Medical scenes in 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 syn- drome with subsequent gangrene. The progression of symp- toms 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 de- scriptions 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.