viii He saved many of his drafts,2 and discussed the progress of his writing through prolific correspondence with close friend and collaborator Louis Bouilhet and longtime lover Louise Colet.3 The result is a trove for Flaubert scholars, much of which is available online.4 We thus know in detail how he wrote, what he intended to portray in his novels, and, through dozens of drafts, the meticulous and excruciating process from thought to printed page. Gustave Flaubert (1821–80) Dissecting Madame Bovary, illustra- 2 Gustave Flaubert came from a family of surgeons. His tion from Parodie, December 1869 (engraving), by J. Lemot. father, Achille-Cléophas Flaubert, was the son of a veterinar- The Granger Collection, NYC. All rights reserved. ian who excelled in his medical studies and trained at the Hôtel Dieu, the main hospital at Rouen. Flaubert the father became chief surgeon there in 1815, a position that included Flaubert’s drafts. Bouilhet studied medicine under Flaubert’s residence on the hospital grounds. Thus young Gustave, born father, but quit to try his hand at poetry.2 He was the source in 1821, was raised in the midst of illness and human suffering, for the descriptions of the symptoms of arsenic poisoning used exposed early and frequently in life to the sights, smells, and by Flaubert in Madame Bovary. brutality of the pre-anesthetic, pre-asepsis practice of surgery and medicine.3 His older brother by eight years, Achille, fol- The botched operation lowed their father into medicine and served under his direc- The pivotal scene in Madame Bovary is the operation that tion while Gustave was still a schoolboy at home. When the goes horribly wrong. In Yonville-l’Abbaye, a backwater village elder Flaubert suffered a fatal thigh infection in 1846 Achille overshadowed by nearby Rouen, the local apothecary Homais attempted a lifesaving amputation. Achille succeeded the fa- suggests to Emma Bovary that the town needs a spectacular ther as chief surgeon at the Hôtel Dieu. achievement to bring it renown. As an avid reader of scientific Young Gustave tried to satisfy his father’s ambitions for journals he suggests that Emma’s husband, the local officier him for a professional career in law. He developed epilepsy, de santé, perform an operation to correct the club foot of however, which freed him from such expectations and allowed young Hippolyte, the village simpleton who performs odd him to pursue the life of a writer in Paris.3 An early room- jobs. Having him stride through the streets after a surgical mate was his close friend Bouilhet, who read and critiqued success, Homais tells Emma, certainly would bring fame and

The Pharos/Winter 2013 29 Medical scenes in Madame Bovary

Madame Bovary (1949), starring Van Heflin as Charles Bovary. MGM. Photographer: S. M. Manatt.

admiration to both the town and the surgeon. Charles makes the disastrous decision to perform surgery. Emma is susceptible to Homais’s suggestion. Emma and Homais ventures a description of Henry’s club foot, iden- Rodolphe, the local squire and serial seducer, having consum- tifying the deformity incorrectly as talipes equinus valgus, mated their tryst, have started to have difficulties. To Emma, when in fact it was talipes equinovarus. Charles prepares for her lover is insufficiently attentive; Rodolphe becomes irri- his operation: tated at her possessiveness. She is disillusioned with romantic love, which led to a marriage with a man she detests and a Charles was studying pes equinus, varus, and valgus, that shallow affair. “All she wanted,” Flaubert writes, “was to be is, strephocatopodia, strephendopodia, and strephexopodia able to able to lean on something more solid than love.” 1p152 (or, to be more exact, the various malformations of the foot, If Charles could become a successful and famous surgeon, downward, inward, and outward), along with strephypopo- the Bovarys would assume their rightful place as an admired dia and strephanopodia (in other words, downward torsion couple. He would be a husband deserving of Emma’s affection and upward straightening).1p152 and their marriage salvaged. Her task is clear: To convince her husband to perform the operation. The passage has the detail of an anatomy text—which it But Charles is no surgeon. An officier de santé was essen- was. Flaubert used verbatim a number of unacknowledged tially a paramedic trained to dispense medications for minor sources, including pharmaceutical and medical texts.2 Porter illnesses and perform simple procedures. Porter and Gray call notes that Flaubert may not have felt inhibited blending cop- him “a ‘public health officer’ trained somewhat less well than ied scientific passages in his fiction because literary copyright a licensed practical nurse.” 3ppxxvii,51 Charles was trained to set protections had only come into place relatively recently, at the simple fractures like the one Emma’s father had near the be- end of the eighteenth century. The use of the textbooks from ginning of the book, not to perform orthopedic surgery—and his father’s and brother’s bookshelves gave Madame Bovary he knows it. But Emma pleads for him to do the operation. scientific and surgical authenticity. Traité pratique du piet- Weak, unable to control her expensive tastes and demands, bot, published in 1839 by Vincent Duval, is a book likely known

30 The Pharos/Winter 2013 to both Flaubert surgeons because it includes a reference to a with the clinical detail young Gustave observed while living in technique practiced by the elder Flaubert for club foot.3 the Hôtel Dieu: Charles is faced with a challenge for which he is com- pletely unprepared and untrained. Flaubert describes the A livid tumefaction was now spreading up the leg, with tumult in Charles’s thoughts as he tries to force himself to phlyctenae [blisters] here and there from which a black liq- cut flesh: uid was seeping out.1p156

in fact he was quaking already, for fear of assaulting some Amputation is the only option to save the boy’s life. As they important part of the foot with which he was unfamiliar. await the arrival of a “real” surgeon, Charles suffers the gos- Neither Ambroise Paré, applying a ligature directly to sip among the uninvolved that seems to spread through every an artery for the first time since Celsus, fifteen centuries hospital after a disastrous event. Flaubert captures the tone of before; nor Dupuytren, about to open an abscess through the comments exactly; modern practitioners recognize know- a thick layer of encephalon; nor Gensoul, when he per- it-alls and second-guessers in doctors’ lounges and locker formed the first ablation of the superior maxilla, had a heart rooms. A priest arrives and uses the occasion to chide poor that pounded so, a hand so tremulous, a mind so tense as Hippolyte for his prolonged absence from services. Monsieur Bovary approaching Hippolyte, his tenotomy knife The long-awaited surgeon from Neufchâtel, Monsieur in his hand.1p154 Canivet, arrives, supremely confident of his skills and superiority. Today’s interns feel the same feverish panic when handed a scalpel for the first time. Charles’s position in doing an op- A medical doctor, fifty years old, who enjoyed a good posi- eration for which he had no training is like an intern facing tion and was full of self-assurance, the colleague did not a craniotomy—alone. His anxiety was familiar ground for scruple to laugh in scorn when he uncovered the leg, gan- Flaubert’s father, brother, and friend. Here, Flaubert shows his grenous up to the knee. Then, after declaring bluntly that it skill as a writer in what was his first novel. would have to be amputated, he went off to the pharmacist Charles’s relief is therefore profound when the operation, to rail against the donkeys who had managed to reduce an a simple division of the Achilles tendon, appears to go well, unfortunate man to such a state.1p159 a feeling familiar to all surgeons after challenging surgery. Emma and he draw emotionally close, a new and unfamiliar Flaubert, living in a hospital among surgeons, had a num- feeling after years of emotional distance. ber of models for Monsieur Canivet. The writer doubtless heard the shop talk among his father and his professional col- The evening was delightful, full of conversation and leagues regarding the latest medical advances. Canivet’s lack shared dreams. They talked about their future wealth, im- of empathy can often be found among specialists in areas like provements to be made in the household; he saw his reputa- surgery, in which performing highly technical and complicated tion growing, his prosperity increasing, his wife loving him procedures take precedence over developing therapeutic forever . . .1p155 relationships.5 Flaubert’s father was conservative in his ap- proach to medical practice, adhering to traditional methods Charles uses a contraption of wood and steel bolts to hold of care (he bled Gustave repeatedly as treatment for epilepsy) the boy’s foot in place. The device is excessively constricting, and scoffing at new innovations like ether anesthesia. Today’s however, and causes excruciating pain. An orthopedic resident surgeons sympathize with Canivet’s reaction because Bovary today would recognize a patient with cast pain and understand had no training in surgery and had no business performing the immediate need to remove the brace. In ignorance Charles the operation in the first place. Surgeons have used Charles does not. When he reluctantly does so days later he sees an Bovary as an example of the folly of attempting an operation orthopedist’s nightmare: for which one is neither trained6 nor has performed because of the temptations of fame and notoriety.7 The shape of the foot had disappeared within a swelling so The village awaits the amputation in silence. “A harrow- extreme that the skin seemed about to split, and the entire ing cry rang out through the air. Bovary turned so white he surface was covered with ecchymoses caused by the much- seemed about to faint.” 1pp161–2 Young Hippolyte survives. vaunted machine [brace].1p156 Guilt-ridden Charles gives him two wooden legs, one that is fancy and expensive that the cripple eschews in favor of an- Charles compounds his error by putting the brace back on, other more modest and practical. assuring disaster. Driven by pain the boy crashes it against The narrative point of view abruptly turns to Emma, one the wall as he flails his limb in agony. When the brace is re- of Flaubert’s stylistic innovations.2 In humiliation, she looks moved a final time, again days too late, gangrene is described at her husband in disgust, seeing her years of marriage as

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nothing but a series of failures culminating in this ultimate Following Charles’s disaster, Emma, hopelessly in debt, disaster. To her, Charles was hounded by her creditors, and rejected by her former lovers, becomes desperate. She decides to kill herself, and is so self- this man who understood nothing, who felt nothing!—for absorbed that she is “in an ecstasy of heroism that filled her there he was, quite calm, not even suspecting that from now almost with joy.” 1p278 Inspired, she visits the shop of Homais, on, the ridicule attached to his name was going to soil her as the apothecary, where she coaxes Justin, the apprentice and well as him. She had made efforts to love him, and she had her secret admirer, into unlocking the door to the upstairs repented in tears for having yielded to another. storeroom. There she finds arsenic and begins eating the pow- “Why, perhaps it was a valgus!” exclaimed Bovary sud- der by hand, to Justin’s horror. She walks home, writes a final denly, meditating. letter, and lies in bed, awaiting her death. At the unexpected shock of that sentence falling upon At first nothing happens, just the sounds of a clock ticking her thoughts like a lead ball on a silver plate, Emma, with and her husband’s breathing. Emma is lulled into believing a shudder, lifted her head to try to understand what he that her death will be a gentle end during sleep. Then she first meant; and they looked at each other in silence, almost experiences “the hideous taste of ink” and thirst. Then she dumbfounded to see each other there, so far apart had their begins to choke and the agony produced by arsenic poisoning thoughts taken them.1p162 become fully manifest:

Charles shows how a case gone bad emotionally isolates And she was overcome by a wave of nausea so sudden surgeons. Despondent, he reaches out to Emma, asks her for a that she scarcely had time to snatch her handkerchief from comforting kiss. She angrily refuses, storms out, and slams the under the pillow. door. Charles is lost. Just as Emma had no idea of the turmoil . . . . She was keeping still, for fear that the least distur- in her husband’s mind, Charles cannot understand the reasons bance would make her vomit. Meanwhile she felt an icy cold behind his wife’s anger and sudden exit. rising within her from her feet to her heart. “Ah! Now it’s beginning!” she murmured. Charles sank back in his chair, overwhelmed, trying to . . . . think what could be wrong with her, imagining a nervous She rolled her head from side to side with a gentle mo- illness, weeping, with the vague sense that in the air around tion full of anguish, at the same time opening her jaws again him was something deadly and incomprehensible.1p163 and again, as though she were holding something very heavy on her tongue. At eight o’clock, the vomiting began Emma goes straight to the arms of her lover: For her and again.1pp280–81 the novel, this is the point of no return. Charles tries to comfort her. Emma’s suicide by arsenic Flaubert used descriptions provided by Bouilhet’s textbooks Then delicately, almost caressingly, he passed his hand to describe Emma’s horrible suffering and death from arsenic over her stomach. She gave a sharp cry. He drew back, ingestion at the end of the novel.2 Homais, the apothecary, alarmed. would have had a good supply of arsenic in his shop. Samuel Then she began to moan, weakly at first. Her shoulders Waxman and Kenneth Anderson in a 2001 paper in The were shaken by a violent shudder, and she turned paler than Oncologist recount the history of the use of arsenic in medi- the sheet in which her clenched fingers were buried. Her cine and its recent reappearance in modern cancer therapy.8 uneven pulse was almost imperceptible now. Arsenic compounds were used therapeutically from the time of Beads of sweat stood out on her face, which was tinged Hippocrates, who used realgar (As2S2) and orpiment (As2S3) as with blue and almost rigid, as though frozen by the exhala- topical remedies for ulcers. Fowler’s solution, arsenic trioxide tion of some metallic vapor. Her teeth were chattering, her in potassium bicarbonate, concocted in the 1700s, was used to dilated eyes gazed vaguely around her, and to each question treat asthma, chorea, eczema, pemphigus, and psoriasis, and her only answer was to move her head back and forth; she later anemia, leukemia, and lymphoma. Paul Ehrlich famously even smiled two or three times. Gradually, her moans grew used an organic arsenical, salvarsan, to cure syphilis. The use louder. A muffled howl escaped her; she claimed she was of arsenical compounds declined in the twentieth century, feeling better and would soon get up. But she was seized replaced by less toxic antimicrobials, and cytotoxic chemo- with convulsions; she cried out: therapy and the development of radiation therapy. Recently “Oh! It’s awful. My God!” 1p281 arsenic derivatives have found a place in the treatment of acute promyelocytic leukemia, its rediscovery in part stemming from The narrative softens briefly as Emma reflects on her tor- its long use in traditional Chinese medicine.9 tured past and her symptoms appear to abate. She asks to see

32 The Pharos/Winter 2013 Berthé, her child, but her mother’s fevered stare and appear- stand aside and let the great man enter. The elder Flaubert ance frighten her and the little girl pulls away. appears to have been the model for Dr. Larivière, a similarly Charles the minimally trained officier de santé is of no austere god-like figure.2 help. He desperately searches for an answer in his medical dictionary. Hippolyte and Justin search for Monsieur Canivet He belonged to that great school of surgery inspired by and Doctor Larivière. Homais is the first to arrive. He blithely Bichat, to that now-vanished generation of philosopher- recommends an antidote, unaware there is no antidote for practitioners who cherished their art with a fanatical love arsenic poisoning. Once Canivet arrives he has a more useful and practiced it with enthusiasm and sagacity! The entire intervention, an emetic, the traditional treatment for inges- hospital shook when he flew into a rage . . . [His] unbut- tion of poisons. It has frightening results: Emma begins to toned cuffs partly covered his fleshy hands—his very fine vomit blood, has convulsions, and begins to scream. Her suf- hands, always gloveless, as though to be more prepared to fering dissolves Canivet’s professional mien and he is shaken. plunge into human suffering.1p284–85 Homais, unfailingly wrong again, offers that Emma might in fact be improving: “The effect should cease, . . . it’s self- Larivière knows there is nothing that can be done. A single evident,” he says.” 1p284 tear reveals his sympathy, and he withdraws to speak with Dr. At this point Dr. Larivière arrives in a carriage drawn by Canivet. Charles follows, imploring the great man to cure his three horses at a full gallop, whipped by their driver. The en- wife. Bluntly, Larivière responds, “Come now, my poor fellow, trance befits Larivière’s reputation; Charles the medic, Homais be brave! There’s nothing more to be done.” Charles, dumb- the chemist, and Canivet the real professional on the scene, struck, asks, “You’re leaving?” “I’ll be back,” Larivière says. It

The death bed of Madame Bovary by Albert-Auguste Fourie, before 1889. Photo credit Erich Lessing/Art Resource, NY.

The Pharos/Winter 2013 33 Medical scenes in Madame Bovary

With a final convulsion that nearly lifts her from her bed and a “horrible, frantic, despair- ing laugh,” she finally dies.1p290 The botched operation and the arsenic ingestion are impressive not only by their clinical accuracy but the portrayal of the medical characters involved. Charles, not a trained surgeon, experiences the most vulnerable point in a surgeon’s career—the commission of a grievous error—and suffers a devastat- ing welter of emotions, depression, and social isolation. Confronted with Emma’s hopeless condition, Larivière exhibits an aloofness and detachment that may allow him to cope with the daily tragedies of a nineteenth-century surgical practice. But he offers no comfort to the suffering. An apocryphal anecdote often cited tells how Flaubert, when asked how he was able to portray the psychology of a petite bourgeoise woman so vividly, memorably de- clared, “Emma Bovary—c’est moi.” 2p40 While Flaubert’s libertine lifestyle may have informed his portrayal of his main character, his keen observation of the surgeons in his family and those with whom he came in daily contact during his boyhood certainly gave life to the doctors and surgeons in his novel.

Madame Bovary (1949), directed by Vincente Minnelli. Shown from left: Van References Heflin, Vincente Minnelli (director). Credit: Photofest/MGM. 1. Flaubert G. Madame Bovary. Davis L, trans- lator. New York: Viking; 2010. 2. Porter LM, editor. A Gustave Flaubert Ency- clopedia. Westport (CT): Greenwood Press; 2001. is a lie; neither he nor Canivet cared “to see Emma die in his 3. Porter LM and Gray EF. Gustave Flaubert’s Madame Bovary: hands.” 1p285 The surgeon accompanies Canivet to breakfast A Reference Guide. Westport (CT): Greenwood Press; 2002. at Homais’s shop to discuss the case. Flaubert’s father no 4. Édition des manuscrits de Madame Bovary de Flaubert. Tran- doubt coped in the same way with similar situations at the scriptions. Classement génétique. http://www.bovary.fr. Hôtel Dieu: candid and blunt in dealing with families, holding 5. Page DW. Are surgeons capable of introspection? Surg Clin N professional discussions away from the patient’s bedside, and Am 2011; 91: 293–304. withdrawing when there was nothing to offer. 6. Lineaweaver WC. Dr Gu and Dr Bovary. Microsurgery 2003; The tone of the narrative softens once again when the 23: 171–72. priest visits Emma and she receives the sacrament. Tears fall 7. Welling D, Rich N. The Dr. Bovary syndrome (DBS). World J from her eyes and with a sigh her head sinks into her pillow. Surg 2012; 1: 5–7. One hopes that she has peace at last. Flaubert, however, is 8. Waxman S, Anderson KC. History of the development of ar- relentless and spares no detail of her final death throes: senic derivatives in cancer therapy. Oncologist 2001; 6 Suppl 2: 3–10. 9. Wang Z-Y, Chen Z. Acute promyelocytic leukemia: From At once her chest began rising and falling rapidly. Her highly fatal to highly curable. Blood 2008; 111: 2505–15. tongue protruded at full length from her mouth; her rolling eyes grew paler, like the globes of two lamps about to go The author’s address is: out, so that one would have thought she was already dead, Medical Education—Department of Surgery except for the frightening, accelerating motion of her ribs, Medical Center of Central Georgia which were shaken by her furious breathing, as if her soul 777 Hemlock Street, MSC 140 were leaping up to break free.1p289 Macon, Georgia 31201 E-mail: [email protected]

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