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How Renoir coped with rheumatoid arthritis

December 1997
The BMJ 315(7123):1704-8

DOI:10.1136/bmj.315.7123.1704

Source
PubMed

Authors:

Sjef van der Linden

Maastricht University

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The muses

Illnesses and creativity

Byron’s appetites, James Joyce’s gut, and Melba’s meals and

mésalliances

Jeremy Hugh Baron

Even for amateurs the retrospective rediagnosis of the

famous is one of the lowest forms of medical history,

but I hope this three course dinner with its appetiser

(Byron), main course (Joyce), and dessert (Melba) will

prove worthy of Christmas 1997.

Byron’s appetites

George Gordon Byron

1–9

was born in 1788 and was

unfortunate in his ancestors. On his father’s side were

psychopathic noblemen. His great uncle, the 5th

“wicked” lord, killed his cousin in 1765 in a duel over

the best way to hang game, and after his wife left him

begat a bastard by one of his servants, “Lady Betty.”

Byron’s admiral grandfather, “Foulweather Jack”, was

an irresponsible rake,as was his father, “Mad Jack”,who

degraded, impoverished and deserted Byron’s mother,

had an incestuous affair with his own sister Frances,

and died in 1792. Catherine Gordon, Byron’s mother,

boasted descent from James I of Scotland, but her

ancestors were brigands and melancholics, with her

grandfather in 1760 and her father in 1779 both

drowning, presumed to be suicidal.

Byron’s widowed mother abused him for his

father’s vices. Byron claimed his nursemaid beat and

seduced him.

In 1798 the 5th lord died, and at the age

of 10 Byron inherited the title and moved with his

mother from Aberdeen to Newstead Abbey, given to

the family by Henry VIII. He lived there on and off

until he left England in 1816, never to return.

It would be presumptuous to extol the glories of

Byron’s poetry or his role as the exemplar of the

Romantic hero. His general medical history is well

known, especially his lameness, usually thought to be a

club foot, for which he wore a brace and boot “which

haunted him like a curse.”

It was probably a simple

dysplasia

for which John Hunter alone correctly pre-

dicted “it will do very well in time.” Byron also suffered

from biliousness, catarrh, chilblains, convulsions,

constipation, faintness, giddiness, gonorrhoea, haem-

orrhoids, kidney stone, liver complaints, rheumatism,

scarlet fever, sunburn, tertian fever, and warts.

In 1823 Byron went to fight for the liberty of

Greece against the Turks. There he caught a fever after

a sudden downpour while riding. His doctors bled him

with leeches and lancets, gave him blisters and clysters,

purgatives, antimony, laudanum, and ether. After a

painful, pathetic illness, probably malaria, he died at

Missolonghi on 19 April 1824. He was only 36.

Byron’s body image

“In his attention to his person and dress, to the becom-

ing arrangement of his hair [he slept in curlers] ‘I am

as vain of my curls as a girl of sixteen’

and to whatever

might best show off the beauty with which nature had

gifted him, he manifested . . . his anxiety to make

himself pleasing to that sex who were, from first to last,

the ruling stars of his destiny.”

Byron is notorious for

what is technically known as sexual polymorph

perversity

—

that is, voracious enjoyment, be it of man,

woman, child, or even his half-sister. His most passion-

ate temptress, Lady Caroline Lamb, encapsulated him

forever in just six words: “mad

—

bad

—

and dangerous to

know.”

Byron had appetite problems which were not sim-

ply sexual, and Wilma Paterson has developed the

hypothesis that he had a bulimia or anorexia eating

disorder.

13 14

Byron was a miserable, fat, and bashful

boy, scurrilously and violently abused by his ungainly,

obese mother.

He was wretched at leaving Harrow in

1805, and wretched at going to Cambridge instead of

Oxford. When he went up to Trinity College he was

miserable and untoward. However, he soon became

less diffident: “I took my gradations in the vices with

Summary points

Byron’s appetite problems were not simply sexual;

there is evidence that he had a bulimia or

anorexia eating disorder

James Joyce’s writings show a profound

knowledge of human disease; his own epigastric

pain, despite various attempts at cure, eventually

led to his death

Melba loved luxury and good food, but after a

doomed affair with a duke she developed erratic

eating habits; her immortality is as much

gastronomic as operatic

Gastroenterology

Division, Mount

Sinai School of

Medicine, Box 1069,

New York, NY

10029-6574, USA

JH Baron,

honorary professorial

lecturer

Correspondence to:

DrJHBaron,

Surgical Division,

Imperial College

School of Medicine,

Hammersmith

Hospital, London

W12 0NN

BMJ 1997;315:1697–703

1697BMJ VOLUME 315 20-27 DECEMBER 1997

great promptitude, but they were not to my taste . . . I

could not share in the common place libertinism of the

place and time without disgust. . . . College is not the

place to improve either morals or income. . . . Since I

left Harrow I have become idle and conceited, from

scribbling rhyme and making love to women.”

Thomas Moore claimed that Byron’s singularities were

chiefly to be ascribed to his college associates, but Hob-

house did not accept this: “Certainly Byron had noth-

ing to learn [in depravity] when he came from

Harrow.”

By the age of 18 Byron was 5 feet 8

⁄

inches (174

cm) tall and weighed 14 stone 6 pounds (90 kg) and

was increasingly melancholic. “I am grown very thin,

however it is the Fact, so much so, that the people here

think I am going, I have lost 18 LB in my weight .. . since

January . . . on account of a Bet with an Acquaintance,

however don’t be alarmed, I have taken every means to

accomplish the end, by violent exercise & Fasting, as I

found myself too plump.

—

I shall continue my

Exertions, having no other amusement, I wear seven

waistcoats, and a great Coat, run and play at Cricket in

this Dress, till quite exhausted by excessive perspira-

tion, use the hot Bath daily, eat only a quarter of pound

Butcher’s meat in 24 hours, no Suppers, or Breakfast,

only one meal a Day, drink no malt liquor, little wine, &

take physic occasionally, by these means, my Ribs

display Skin of no great thickness, and my Clothes,

have been taken in nearly half a yard, do you believe me

now? . . . I grow thin daily; since the commencement of

my System I have lost 23 lbs in my weight . . . to 12 st 11

lb . . . I shall still proceed until I arrive at 12 st and then

stop, at least if I am not too fat, but shall always live

temperately and take much exercise. . . . I have reduced

myself . . . to 12 stone 7 lb. . . . I . . . now .. . weigh 12 stone

. . . I shall reduce myself to 11, & there stop . . . many of

my acquaintance . . . have hardly believed their optics,

my visage is lengthened, I appear taller, & somewhat

slim, & mirabile dictu !! my Hair once black or very dark

brown, is turned . . . to a light Chesnut, nearly approach-

ing yellow, so that I am metamorphosed not a little. . . . I

. . . am barely 11 stone . . . with all my clothes, heavy

shoes, gaiters &c . . . I find I am not only thinner,but

taller by an Inch since my last visit, I was obliged to tell

everybody my name, nobody having the least

recollection of my visage, or person. . . . My weight is

now 10 stone 11 lb !!! . . . now only ten stone and a half.”

This crash diet brought him down to 9 stone 11

1/2 pounds (61 kg). He later became a “leguminous-

eating Ascetic.”

“I have long left off Wine entirely . . .

my meal is generally at ye Alfred, where I munch my

vegetables in place. . . . For a long time I have been

restricted to an entire vegetable diet, neither fish or

flesh coming within my regimen, so I expect a powerful

stock of potatoes, greens, & biscuit, I drink no wine.”

Nothing gratifies him so much as being told that he

grows thin: “Don’t you think I get thinner? Did you ever

see any person so thin as I am, who was not ill?”

“Web-

ster . . . found me thinner even than in 1813, for . . . I

have subsided into my former more meagre outline. . ..

I am as thin as a skeleton

—

thinner than you saw me at

my first arrival in Venice and thinner than yourself there

is a climax!”

Byron’s accounts reveal payments for all

his food and drink, and in 1811 he bought a treatise on

corpulence.

This treatise was probably William Wadd’s

Cursory Remarks on Corpulence, published anonymously

in 1810. Wadd cited Coelius Aurelianus’s triad of diet,

exercise, and sweating. “His food is to be chiefly bread

made with bran, vegetables of all kinds; a very small

quantity of animal food, which should be dry and free

from fat. He advises very little sleep, and positively for-

bids it after meals.”

When Byron dined with Samel Rogers in

November 1811 he asked for just “hard biscuits and

soda water.” These were not available, so he dined on

bruised potatoes drenched with vinegar.

Rogers’s

anecdote that Byron later went to his club “and eaten a

hearty meat-supper” is probably a fiction. In 1821 his

breakfast “consisted of a cup of strong green tea, with-

out milk or sugar, and an egg, of which he ate the yolk

raw. . . . My digestion is weak; I am too bilious . . . to eat

more than once a-day, and generally live on vegetables.

To be sure, I drink two bottles of wine at dinner, but

they form only a vegetable diet. Just now, I live on claret

and soda water.”

In spite of his cult of thinness he remained a

passionate gourmet and giver of famous dinner parties.

One menu does survive from a Byron dinner, on 2

January 1822 in Pisa, with just three main courses, but 18

dishes.

For each course all the dishes would have been

served at once and laid on the table for the guests to help

themselves. The first course was thick dark vegetable

soup, or herb soup à la santé, with fried sweetbreads or

cream cheese; a salami of pork with lentils, spinach, and

ham; boiled capons; beef garnished with potatoes; and a

fish stew. That course would then have been removed

and in came the grand set piece, which the host carved.

There was veal, roast capons, roast woodcocks, baked

fish, a fricasee of poultry, and another stew. The dessert

was blanched and plain almonds with pears, oranges,

and chestnuts. With dinner they would have drunk claret

and hock, and afterwards coffee and tea. (This was a

modest dinner compared with what the Prince Regent

was serving in Brighton about the same time, when in

1817 the kitchens of his Royal Pavilion produced 36

courses of 112 dishes.

)

Yet Byron was almost never seen, and did not like

to see others, eating. “I don’t know how I shall manage

this same wooing . . . I am sadly out of practice lately,

except for a few sighs to a Gentlewoman at supper who

was too much occupied with ye fourth wing of her

second chicken to mind anything that was not material.

. . . I only wish she did not swallow so much supper,

chicken wings

—

sweetbreads

—

custards

—

peaches and

Port wine

—

a woman should never be seen eating or

drinking, unless it be lobster sallad & champagne, the

only true feminine & becoming viands. . . . I have preju-

dice about women: I do not like to see them eat.”

“He

disliked seeing women eat, or to have their company at

dinner, from a wish to believe if possible, in their more

ethereal nature . . . his chief dislike . . . arose from the

fact of their being helped first, and consequently

getting all the wings of the chickens, whilst men had to

be content with legs or other parts.”

He rarely dined

with his wife, Annabella, who remarked, “For four or

five months before my confinement, he objected

unkindly to dine with me, though I was willing to con-

form to his hours, and once when his dinner was acci-

dentally served at the same table with mine, he desired

his dish to be taken into another room.”

19 20

Nor did he

sit and eat with his devoted mistress, Teresa Guiccioli.

The muses

1698 BMJ VOLUME 315 20-27 DECEMBER 1997

Probably he dined alone to gorge in secret, and

then perhaps make himself sick. His sister Augusta

wrote, “I am quite convinced that if he would

condescend to eat & drink & sleep like other people he

would feel ye good effects

—

but you know his way is to

fast till he is famished & then devour more than his

stomach in that weak state can bear

—

& so on.”

“Stuffed myself with sturgeon, and exceeded in

champagne and wine in general, but not to confusion

of head. When I do dine I gorge like an Arab or a Boa

snake; on fish and vegetables, but no meat. I am always

better, however, on my tea and biscuit than any other

regimens and even that sparingly. . . . To dine today . . .

for which I have some appetite, not having tasted food

for the preceding forty-eight hours. I wish I could leave

off eating altogether.”

Byron refused most dinner invitations. “I dare not

venture to dine with you tomorrow

—

nor indeed any

day this week

—

for three days of dinners during the last

seven days

—

have made me so head-achy and sulky. . . . I

hope you will not take my not dining with you again

after so many dinners

—

ill

—

but the truth is

—

that your

banquets were too luxurious for my habits.”

When he

did dine with the Blessingtons in 1823 in Genoa he

took two helpings of plum pudding à l’Anglaise: “for

several months I have been following a most

abstemious regime, living almost entirely on vegeta-

bles; and now that I see a good dinner, I cannot resist

temptation though tomorrow I shall suffer for my

gourmandise, as I always do when I indulge in

luxuries.”

“Forgot there was a plum-pudding, (I have

added, lately, eating to my ‘family of vices’). . . . Mrs

Ingram has promised me a minced pie, a dainty I have

not seen these seven years.”

“Last night I supped with Lewis;

—

and, as usual,

though I neither exceeded in solids nor fluids, have

been half dead ever since. My stomach is entirely

destroyed by long abstinence. . . . That confounded

supper at Lewis’s has spoiled my digestion and my phi-

lanthropy. I have no more charity than a cruet of

vinegar. Would I were an ostrich, and dieted on

fire-irons,

—

or any thing that my gizzard could get the

better of. . . . I am in the most robust health

—

have been

eating and drinking

—

& fallen upon illfortune. . . . I

began very early and very violently

—

and alternate

extremes of excess and abstinence have utterly

destroyed

—

oh! unsentimental world!

—

my stomach

—

and as Lady Oxford used seriously to say a broken heart

means nothing but bad digestion. I am one day in high

health

—

and the next on fire or ice

—

in short I shall turn

hypochondriacal

—

or dropsical

—

whimsical I am already

—

but don’t let me get tragical ...three days of dinners

during the last seven days

—

have made me so

head-achy and sulky

—

that it will take me a whole Lent

to subside again into anything like independence of

sensation from the pressure of materialism.”

His medical adviser had advised a more nutritious

regimen, “but he declared, that if he did, he should get

fat and stupid, and that it was only by abstinence that

he felt he had the power of exercising his mind. . . .

When he eats as others do he gets ill, and loses all

power over his intellectual faculties.”

“I have dined

regularly today, for the first time since Sunday last

—

this

being Sabbath too. All the rest, tea and dry biscuits

—

six

per diem. I wish to God I had not dined now!

—

It kills me

with heaviness, stupor and horrible dreams;

—

and yet it

was but a pint of bucellas [a Portugese wine], and fish.

Meat I never touch,

—

nor much vegetable diet. I wish I

were in the country, to take exercise,

—

instead of being

obliged to cool by abstinence, in lieu of it. I should not

so much mind a little accession of flesh,

—

my bones can

well wear it. But the worst is, the devil always came with

it,

—

till I starve him out, and I will not be the slave of my

appetite. If I do err, it shall be my heart, at least, that

heralds the way.”

He feared being dominated by

animal appetites “the wear and tear of the vulture pas-

sions.”

Byron knew his sexual excesses came when he

was at his fattest. He avoided meat for the curious

philosophy one sometimes still hears from patients

today that “animal food engenders the appetite of the

animal fed upon.

Thus he dined alone often with

Thomas Moore but ate nothing, just drinking claret.

“Moore, don’t you find eating beef-steak makes you

ferocious? . . . I have been fat, & thin (as I am at present)

and had a cough & a catarrh & the piles and be

damned to them, and I have had pains in my side and

left off animal food which has done me some service.”

For two days he ate only a few biscuits and chewed

mastic to appease his appetite, and then after seeing

Kean playing Othello he managed three lobsters, half a

dozen glasses of brandy, and a bottle of claret.

“I am better than ever

—

and in importunate

health

—

growing (if not grown) large & ruddy

—

& con-

gratulated by impertinent persons on my robustious

appearance

—

when I ought to be pale and interesting.”

He would then boast of intolerable leaness, a meagre

outline, “nearly transparent.”

Yet to Hunt in 1822,

“Upon seeing Lord Byron, I hardly knew him, he was

grownsofat.”

Byron’s friends confirmed his eating

disorder. Trelawny wrote: “Byron had not damaged his

body by strong drinks, but his terror of getting fat was

so great that he reduced his diet to the point of

absolute starvation. He was of that soft, lymphatic tem-

perament which it is almost impossible to keep within

George Gordon Byron, 6th Baron Byron, painted in 1813 by Richard

Westall

NATIONAL PORTRAIT GALLERY

The muses

1699BMJ VOLUME 315 20-27 DECEMBER 1997

a moderate compass, particularly as in his case his

lameness prevented his taking exercise. When he

added to his weight; even standing was painful, so he

resolved to keep down to eleven stone, or shoot

himself. He said everything he swallowed was instantly

converted to tallow and deposited on his ribs. He was

the only human being I ever met with who had

sufficient self-restraint and resolution to resist this

proneness to fatten: he did so; and at Genoa, where he

was last weighed, he was ten stone and nine pounds,

and looked much less. This was not from vanity about

his personal appearance, but from a better motive; and

as, like Justice Greedy, he was always hungry, his merit

was the greater. Occasionally he relaxed his vigilance,

when he swelled apace. I remember one of his old

friends saying: ‘Byron, how well you are looking! . . . You

are getting fat,’ Byron’s brow reddened and his eyes

flashed

—

‘Do you call getting fat looking well, as if I

were a hog?’ Byron said he had tried all sorts of experi-

ments to stay his hunger, without adding to his bulk. ‘I

swelled,’ he said, ’at one time to fourteen stone, so I

clapped the muzzle on my jaws, and like the hybernat-

ing animals, consumed my own fat’ . . . his brain was

always working at high pressure. . . . By starving his

body Byron kept his brains clear. He would exist on

biscuits and soda-water for days together, then, to allay

the eternal hunger gnawing at his vitals, he would

make up a horrid mess of cold potatoes, rice, fish or

greens, deluged in vinegar, and gobble it up like a fam-

ished dog.”

He took quantities of vinegar to lessen his appetite,

dosed himself with Epsom salts, magnesia, and strong

laxatives, and always had the highest spirits when he

had emptied himself at one or both ends, that is after

the purgatives had acted, or he had vomited. He also

used tobacco “to take off the pinguify propensities of

the appetite.”

In Athens he had Turkish baths daily

and a diet of vinegar, water and rice.

He drove himself

to excess exercise and perhaps would be classified

today as also having exercise bulimia. “I am in tolerable

leanness, which I promote by exercise and abstinence.”

He swam the Hellespont, in imitation of Leander,

enjoyed being tossed by the sea for days on end in a

boat

and his last fatal illness followed being drenched

during a long ride in Greece.

James Joyce’s gut

James Joyce,

24–26

perhaps the greatest of the many

famous Irish writers, was born in Dublin in 1882. Both

he and his father became medical students, his father at

Cork from 1867 to 1869: “He was enrolled in the school

of medicine for three years . . . studied as little as possible,

and instead made a big name in sport and dramatics,

and by his wild life while a student . . . many human lives

were saved by his giving up the study of medicine.”

Joyce entered medical school in University College

Dublin in October 1902. By December he had

transferred to the Sorbonne in Paris. (“Of all the wild

youths I have ever met he is the wildest.”

) He came

home the following Easter because of the fatal illness

of his mother. He could not have spent much time

studying medicine, but he did spend his evenings

frequenting the doctors’ quarters of Dublin hospitals

for the social life. Joyce was a close friend of many

Dublin medical students, especially Oliver St John

Gogarty, the Buck Milligan of Ulysses, physician,

journalist, senator, and poet

—

but bizarrely fated to be

best known anonymously as the author of a limerick:

There was a young man of St John’s

Who wanted to bugger the swans

Oh no! said the porter

Oblige with my daughter

For the swans are reserved for the dons.

Joyce had a profound knowledge of human disease,

and diseases and doctors and hospitals are continually

referred to in his Portrait of the Artist as a Young Man,in

Dubliners, and in Ulysses. He met his wife to be, Nora

Barnacle, on 16 June 1904

—

the famous Bloomsday.

I shall ignore his urethritis, arthritis, intestinal

disorder, and recurrent iridocyclitis, recently attributed

to Reiter’s syndrome.

From the age of 21, however,

Joyce had bouts of epigastric hunger pain. These began

when he was a penniless student in Paris, when he

might pass 20, or once 42, hours without food while

waiting for a money order to come from Dublin. He

used to vomit on waking, and this continued after his

mariage to Nora. Joyce blamed his own psyche

—

for

example, “two days of severe gastrical disarrangement”

if his brother did not write; and “trouble and bustle

always finds its way into the bosom of my stomach.” He

was better when he feasted (box).

James Joyce, painted in 1935 by Jacques-Emile Blanche

NATIONAL PORTRAIT GALLERY

James Joyce, feasting—Rome 1907

10.30 am Ham, bread and butter, coffee

1.30 pm Soup, roast lamb, potatoes, bread, wine

4.00 pm Beef-stew, bread, wine

6.00 pm Roast veal, bread, gorgonzola cheese

8.30 pm Roast veal, bread, grapes with vermouth

9.30 pm Veal cutlets, bread, salad, grapes, wine

The muses

1700 BMJ VOLUME 315 20-27 DECEMBER 1997

His friends with similar symptoms told him that he

had an ulcer, but his French doctors made other diag-

noses. In 1928 it was inflammation of the intestine. In

1933, after a night of acute soreness of all his inside,

leaving him helpless and strengthless, he was seen by

Dr Debray’s assistant, Dr Fontaine. She had a particular

interest in contemporary literature in English and

looked after other expatriate authors such as Ernest

Hemingway and Samuel Beckett. Dr Fontaine dis-

counted the diagnosis of colitis and attributed the

spasms to a “disequilibrium of the system of the

sympathetic nerve with the focus of the dislocation in

the epigastric part of the stomach”: she advised

absolute and complete calm.

Joyce was then well for some months, but the pains

returned with a loss of 7 kg in weight. The pains lasted

up to eight hours and were attributed by Dr Debray to

“nerves” from his worries over so many years; Debray

treated him with laudanum compresses. His friends

and family still considered that he had a peptic ulcer,

which made Debray even crosser

—

“une interpretation

trop facile.” In 1934 Jung described Joyce’s “psycho-

logical style” as “definitely schizophrenic.”

He continued to be ill over the next four years, with

similar symptoms. In 1939, with constant stomach

cramps and indigestion, he was described as abnor-

mally pale. In 1940 he and his family fled Paris from

the Germans; on arrival in Switzerland he was

described as so undernourished as to look like an

angular figure in a Picasso drawing.

At 4 am on Friday 10 January 1941 at his home in

Zurich, he was woken by severe abdominal pain. His

usual doctor was away and another came, made no

diagnosis, and gave an injection of morphine. Joyce did

not improve and in the evening was seen by the

surgeon Heinrich Freysz, who had studied in

Lausanne, Munich, and Zurich under Kocher, Krön-

lein, and Sauerbruch (who had dismissed him) and

then worked in Strasbourg, Berne, Geneva, and

Vallence before returning to Zurich.

Freysz found Joyce with a rapid pulse and a tender

distended abdomen, but without rebound tenderness,

presumably because of the morphia. Joyce was

admitted to the Schwesterhaus vom Roten Kreuz,

where the next morning gastric aspiration gave

positive results on a benzidine test and x ray films

showed air below the diaphragm. It was 32 hours after

the perforation when, at midday on Saturday 11 Janu-

ary, Freysz opened the abdomen under local anaesthe-

sia and found and sutured a 2 mm perforated

indurated duodenal ulcer near the pylorus, and then

covered it with a patch of omentum. Joyce was given

intravenous fluids but later that afternoon collapsed

from an internal haemorrhage.

Blood donors were summoned, and Joyce thought

it a good omen that one of them came from Neuchatel

because of Joyce’s liking of the wine of that area;

indeed, he had drunk a considerable amount of it the

evening before the ulcer perforated. The transfusion

was given by William Löffler (famous for Löffler’s syn-

drome), later director of the medical clinic and

policlinic of Zurich University. Paralytic ileus devel-

oped, and at 1 am on 13 January Joyce asked the

nurses for his wife and son before he died. “Lonely in

me loneness. For all their faults. I’m passing out. O bit-

ter ending. I’ll slip away before they’re up.”

The necropsy showed enormously dilated loops

of intestine with a fibrinous exudative peritonitis.

Freysz’s patchwork on the perforated ulcer was

intact, but there was a second shallow ulcer containing

blood clots in the duodenum. The pancreas had a

rag-like consistency; perhaps alcoholic pancreatitis?

William Osler once boasted that any patient admitted

to his service at Johns Hopkins was guaranteed

thrice over: a careful history, a thorough physical

examination, and a scrupulous postmortem examin-

ation. But Osler did not live in Switzerland, where

there is a fourth dimension: the bill (300 Swiss francs

—

£20 in 1941).

Melba’s men and meals

My third course, the dessert, must be Dame Nellie

Melba, who was born Helen Mitchell in Melbourne,

Australia, in 1861.

27–30

She was determined to be a

singer and trained as such. In 1882, however, when she

was 21, she met the first of the many men in her life on

a visit to Queensland: Charles Nesbitt Armstrong, the

youngest son of an English baronet. She married him

but was soon unhappy with him and with both the cul-

tural desert of Queensland and its tropical climate,

which made mouldy her clothes, music, and piano. In

1884 she had a son, but she left her husband two

months later.

Her father took her to Europe, where she studied

with Mathilde Marchesi in Paris before her debuts, in

Brussels in 1887 and the next year in Covent Garden,

where she sang almost every season until she retired in

1926. She had a wide repertoire, and she sang

frequently at the Metropolitan Opera in New York,

where in 1896 she had her only failure as Wagner’s

Brünnhilde.

Dame Nellie Melba, photographed by Baron Adolf de Meyer in 1926

NATIONAL PORTRAIT GALLERY

The muses

1701BMJ VOLUME 315 20-27 DECEMBER 1997

In spite of, or because of, her frugal Scottish-

Australian background, Melba loved luxury and good

food. In London she always stayed at the newly

opened Savoy Hotel, for which D’Oyly Carte had

hired Ritz as manager.

The first reference to her

eponymous peach is at a bizarre lunch party. The ear-

liest peaches of the year had just arrived and were

thought precious and costly

—

whereas in her garden in

Melbourne peaches had grown as profusely as

blackberries. Her host picked up a peach and threw it

at the occupants of the benches in the public gardens

below; then Melba and all the other diners joined in

this riotous behaviour.

The chef at the Savoy was Escoffier, who had

worked for Emperor Napoleon III and for the Kaiser,

who had entitled him the Emperor of Cooks. Escoffier

was the son of a blacksmith and he was 14 before he

could read or write, and he never mastered more than

a few words of English. He explained that if he spoke

English he might also learn to cook like an

Englishman. He had two nightmares, the English

and the Americans: the English because they gorged

tea and cakes, ruining their palates for his divine

dinners; the Americans because they ruined their

palates by drinking cocktails before, and iced water

with, his dinners. Like Byron, Escoffier dined alone,

on no more than vegetable soup, and rice, followed

by fruit.

In 1890 Melba, aged 31, met the second and last

great love of her life, a mésalliance destined to be one

of the royal love scandals of the 1890s. Louis Philippe

Robert, 14th Duke of Orléans, was the eldest son and

heir of the Comte de Paris, the Bourbon Pretender to

the throne of republican France. He was eight years

younger than Melba, lean, handsome, 6’ 2” (188 cm),

highly educated, and an entertaining companion. He

had been educated at the Royal Military College, Sand-

hurst, and then spent a year with a British regiment in

India. The Bourbon family had been exiled from

France in 1886, but the duke went back to Paris

demanding as a Frenchman to do his military service.

He was arrested and sentenced to two years in jail.

Released after a few months, he returned to England

and fell in love with Melba.

He followed her to St Petersburg, where she sang

Juliette. At the end he of course applauded, which was

against court etiquette: no one must applaud before

the Tsar. Melba’s duke was promptly expelled from

Russia. Melba and the duke lived and travelled

together throughout her performances at the opera

houses of Europe. To achieve his ambition to return to

France, however briefly, Melba “hired a carriage,

dressed him in livery, and made him act as her coach-

man.” They crossed the frontier from Germany,

“lunched in France and returned without the slightest

contretemps.”

Disaster struck. The affair reached the newspapers,

and eventually the Australian papers reprinted the

scandal. Melba’s husband sued for divorce and cited

the duke. To avoid the process servers the Duke moved

around Europe, but eventually they caught up with him

in Vienna. Heavy political pressure was applied, from

French official quarters and probably through British

diplomatic channels, and the divorce action was

dropped in October 1892. Nevertheless the affair was

doomed. The duke could not marry Melba: she was a

commoner. Moreover, she was a Protestant, and he was

Catholic. And she was already married.

Melba had one last attempt to keep her duke. At

Covent Garden in 1894 she sang Else in Wagner’s

Lohengrin, with Jean de Reszke as the swan prince.

The next evening she gave an intimate supper for the

duke and asked Escoffier for pêches flambées. Escoffier

was determined to excel even himself on such a critical

evening and wheeled in as dessert a swan carved out of

ice in tribute to Lohengrin. Escoffier had made a nest

of spun sugar and strawberry leaves with a superb

peach resting on a vanilla flavoured ice, coated lightly

with raspberry jam.

Thus Pêches Melba was created. Alas, the Duke

submitted to family pressure, deserted Melba, and was

sent off to Africa on safari for two years to forget her,

after which he agreed to marry a Hungarian

archduchess. Nevertheless France is still a republic.

Escoffier also created Poires Melba and Fraises Melba,

but they are not remembered.

Then Melba, like so many opera singers, went to

seed and put on much weight. She developed erratic

eating habits, gorging and fasting on alternate days.

Again Escoffier was called to the rescue. For her to lose

weight, he created the crisp austerity of the thin Melba

toast, and at one stroke he doubled Melba’s

gastronomic immortality.

Envoi

Today’s doctors, and indeed any British or American

gastroenterologist in the 1930s or 1940s, would have

diagnosed and treated James Joyce’s chronic duodenal

ulcer. We have all struggled with patients with anorexia

or bulimia, or both. A good read is Byron’s fantastic

Don Juan, with its clear associations of sexual and

gastric preoccupations. The next time you gorge or

diet, think of Byron, James Joyce, and Melba and then

recall the refrain of every waiter in New York: “Enjoy

your meal!”

I am grateful to Wilma Paterson for allowing me to explore

further her studies of Byron’s eating disorder. Details of the

references to Byron’s letters may be obtained from the author.

1 Medwin T. Conversations of Lord Byron.London: Colburn, 1824.

2 Moore T. Letters and journals of Lord Byron with notices of his life. 3rd ed.

London: John Murray, 1833.

3 Blessington Lady. Conversations of Lord Byron with the Countess of Blessing-

ton. London: Henry Colburn, 1834.

4 Origo I. The last attachment. London: Jonathan Cape & John Murray,

1949;378.

5 Marchand LA. Byron—a biography. London: John Murray, 1957.

6 Marchand LA, ed. Byron’s letters and journals. 12 vol. London: John

Murray, 1973-82.

7 Moore DL. Lord Byron accounts rendered.London: John Murray, 1974.

8 Richardson J. Lord Byron and some of his contemporaries. London: Folio

Society, 1988.

9 Grosskurth P. Byron,the flawed angel.London: Hodder & Stoughton, 1997.

10 Browne D. The problem of Byron’s lameness. Proc R Soc Med 1960; 53:

440-442.

11 Raymond J, ed. The reminiscences and recollections of Captain Gronow being

anecdotes of the camp, court, clubs & society. London: Bodley Head,

1964:121-2.

12 Morgan S. Memories,autobiography,diaries and correspondence.Vol 2. 2nd ed.

London: WH Allen, 1862:200.

13 Paterson W. Was Byron anorexic? Wo r l d M e d 1982 May 15:35-8.

14 Paterson W. Lord Byron’s relish:Regency recipes with notes culinary & Byronic.

Glasgow: Dog & Bone, 1990.

15 Hobhouse JC (Lord Broughton). Recollections of a long life with additional

extracts from his private diaries. Vol 4. London: John Murray, 1910:5.

(Edited by Lady Dorchester.)

16 [Wadd W.] Cursory remarks on corpulence: by a member of the Royal College of

Surgeons. London: J Callow, 1810.

THE SAVOY GROUP

Escoffier, Savoy

chef

MANDER AND MITCHENSON

The muses

1702 BMJ VOLUME 315 20-27 DECEMBER 1997

17 Rogers S. Recollections and table talk. New Southgate: H A Rogers, 1887:

231-2. (Edited by Alexander Dyce.)

18 Dinkel J. The Royal Pavilion Brighton. Brighton: Borough Council,

1986:28.

19 Elwin M. Lord Byron’s wife. London: John Murray, 1962:326.

20 Mayne EC. The life and letters of Anne Isabella, Lady Noel Byron. London:

Constable, 1929:184.

21 Hunt JHL. Lord Byron and some of his contemporaries; with recollections of the

author’s life and of his visit to Italy.Vol 1.2nd ed. London: Colburn, 1828:15.

22 Trelawny EJ. Recollections of the last days of Shelley and Byron. In: Hogg

TJ, ed. The life of Percy Bysshe Shelley. Vol 2. London: J M Dent, 1933:184-5.

23 Wadd W. Comments on corpulency/lineaments of leanness/ mems on diet and

dietetics. London: John Ebers, 1829:80.

24 Lyons JB. James Joyce and medicine. Dublin: Dolmen Press, 1973.

25 Paton A. James Joyce

—

a case history. BMJ 1975;ii:636-7.

26 Cole D. My impossible health or the case of James Joyce. London: Royal

College of Physicians, 1977.

27 Colson P. Melba:an unconventional biography. London: Grayson and Gray-

son, 1932.

28 Hetherington J. Melba—a biography. New York: Farrar, Straus & Geroux,

1967.

29 Melba N. Melodies and memories.London: Hamish Hamilton, 1980.

30 Jackson S. The Savoy.A century of taste. London: Frederick Muller, 1989.

Commentary: Ambivalence toward fatness and its origins

Arthur Crisp

At this distance the diagnoses cannot be absolutely

certain, despite the extraordinary details Hugh Baron

has so splendidly mustered. Anorexia nervosa is

supposed to be a modern disease. I believe it has been

around for a long time, probably ever since postpubes-

cent humans were capable of contemplating their

newly awakened adult destiny, experiencing it as

unwelcome and linked to their recent growth. One

response, then as now, might have been, through the

mechanism of reversal of that growth, to eliminate the

related burgeoning panic stemming from a sense of

imminent alienation, disgrace, or longer term danger

and decay. Then again, the condition is rare indeed in

males, though one of Morton’s two original case

descriptions, which are almost certainly of what today

we would call anorexia nervosa, was in a male subject.

Byron undoubtedly had a persistent severe eating

disorder. Moreover, it was clearly powerfully driven and

maintained by his fear of fatness and self loathing in

this respect.

There is a devastating family history of severe psy-

chiatric morbidity; he was obese as a child; seems to

have been physically, socially, and sexually abused in

childhood; was bisexually promiscuous in

adolescence

—

all these are common, recognisable ante-

cedents of the severe end of the spectrum of eating

disorders.

His repugnance of his obesity at the age of 18

(body mass index around 30) probably led to his first

major weight loss through his electively restricted food

intake, excessive exercise, and dehydrating strategies at

that time. The lowest reported body mass index in the

article is about 19; not quite low enough for a textbook

diagnosis of anorexia nervosa. Also unusual is his

awareness of and acknowledgement that he was so

thin. Perhaps this was the burning insight and

necessary honesty of a great poet. More typically, so far

as anorexia nervosa is concerned, it is apparent that he

relished his extreme thinness. Moreover, as this report

indicates, he probably lost yet more weight at times

thereafter. I think, therefore, that he is very likely to

have had full blown anorexia nervosa then and at sub-

sequent intervals. However, it is noteworthy that he

seems to have sired children, an impossibility with con-

current anorexia nervosa. His paternity of various off-

spring seems beyond reasonable doubt. Perhaps

dehydration contributed importantly at times to his

lowest recorded body weights; lean body mass would

then have been relatively greater than was apparent, as

also would have been his reproductive potential.

Probably prompted by his underlying impulse-

ridden nature and tendency to obesity, as well as in

reaction to his starvation, he also seems to have binged

hugely at times. At such times he attempted to defend

against consequent massive and doubtless terrifying

weight gain due to the high dietary calorie loads and

associated fluid retention, by the variety of strategies by

then at his disposal. These included reported recurrent

severe vomiting. Nevertheless, there were also times

when he was obviously overweight during this second

half of his life.

His disgust with his fatness equates, in his own

mind, with his licentiousness and his intense ambiva-

lence towards it and its origins. I would attribute the

foundation of his eating disorders to this biological

and psychopathological link.

The case for anorexia nervosa during (long)

periods within the second half of Byron’s life is strong.

He sought the ascetic ideal and achieved it at times

only through his anorexia nervosa. Then he found

himself free from the distractions of his “baser”

impulses and the related social life and able instead to

foster and express his intellectual and poetic self. At

other times he considered himself corrupted, when

losing control over his food intake and suffering some

slight or greater weight gain. His fear was not just of

obesity but of any weight gain at all. Self disgust and

despair erupted at such times. When up to or above

normal weight, but with his continued bingeing and

purging, he would nowadays be diagnosed as having

“bulimia nervosa.” Poor Byron, to be reduced to our

labelling.

It is typical of public attitudes to the eating

disorders that Byron’s own eating disorders

—

which

reflected his most basic flaw in personal adolescent

development, and which underwrote most of his daily

concern, distress, and behaviour thereafter

—

are once

again largely ignored in the latest biography.

Baron has given a vivid 18th century account

almost certainly of both anorexia nervosa and bulimia

nervosa, and in a male. This is also the story of a

renowned and desperate poet

—

and reveals the kind of

price that sometimes must be paid for such creativity.

1 Morton R. Phthisiologia: or, a treatise of consumptions. London: Smith and

Walford, 1694.

2 Grosskurth P. Byron, the flawed angel. London: Hodder and Stoughton,

1997.

MARY EVANS PICTURE LIBRARY

A scene from

Byron’s Don Juan

The muses

Psychiatric

Research Unit,

St George’s

Hospital Medical

School, London

SW20 0NE

Arthur Crisp,

emeritus professor of

psychological medicine

a.crisp@sghms.ac.uk

1703BMJ VOLUME 315 20-27 DECEMBER 1997

How Renoir coped with rheumatoid arthritis

Annelies Boonen, Jan van de Rest, Jan Dequeker, Sjef van der Linden

Out of doom and misery, the most beautiful song may rise

Few people know that Pierre-Auguste Renoir, who

lived from 1841 to 1919, suffered from severe rheuma-

toid arthritis for the last 25 years of his life. At the 13th

European congress of rheumatology in Amsterdam in

1995 Mr Paul Renoir, the artist’s 70 year old grandson,

revealed several previously unpublished aspects of his

grandfather’s disease.

Disease and evolution

There is little doubt that Renoir suffered from rheuma-

toid arthritis, but there is still some discussion about

the precise year the arthritis started.

It must have been

around 1892, when Renoir was about 50 and in the

prime of life. He was married to Aline Charigot, and

two of his three sons had already been born. He was

recognised as an established painter, having had exhi-

bitions not only in Paris and other places in France but

also in Brussels, London, Boston, and New York.

He was active and hardworking, painting and mak-

ing study tours to Algiers, Italy, Germany, and Spain.

His friends included the painters Manet, Sisley, and

Cézanne and the writers Zola and de Montpassant.

Although no medical records remain, it is possible,

thanks to photographs, his personal letters, and

biographical notes by people who knew him well to get

a reasonable idea about the course of his disease. The

arthritis started around the age of 50, took on an

aggressive form from 1903 onwards, when he was

about 60, and made him quite handicapped from the

age of 70 for the last seven years of his life.

In a photograph of 1896, when he was 55, the

swelling of the metacarpophalangeal joints can be

clearly seen (fig 1). Five years later, in 1901, when he

was 60, he could still use his hands fully as witnessed in

the way he holds his pipe (fig 2). Then the arthritis

became more aggressive, and in the photograph of

1903 (fig 3), at the age of 62, we see the dramatic

change where he tries to hold his inseparable cigarette

in his deformed hands. The aggressive nature of the

disease resulted in the destruction and ankylosis of his

right shoulder and ruptures of several extensor

tendons of fingers and wrists, leading to poor hand

function, as shown in the picture of his hands of 1912

(fig 4), when he was 71. Despite these deformed hands,

he continued to roll his cigarettes and, according to his

grandson, produced more than 400 paintings.

A comparable series of pictures illustrates how the

disease affected his feet and legs. In 1901, at the age of

60, when his youngest son, Claude (“Coco”), was born,

he used one walking stick (fig 5). In 1908 when it

became difficult to walk with one cane he had to use

two (fig 6). In 1912, at the age of 71, a stroke was

reported, which partially paralysed his arms and legs. It

is more likely that the paralysis was due to rheumatoid

arthritis, affecting the cervical spine. From then on he

could not walk anymore and he was confined to a

wheelchair. A photograph shows him sitting in his stu-

dio next to the canvases and his model, Catherine

Hessling (“Dédée”), who lived with the Renoir family

and later became his daughter in law (fig 7).

He had to stop travelling abroad, but continued to

make frequent trips in France, driven by his loyal

chauffeur, Batistin. However, the deformities of the feet

Fig 1 Renoir during a boat tour on the Seine near Chatou in 1896. Swelling of the

metacarpophalangeal and proximal interphalangeal joints can be seen. Fig 2 In 1901 Renoir

could still use his hands normally, as can be seen in the way he holds his pipe. Fig 3 This

photograph taken in 1903 shows the dramatic progression of the deformities in Renoir’s

hands. Fig 4 With these deformed hands Renoir continued to roll his own cigarettes and

completed more than 400 works of art. The bandages served to absorb the sweat to prevent

maceration

Summary points

Pierre-Auguste Renoir, one of the great French

impressionist painters, suffered from severe

rheumatoid arthritis

In June 1995, at the 13th European congress of

rheumatology, his grandson Paul Renoir revealed

how his grandfather coped with the disease

Renoir applied modern principles of

physiotherapy and psychotherapy long before

these terms entered the vocabulary of

rheumatologists

The muses

Department of

Rheumatology,

University Hospital

Maastricht,

Maastricht, the

Netherlands

Annelies Boonen,

rheumatologist

Sjef van der Linden,

rheumatologist

continued over

BMJ 1997;315:1704–8

1704 BMJ VOLUME 315 20-27 DECEMBER 1997

increased and he was soon unable to wear shoes. His

feet had to be wrapped in woollen slippers (fig 8). He

developed fixed flexions of his knees two years before

his death. But this did not prevent him from visiting the

Louvre in a sedan chair to see a private exhibition

some months before he died (fig 9).

There is evidence that the rheumatoid arthritis

affected not only his joints. At the beginning of the dis-

ease a pleuritis is reported and later a facial palsy,

which was treated with electrotherapy. From 1904

onwards, at the age of 63, he began to lose weight

because of rheumatoid cachexia (fig 10). He reports

this quite cynically in a letter: “I can’t stay seated

because I’m so thin. Forty six kilos, that can’t be called

fat. My bones are sticking through my skin and this

despite a good appetite.”

Renoir’s rheumatoid arthri-

tis was nodulous and the nodules on his back became

particularly troublesome after 1912, the year he

became wheelchair bound. These nodules were

removed by Dr Prat, a surgeon at the Belvédère Hospi-

tal in Nice. In 1918 gangrene of his foot was described.

Despite good care, he also developed bedsores. Finally,

in 1919, on his return from Paris to his house in the

south of France, he caught pneumonia and died on 3

December, having spent several hours painting that

evening on a still life of apples in a basket that his

youngest son, Coco, had brought him.

Treatment

In the early years of the disease Renoir was treated by

his two family doctors

—

Dr Baudot at Essoye in the

Aube region, where he had a studio, and Dr Journeac,

his doctor in Montmartre. They prescribed purges and

antipyrine. He followed their advice but limited the use

of antipyrine because he was frightened that it would

influence his artistic creativity. He relied more on

physical exercise to remain in good condition and to

keep the optimal use of his hands and arms. A quota-

tion from the bibliography written by Renoir’s second

son, Jean (the film director), illustrates this: “He had no

great faith in the benefit of walking which brought into

play only certain muscles. He believed much more in

ball-games and began juggling every morning 10 min-

utes before going to his studio.”

His grandson told us that the wooden sticks he

used for juggling were made according to the master’s

instructions by his Paris coal merchant. He also liked

playing billiards because this obliged him to adopt all

sorts of awkward postures. He used to play it with his

wife, Aline, who became the better player and beat him

repeatedly. Another game to exercise his arms was bil-

bouquet. This difficult French ball game involves a

wooden ball with a hole in it, weighing between 500 g

and 3 kg. The player has to throw the ball and then to

try to catch it on a wooden stick via the hole.

To experience the benefits of warmth and physical

exercise he visited French spas such as Vichy,

Bourbonne-les-Bains, and Aix-les-Bains four or five

times between 1899 and 1914. He used to move there

for several months along with his entire family, his staff,

and even his piano and parrot. His hope for some cure

is expressed in a letter of 1903 to one of his friends:

“I’ve the impression I have come to the right place, a lot

of people here seem well satisfied with the waters.”

When the disease deteriorated he agreed that

warmth was beneficial and gave some pain relief. For

that reason he spent more and more time in the south

of France. At first there were family holidays with the

Manets and Cézannes. Later, he and his wife bought a

big estate in Cagnes-sur-Mer, near Nice. One of his

reasons for buying the estate was to save several 1000

year old olive trees that were threatened with being cut

down. He built a house, “Les Colettes,” and a studio,

and in 1908 the family moved to Cagnes-sur-Mer.

But even in the hot Mediterranean climate, Renoir

wanted to be dressed warmly (fig 8). This is described

by one of his best friends: “He wears no special paint-

er’s garb. He sits in his armchair, his spindly legs

crossed, his poor feet wrapped in woollen slippers, his

body covered in shawls and his pale fine head muffled

to the ears in a cap or white linen hat according to the

Fig 5 In 1901, when his youngest son was born, Renoir already had to use a walking cane.

Fig 6 In 1908 Renoir had to use two walking canes, under which he had attached rubber

stops to prevent them from slipping. Fig 7 From 1912 onwards Renoir became wheelchair

bound. In this photograph he is sitting next to his canvasses and his model Dédée (Blonde à

la Rose 1915). Fig 8 Renoir had to have his poor feet wrapped in woollen slippers

(Cagnes-sur-Mer, 1915-6). Fig 9 Renoir was carried in his sedan chair by his friends or staff

to places that were difficult to reach in a wheelchair (garden in Cagnes-sur-Mer, 1917). Fig

10 Renoir in 1915, when rheumatoid cachexia was clearly visible

107

The muses

Reumafonds,

PO Box 80208,

2508 GE The

Hague, the

Netherlands

Jan van de Rest,

president, 13th

European congress of

rheumatology

Department of

Rheumatology,

University Hospital

of Leuven, Leuven,

Belgium

Jan Dequeker,

rheumatologist

Correspondence to:

Dr Boonen

aboo@sint.AZMONL

1705BMJ VOLUME 315 20-27 DECEMBER 1997

season.”

Also, to share their warmth, he often nursed

one of the many cats that lived around the house.

Occasionally, the Institut Pasteur in Paris, checking the

authenticity of Renoir’s paintings, has found cats’ hairs

in the paint. This helps to date the paintings. His family

doctor at this time was Dr Gachet. He was an art con-

noisseur and is well known from the portrait by Van

Gogh, who was also one of his patients.

Influence on style and technique of

painting

There has been discussion among experts about

whether the disease had an influence on Renoir’s

painting.

There is certainly a change in style around

1880. That year Renoir travelled to Italy and,

influenced by the classic Italian Renaissance painters,

he had a so called artistic crisis. For a time his style

became more harsh and the colours he used were

more vivid. However, this was several years before his

arthritis started.

Of course, the progressive deformities of his hands

and the ankylosis of his shoulder obliged him to adapt

his painting technique continuously. Photographs and

testimonies help us to reconstitute how he painted.

When it became difficult to hold his palette in his hand

he first let it balance on his knees and the edge of the

easel. Later, he asked for it to be fixed, like a rotating

table on the arm of his wheelchair (fig 11).

As time passed, he found it increasingly difficult to

pick up and hold the brushes. His wife, son, or model

had to fix the brush in his deformed hands. In figure 12

his grandson shows how he finally held the brush,

wedged in the first metacarpal space. The bandages did

not serve to fix the brush but to absorb the sweat of the

palms of his hands to prevent maceration and possible

infection. He obviously changed his brush less often

than before and became slower in painting. This might

also explain why he used a progressively shorter

brushstroke and started to paint dry on dry instead of

wet on wet. Still, he always continued to paint starting

with a touch of white, then adding and mixing the

other colours afterwards. Throughout his life he used

the same 11 colours, only later adding black.

The ankylosis of his right shoulder limited him to

painting only small areas of about 30 cm by 30 cm. To

reach a bigger area he moved his whole body, and with

some imagination this can be seen in figure 13. Renoir

was ambidextrous and twice, after breaking his arm, he

made use of this ability. Even art specialists cannot

notice the difference in his paintings.

Renoir’s invention of the moving canvas or picture

roll was important for his painting technique; it

replaced his easel. The linen was fixed on wooden slats,

Fig 11 Renoir had to adapt his painting technique continuously; the brushes had to be fixed

in his hands by his wife or model and he couldn’t hold his palette, so he let it balance on his

knees and the edge of the easel. His wheelchair was already of modern design, and he filled

the back with cushions to prevent the development of bedsores. Fig 12 Renoir’s grandson

Paul shows how Renoir held his brush when his hands were severely deformed by arthritis.

Fig 13 With some imagination you can see the master moving his whole body to overcome

the limited movement of his arm due to ankylosis of his shoulder. Fig 14 Les Grandes

Baigneuses. This painting, measuring 160 cm by 110 cm, was painted in 1918 and 1919 on

the picture roll. Fig 15 Inspired by the sculptor Maillol, Renoir made some bronzes, such as

this medallion of his youngest son, Coco, dated 1908

BRIDGEMAN ART LIBRARY

12 13

ART INSTITUTE OF CHICAGO/BRIDGEMAN ART LIBRARY

On the Terrace 1878. Renoir revealed the happy side of life in his

images. “For me a picture must be an amiable thing, joyous and

pretty—yes, pretty! There are enough troublesome things in life

without inventing others.” Marcel Proust said: “Women who go by in

the streets are different from their predecessors—now they are

Renoirs”

The muses

1706 BMJ VOLUME 315 20-27 DECEMBER 1997

which could turn around two spindles linked by the

chain of his old bicycle and driven by a crank to move

the canvas up and down. Unfortunately, no pictures

exist of this special easel. The picture roll allowed him

to continue to paint large works and Les Grandes

Baigneuses is one of the works painted in this way (fig

14). It measures 160 cm by 110 cm and was painted in

1918 and 1919, when his hands were severely

deformed and the mobility of his right shoulder was

restricted. On some paintings of this period the traces

of the bars can be seen.

It might seem surprising that Renoir started sculpt-

ing during the last 12 years of his life. He was inspired

by the sculptor Maillol, who at that time made a bust of

Renoir because the painter was appointed chevalier

d’honneur. Renoir made a bust and later a medallion

(fig 15) of the head of his youngest son, Coco. The

medallion served as a decoration for the fireplace in

their new house “Les Collettes.” A reproduction of the

medallion is available from the Renoir family, who are

pleased to give information about it. He made other

bronzes in cooperation with Guino, Maillol’s pupil,

who served as the executor of Renoir’s ideas.

Other devices

Renoir used his creativity not only to be able to

continue painting but also to let him function as

normally as possible in his personal life. In his daily life

he adapted other tools

—

for example, his walking sticks.

He started using them in 1901, when he had difficulty

walking. He attached rubbers under them to prevent

him from slipping. In 1912, the year he became

paralysed, he bought a wheelchair in Nice and later on

two others to use in Paris. They were modern in design

(fig 11). He filled them with cushions to protect his

bones and to prevent the development of more

bedsores. He also had a sedan chair, in which he was

carried in places inaccessible to wheelchairs (fig 9).

Coping

When looking at Renoir’s paintings it is easy to forget

that he suffered a great deal. Not only did he have to

put up with the pain, progressive disability, and periods

of depression but his two eldest sons were injured in

the first world war, and his wife, Aline, died in 1915.

Painting was almost a physical need and sometimes

a cure, as if Renoir wanted to create on the canvas

those things which he had to miss in real life because of

his disability. Even when he woke at night crying in

pain, he asked for some painting material and started

to make small paintings on wood (fig 16). The beauty of

nature and women constantly inspired him, and music

played an important part in his life. As a small boy, in

his Paris school, he had singing and piano classes from

Charles Gounod, who suggested that he should follow

a musical career. But even at the age of 12 the young

Renoir had developed an interest in painting and

turned down the offer, though he kept his love for

music. He was always singing or humming tunes from

operas while painting, and his piano always moved

with him. The Renoirs moved 53 times in Paris alone.

His happy and fruitful life would have been impos-

sible without the continuous support and motivation

of his friends, the models, his staff, and his family. His

Fig 16 When Renoir woke at night because of pain, he asked for painting materials and made

small paintings on wood. Painting helped him to endure and forget his pain. Fig 17 Henri

Matisse, Albert André, Pierre Renoir (the eldest son), and Malec André around Renoir at New

Year 1919. Fig 18 Aline was more than a wife: she devoted her life to him. After her death,

Coco, their youngest son, took her place as much as possible

Blonde à la Rose 1915. Andrée Madelaine Heuschling (also called

Catherine Hessling or Dédée), an actress from Alsace, was Renoir’s

model for more than 100 paintings (see also fig 7). She was found

by Aline, Renoir’s wife, in a photographer’s shop in Nice after they

had been searching for several years for a model with such beauty.

Dédée married Renoir’s son Jean, the film director, in 1920

GIRAUDON/BRIDGEMAN ART LIBRARY

The muses

1707BMJ VOLUME 315 20-27 DECEMBER 1997

most dedicated friends were the Cézannes, Albert

André, and some of the art dealers of the time. They

visited him frequently and brought interesting people

with them such as Rodin and Matisse, who visited

Cagnes-sur-Mer a couple of times (fig 17). His cook

and his chauffeur were devoted to him. The cook

carried him in her arms around the house or garden,

and his chauffeur drove him everywhere until the last

months of his life, stopping at all the places that Renoir

wanted to admire and paint.

Without doubt Aline, his wife, was the most impor-

tant person in his life (fig 18). She devoted her life to

him, making sure that he had no worries about the

household and that he was always surrounded by

friends. The visitors and models were welcomed with

open arms, and Aline’s excellent cooking and choice of

good wine were well known. Her death in 1915 was a

great loss to him. From that time on, his youngest son,

Coco,who was only 14, took over his father’s care in the

evening after the staff had left (fig 18). Renoir was com-

pletely dependent on him and made sure a teacher

came to the house so that he could see his son as much

as possible. He took great pleasure in teaching him

ceramics in a specially built studio.

We acknowledge the help from Paul Renoir and his wife, Marie-

Paul Renoir, who spent many hours talking with AB and lent us

the family’s photograph albums.

1 Van Duinkerken A. De mensen hebben hun gebreken. Utrecht: Spectrum,

1958.

2 Saudan Y. Did Renoir’s arthritis have a repercussion on his work? In:

Appelboom T, ed. Art, history and antiquity of rheumatic diseases. Brussels:

Elsevier, 1987:46-8.

3 White BE. Renoir,his life, art and letters. New York: Abrams, 1984.

4 Renoir J. Pierre-Auguste Renoir:mon père. Paris: Gallimard, 1981.

5 Riviere G. Renoir et ses amis. Paris: Flouru, 1921.

6 Louie JS. Renoir, his art and his arthritis. In: Appelboom T, ed. Art, history

and antiquity of rheumatic diseases. Brussels: Elsevier, 1987:43-4.

La salle de garde: bastion of the French lunch hour for

junior doctors

Bernard D Prendergast

The Parisian teaching hospitals are guardians of a

number of proud traditions, including (predictably)

catering arrangements for internes, or junior doctors, at

lunchtime. La salle de garde, originally conceived in the

mid-19th century to provide a convivial, mess-like facil-

ity for all doctors resident in the hospital, now functions

as the junior doctors’ dining room, where central funds

finance a simple, sustaining midday meal. Originally a

bachelors’ preserve, each salle retained a refined

ambience (albeit male oriented), being finely decorated

in the style of la belle époque (around 1900). Nowadays,

despite the advent of sexual equality, the prevailing

atmosphere is somewhat akin to that of a rugby club late

on a Saturday night. Artistic frescos have been replaced

by lurid, semipornographic murals, which are updated

regularly by students at the Ecole des Beaux Arts in Paris

to depict current members in various states of undress.

Nevertheless, despite the passage of time, certain

original rituals remain.

Daily rituals

Internes arrive from half past 12 onwards, and after cer-

emonially greeting everyone present with a tap on the

shoulder take their place at table in a strictly appointed

order. Proceedings are overseen by the elected interne

économe, whose duties include the preservation of tradi-

tion and maintenance of house rules. Lunch is not

served until he (the honour is nearly always given to a

man, usually a surgeon, most commonly an orthopae-

dic surgeon) is seated at high table at one o’clock sharp,

and house rules apply until his coffee is served, usually

a good hour later. His decisions are final: nobody may

leave without his permission, even to answer bleeps,

which sound remarkably infrequently (lunchtime is

sacred in France). Communication with kitchen staff is

also through his table. Offences are punishable by a

forfeit determined by the spin of a wheel high on the

wall behind him and range from singing a drinking

song to buying a round of red wine for everyone. On

more ribald occasions offenders may be asked to

partially strip or to kiss their neighbour.

Dismissal or (more commonly) dousing with a

bucketful of cold water or kitchen leftovers is the pun-

ishment for failing to comply.

White coats are mandatory, although external

badges of office and protruding medical paraphernalia

are frowned on. Medical discussion is forbidden, but

conversation buzzes (reassuringly), interspecialty refer-

rals being made in code. The suitability of topics under

discussion is judged by the head cook. The term of

address is always the familiar tu, not the more formal

vous, and medical hierarchy is abolished. Tables are

covered with aging discarded hospital sheets

—

which

function as tableclothes, hand towels, and serviettes

—

and are bestrewn with bottled beer, mineral water, and

the occasional pitcher of earthy red wine. Vast platters

of wholesome food pass from table to table in strict

order. Typically, a salad based hors d’oeuvres is

followed by meat in a cream sauce (perhaps steak,

though more usually chicken or minced beef) and a

COLLECTION DE SALLE DE GARDE COCHIN

COLLECTION SALLE DE GARDE COCHIN

The muses

Institut National de

laSantéetdela

Récherche

Médicale, Unite de

Récherches sur la

Biologie et la

Pathophysiologie

du Système

Cardiovasculaire,

Hôpital

Lariboisière, 75010

Paris

Bernard D

Prendergast,

Medical Research

Council French

exchange fellow

BMJ 1997;315:1708–9

1708 BMJ VOLUME 315 20-27 DECEMBER 1997

large cheeseboard (served before dessert, naturally),

with bowls of fresh fruit and yoghurt to finish. At the

weekly amelioré, organised by the économe, subscriptions

augment the quality and quantity of food, are given as

gratuities to the kitchen staff, and occasionally pay for

entertainment

—

a musician, comedian, or stripper. Per-

formances are usually risqué, accompanied by noisy

interjections, audience participation, and a cacophony

of appreciative plate banging (clapping is forbidden).

At two o’clock, after the économe leaves, everyone

dons their bleeps and enters the world of the hospital

again, mentally and physically refreshed for an

afternoon’s work.

Other rituals

Twice each year, in May and November, the rotation of

jobs is celebrated with a raucous all night party, le tonus.

Partners are forbidden, and the evening takes the form

of a prolonged dinner with copious quantities of red

wine and an accompaniment of drinking songs and

games traditional to the salle de garde. Dinner is

followed by more songs and jokes, medical sketches

with a broadly medical or sexual theme, or both, and a

series of speeches by senior members ridiculing the

économe and senior hospital staff. Unsurprisingly,

proceedings often get out of hand, culminating in food

fights and mischief around the hospital complex.

Another highlight in the calendar is l’enterrement

(literally burial), held to mark the promotion of a

member to chef de clinique (senior registrar or

experienced specialist registrar). During an extended

tonus humorous speeches of tribute (and otherwise) are

made about the new incumbent, recalling misdemean-

ours and narrow escapes during his (or her) four to five

yearsasaninterne. Departure to another life is symbol-

ised by a drunken funeral procession (complete with

coffin containing the promoted interne) through the

hospital at around 3 am in full view of patients

—

scenes

difficult to imagine elsewhere.

A sad (yet familiar) footnote: the future of the salle

de garde is under threat from hospital managers, who

consider it an unaffordable luxury.

The pictures are taken from pp 78 and 79 of La Salle de Garde ou

Le Plaisir des Dieux, Tome 2 by Patrick Balloul, which was first

published in 1994 in Paris by Publications Patrick Balloul (ISBN

2-9508738-0-4).

The hidden delight of psoriasis

Frans Meulenberg

In John Updike’s novel The Centaur young Peter Cald-

well has psoriasis.

He is not sure whether to tell his

girlfriend, but he is also aware of the power that the

disease can involve, when he wonders: “Should he tell

her? Would it, by making her share the shame, wed

them inextricably; make her, by bondage of pity, his

slave? Can he, so young, afford a slave?” And he does

not conceal the fact that the disease also gives him

pleasure. “The delight of feeling a large flake yield and

part from the body under the insistence of a fingernail

must be experienced to be forgiven.”

The visibility of psoriasis appeals to the imagina-

tion, perhaps because of the chronic, variable, and

unpredictable nature of the disease, and has even led to

literary language in the medical literature.

For

example, Ingram describes the plaques and colourful

configurations as patterns that “may rival the heavens

for beauty and design,” to which he adds with a sense of

drama: “To leave a trail of silver scale about the house

and blood-stains on the sheets and to fear the public

gaze

—

this is a cruel fate.”

The psychosocial dimensions of skin disorders like

psoriasis have been described in the medical

literature.

4-7

But psoriasis has also been a theme in

non-medical literature

—

autobiographies as well as fic-

tion. Novelist Connie Palmen pointed out in The Laws

that psoriasis seems to be “a perfectly visible, exterior,

unhidden disease, but it is precisely the disease of the

one who hides.”

Autobiographical prose

John Updike devoted the chapter “At war with my

skin” to psoriasis in Self-consciousness.

He argues that

psoriasis keeps you thinking: “Strategies of conceal-

ment ramify, and self-examination is endless.” The

patient constantly invents new ways of hiding the

symptoms.

After an attack of measles in 1938 psoriasis

paraded “in all its flaming scabbiness from head to

toe.”

Disease is too strong a word in his opinion, as

psoriasis is neither contagious nor painful, nor does it

COCHIN PHARMACIE (1994)

The muses

Dutch College of

General

Practitioners,

Oudegracht 16,

3511 AN Utrecht,

Netherlands

Frans Meulenberg,

General practitioner

BMJ 1997;315:1709–11

1709BMJ VOLUME 315 20-27 DECEMBER 1997

weaken the body. However, the disorder does isolate

the patient from the “happy herds of the healthy.”

Updike was lucky. By now treatment with psoralens

and ultraviolet A (PUVA) had been developed. “It is

pleasant, once or twice a week, to stand nearly naked in

a kind of glowing telephone booth.” As a child he never

got used to psoriasis because it came and went. At the

time when Updike was working on his autobiography,

he had been accustomed to psoriasis for 50 years, and

he had come to understand that the war with his skin

was solely a matter of self consciousness, self esteem, of

accepting himself. Of even more importance is this

statement: “What was my creativity, my relentless need

to produce, but a parody of my skin’s embarrassing

overproduction?”

Vladimir Nabokov concealed his psoriasis. For

example, in the collection of interviews with Nabokov

the term psoriasis is never used.

In February 1937

Nabokov suffered a bad attack.

On 15 May of that

year he somewhat pathetically wrote to his wife, Vera: “I

continue with the radiation treatments every day and

am pretty much cured. You know

—

now I can tell you

frankly

—

the indescribable torments I endured in

February, before these treatments, drove me to the

border of suicide

—

a border I was not authorised to

cross because I had you in my luggage.”

His

biographer mentions only one more exacerbation of

psoriasis after that, which occurred in the late 1960s

when the strain of writing the novel Ada fell from

Nabokov’s shoulders.

The English author Dennis Potter suffered from

arthritis psoriatica. “With the extreme psoriatic

arthropathy that I have you can’t find a point of normal

skin. Your pores, your whole face, your eyelids,

everything is caked and cracked and bleeding, to such

a degree that without drugs you could not possibly sur-

vive. It was physically like a visitation, and it was a crisis

point, an either or situation: either you give in, or you

survive and create something out of this bomb-site

which you’ve become

—

you put up a new building.

That’s what it amounted to.”

When he was home

alone, young Potter listened endlessly to songs on the

radio (songs make mankind unanimal-like, songs

awake the angel in man). “You know that so-called

cheap songs actually do have something of the Psalms

of David about them.”

Fiction

In Updike’s novel The Centaur Peter Caldwell cherishes

his clothing as a disguise: “Otherwise, when I was in

clothes, my disguise as a normal human being was

good. On my face, God had relented; except for traces

along the hairline which I let my hair fall forward to

cover, my face was clear. Also my hands, except for an

unnoticeable stippling of the fingernails.”

undresses furtively, avoiding to be seen as much as

possible, knowing that his belly looks like it has been

pecked by a great bird. Peter Caldwell experiences the

disorder as a disgrace and thinks it is “allergic, in fact, to

life itself.”

From the Journal of a Leper

In addition to The Centaur, Updike devoted the novella

From the Journal of a Leper to psoriasis.

This is the diary

of an anonymous, bumptious potter; 70% of his body is

covered in psoriasis plaques. The diary begins as he

starts treatment with PUVA. “Falling in love with the

lights,” as he calls it. The basis of the story is the erotic

profile of the patient with psoriasis: “Lusty, though we

are loathsome to love. Keen-sighted, though we hate to

look upon ourselves.” Initially, he looks at women with

desire; he loves Carlotta, his mistress, longs to hide

between the breasts of a waitress, lusts after the nurse

with the body of a puma, and dreams about a female

fellow patient. But as his skin clears up, Carlotta

—

who

has saintly tendencies

—

cools on him, once he no

longer has the affliction. From his part he becomes less

and less interested in women. When he lies next to her

with a clear skin, he discovers blemishes and spots on

her skin, which once seemed so flawless. But while she

loved him throughout the previous years (in the morn-

ing she would carefully brush his flakes off her body),

the pale fire of his sexual desire dulls. And there is an

artistic transformation worked on him by his cure as

well. He loses perfectionism as a potter. He needed the

affliction to create great art in compensation.

Ada

Whereas Updike has written about psoriasis at length,

Nabokov devotes one page to the disease, in the novel

Ada.

He mentions “a spectacular skin disease that had

been portrayed recently by a famous American novel-

ist in his Chiron and described in side-splitting style by

a co-sufferer who wrote essays for a London weekly.”

The two patients with psoriasis in Ada exchange notes

with tips: “Mercury!” or “Höhensonne works wonders.”

Other pieces of advice are found in a one volume

encyclopaedia, and involve taking hot baths at least

twice a month and avoiding spices.

GETTY IMAGES

John Updike

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1710 BMJ VOLUME 315 20-27 DECEMBER 1997

The Singing Detective

The television series The Singing Detective

—

based on a

scenario by Dennis Potter

—

has had a great impact;

patients call it an important source of information

and doctors even recommend it as such.

The main

character, Philip Marlow, is a former writer of detective

stories, who has been admitted to a hospital with a

severe arthritis psoriatica. Potter introduces him as fol-

lows: “Marlow is glowering morosely, crumpled into

himself, and his face badly disfigured with a ragingly

acute psoriasis, which looks as though boiling oil has

been thrown over him.” He is an example of extreme

psoriasis at its worst, “cracked, scabbed, scaled, swollen,

scarlet and snowy white and boiling with pain.” His

medical history is impressive: coal tar, prednisone, cor-

ticosteroids, gold injections, and methotrexate, after a

positive liver biopsy. All this in a cocktail with barbitu-

rates and antidepressants. He is in agony. His ex-wife is

revolted by him because he looks like a burns victim.

This gains her torments of abuse from Marlow with his

blinding rage.

His condition is serious, his body temperature is so

high that he starts hallucinating, which causes the

boundaries between fiction and reality to blur. And in

those visions he sometimes returns to his childhood; at

other times one of his books is revived in his fantasy,

allowing him to play the lead as the singing detective

himself

—

an entertainer who sings appropriate songs

such as “Dry Bones” and “I’ve got you under my skin.”

All the songs are remembered tunes from Marlow’s

childhood.

Marlow, sunk in his scabby self, is neither

communicative nor helpful. This leads to fierce

confrontations with his doctors. The nurses, too, are

targets of his snide remarks, except for the beautiful

and, in spite of herself, sensual, “diaphanous” nurse

Mills. The hands of nurse Mills rubbing his penis with

ointment never fail to arouse him: no matter how

determined Marlow is to focus on boring things, he

fails at avoiding an erection.

Eventually, it is the psychologist who demolishes

the facade. Marlow is confronted with the fact that a

chronic illness is a perfect shelter. It is a hiding place of

the same kind as the high tree in which young Philip

used to conceal himself in order to spy on the world.

The Unconsoled

In the novel The Unconsoled by Kazuo Ishiguro we find

Leo Brodsky, a constantly drunken outcast, with a

scabby dog as his sole companion.

Brodsky, once a

famous conductor, is still in love with his former

girlfriend, Miss Collins, even though they have not

spoken for decades after a quarrel. He dreams of her,

but he cannot fulfill his erotic fantasies because of the

condition of his skin: “My skin, I have these scales, they

keep flaking off, I don’t know what it is.” And he com-

bines his disease

—

its name is not mentioned in the

novel

—

with his sexual fantasies: “They smell like fish

too, these scales. Well, they’ll keep falling, I won’t be

able to stop that, she’ll have to put up with it, so I won’t

complain about her pussycat smelling the way it does,

or the way her thighs won’t part properly without click-

ing, I won’t get angry, you won’t see me trying to force

them apart like something broken, no no.” Brodsky is a

tragic man, crippled and wrinkled by lust and psoriasis.

Discussion

All aspects known from medical literature are also

found in non-medical literature. Patients subject them-

selves to a deliberate seclusion and keep psoriasis as a

secret or at least hide it. In this hiding place Peter Cald-

well cherishes his daydreams. In the case of Leo Brod-

sky these innocent daydreams have developed into

sexual fantasies, while in The Singing Detective, they

become veritable hallucinations of the protagonist

Philip Marlow.

One of the surprising similarities is the role music

plays in Peter Caldwell’s life, the former life of conduc-

tor Leo Brodsky, Dennis Potter’s memories, and the

hallucinations he has provided Philip Marlow with.

The paradoxical combination of a monstrous appear-

ance and an artistic air is remarkable as well. This can-

not be detached from the fact that many protagonists

are given artistic professions. This transformation from

disease to work of art parallels the metamorphosis

from a normal and clear skin to the tarnished body of

a patient with psoriasis.

In all works the past or memories of the past are

overwhelmingly present in the life of the protagonist. It

is as if the authors argue that you can understand the

patient with psoriasis only when you have fathomed

his or her past. To what degree this can be realised

remains unanswered, especially since the patients seem

to be reluctant or unable to separate reality from the

equally fascinating reality of memory or imagination.

Psoriasis functions as a metaphor for the creative

process. Psoriasis is the result of the implosion of the

artist, and the novels on psoriasis cultivate the idea that

the psoriasis plaque is the Achilles heel of the introvert

individualist, the artist who looks upon the world as a

guardsman from the ivory tower of his psoriasis. His

salvation is a make believe world or an entirely private

world: the imagined past or the world of art.

I thank John Updike for his encouragement and support.

1 Updike J. The centaur. London: Andre Deutsch,1963.

2 Farber EM. The language of psoriasis. Int J Dermatol 1991;30:295-302.

3 Ingram JT. The significance and management of psoriasis. BMJ

1954;ii:823-9.

4 Wittkower E. Psychological aspects of psoriasis. Lancet 1946;i:566-9.

5 Gupta MA, Gupta AK, Ellis CN, Voorhees JJ. Some psychosomatic

aspects of psoriasis. Adv Dermatol 1990;5:21-32.

6 Jowett S. Ryan T. Skin disease and handicap: an analysis of the impact of

skin conditions. Soc Sci Med 1985;20:425-9.

7 Ramsay B. O’Reagan M. A survey of the social and psychological aspects

of psoriasis. Br J Dermatol 1988;118:195-201.

8 Palmen C. The laws. London:Minerva,1992.

9 Updike J. Self-consciousness—memoirs. London: Deutsch,1989.

10 Updike J. Footnotes to self-consciousness. In:Odd jobs—essays and criticism.

New York: Alfred Knopf, 1991:865.

11 Nabokov V. Strong opinions. London: Weidenfeld and Nicolson,1974.

12 Boyd B. Vladimir Nabokov.The Russian years. London: Chatto and

Windus,1990.

13 Nabokov V. In: Nabokov D, Brucolli MJ, eds. Selected letters 1940-1977.

London: Weindenfeld and Nicolson, 1990:25-6.

14 Boyd B. Vladimir Nabokov.The American years. London: Chatto and

Windus,1991.

15 Fuller G. Potter on Potter. London: Faber and Faber, 1993.

16 Pouer D. Seeing the blossom—two interviews and a lecture. London: Faber and

Faber, 1994.

17 Updike J. From the journal of a leper. In: Problems and other stories. Lon-

don: Deutsch, 1980:181-97

18 Nabokov V. Ada or Ardor: a family chronicle. London: Penguin Books,1971.

19 Potter D. The singing detective. London: Faber and Faber,1986.

20 Lanigan SW, Layton A.Level of knowledge and information sources used

by patients with psoriasis. Br J Dermatol 1991;125:340-2.

21 Bennett P. Psoriasis

—

a problem shared. Practitioner 1991;235:241-6.

22 Ishiguro K. The unconsoled. London: Faber and Faber,1995.

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1711BMJ VOLUME 315 20-27 DECEMBER 1997

Books

Gimme five—books, that is

We can probably agree that the best doctors will try to understand

how the world looks to their patients. But how can we hope to

achieve such understanding? We are prisoners of our own

backgrounds (usually privileged), culture and experience (always

limited), and training (narrow, overstuffed, and reductionist). One

route to broader understanding is books. Chris Bulstrode, a trauma

surgeon who teaches creative writing to medical students, suggested

that we try to compile a list of the best books for medical students

and doctors to read. We asked the people below to start us off, but

now we want your suggestions. Please send us a list of five books with

a sentence or two on why each is worth reading.

We will publish all the lists on our website, compile a

comprehensive list there, and then publish a list of the top 10 (or

possibly more) in the paper version of the journal

—

perhaps with a

summary of each and some of the best quotes. And once we’ve done

books we might try films. Or music?

Kate Adams, medical student, United Kingdom

Jonathan Livingstone Seagull, Richard Bach

I have been lost in flight with Jonathan Seagull on numerous

occasions. It is a truly inspiring book that reminds me that life is

about living and not just following the flock. Since reading this book

I have not been able to look at a seagull in the same light.

Some Lives, David Widgery

This book helped me decide to train in east London. Written by a

general practitioner with 20 years of experience, it gives an interest-

ing account of the history, politics, and solidarity of the east end.

Birdsong, Sebastian Faulks

A beautifully written, powerfully descriptive, and deeply moving

story about the first world war. The personal touches made me feel

as though I was also there in the trenches.

Intimate Death, Marie De Hennezel

Written by a French psychologist who supported François Mitterand

through his terminal illness. She is deeply spiritual and recounts

powerful experiences that she has had with people close to death.

This book is not depressing. In fact, to quote Mitterand, the book is a

“lesson in living.”

The Benn Diaries (new single volume edition), Tony Benn

A fascinating insight into political life and the wheelings and

dealings that have gone on behind the scenes over the past 50 years.

It made government feel more accessible, personal, and vulnerable.

Jeremy Anderson, psychiatrist, Australia

Manufacturing Consent: The Political Economy of the Mass Media,

Edward S Herman and Noam Chomsky, Vintage, 1994

A contemporary polemic. Required reading for anyone who opens a

newspaper, or perhaps a medical journal. Available on video for

those political couch potatoes unable to turn a page.

The Cornish Trilogy, Robertson Davies, Penguin. Comprises The

Rebel Angels (1982), What’s Bred in the Bone (1985), and The Lyre of

Orpheus (1988)

Subtle wit and pratfalls, academe and Rabelais, mysticism, and pierc-

ing common sense.

Vineland, Thomas Pynchon, Minerva, 1990

The froth and bubble of the youth culture of ’80s California artfully

described. In a way this combines my first two selections. Read this

book and ponder if paranoia is the only sane response to the

modern world.

Sweet Soul Music:Rhythm and Blues and the Southern Dream of

Freedom, Peter Guralnick, Penguin, 1986

Music fans of all persuasions have books that illuminate their obses-

sions; this is one of mine. Through the voices of the original

protagonists, Guralnick provides a cultural history that encompasses

much of the American South of the ’60s. Ray Charles, Solomon

Burke, Dan Penn, Aretha Franklin

—

all these and many more speak

to us here. An excellent companion compact disc provides the

soundtrack (Sweet Soul Music: Voices from the Shadows, Sire/Warner/

Blue Horizon 9-26731-2).

Bad City Blues, Tim Willocks, Jonathan Cape, 1991

Like Chekhov, Willocks started to write after graduating in medicine,

but the similarities end there. This book is a taut, sexy, and

gratuitously violent thriller included here because it introduces the

baddest psychiatrist in literature. Not for the faint hearted.

James Barrett, psychiatrist, United Kingdom

Catch 22, Joseph Heller

The best book I’ve ever read. Rather profound philosophy applicable

to a seemingly insane world, wrapped up in a surreal story.

Che Guevara’s Motorcycle Diaries

Bush medicine, bed hopping, and a challenging and currently

unpopular brand of socialism by an icon of our times who happened

to be an immunologist too.

A Liar’s Autobiography, Graham Chapman

How one man chose whether to be a consultant in ear, nose, and

throat surgery or in something completely different. A choice that

faces many doctors and medical students.

The Prophet, Khalil Gibran

A beautiful extended poem, seemingly from another time but

written this century. Poetry for those who don’t like poetry.

Solly Benatar, professor of medicine, South Africa

Obedience to Authority, Stanley Milgram, Harper Torch

Provides chilling insights into moral dangers that result from the

human propensity to obey authority.

Animal Liberation, Peter Singer, Avon

Argues compellingly for a re-evaluation of our relationship with ani-

mals.

Causing Death and Saving Lives, Jonathan Glover, Penguin

A scholarly examination of moral issues pertaining to matters of life

and death.

The Passion of the Western Mind, Richard Tarnas, Ballantine

An eloquent and easily readable account of the ideas that have

shaped our world view.

A History of Civilizations, Fernand Braudel, Allen Lane

An integrated systems approach to world civilisations, written by one

of the greatest historians of the 20th century for final year secondary

students.

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Chris Bulstrode, professor of orthopaedics, United Kingdom

Touching the Void, Joe Simpson, Pan, 1988

The greatest climbing book of all time. When I finally put it down at

5 am, having read it non-stop, I was physically exhausted. Not fiction,

just rank escapism.

Catch 22, Joseph Heller, Vintage

There are many great books on institutional madness, a subject

which fascinates me. This is the most accessible and the funniest. The

rest, like the biography of Albert Speer, The Best and the Brightest, are

important but no fun.

Microserfs, Douglas Coupland

The world of computer geeks and nerds exposed at last. Like lifting

a stone and exposing a whole lot of endearing invertebrates to the

sun for the first time.

One Flew Over the Cuckoo’s Nest, Ken Kesey, Picador, 1976

I suppose it is the old “Who exactly is mad anyway?”

The Grapes of Wrath, John Steinbeck, Penguin, 1963

Dispossessed people are a big problem for doctors. This book

encapsulates the problems for me.

Simon Chapman, public health academic, Australia

Rookmaaker LC. Captive rhinoceroses in Europe from 1500 until

1810. Bijdragen tot de Dierkunde 1973;43:39-63.

Not a book, but a masterpiece. Between 1500 and 1810, 10 rhinos

were successfully brought to Europe for the edification of various

courts. One was “fond of the smell of tobacco and now and then the

ones who took care of it blew smoke into his nostrils and mouth.”

Another “was fond of wine, of which it sometimes drank three or

four bottles in a few hours.” We all know people like that.

How to Help Your Husband Get Ahead in His Business and Social Life,

Dorothy Carnegie, World’s Work, 1954

Ladies, read six ways to raise your EQ (enthusiasm quotient, silly!);

how to make mountains out of his virtues; and how to stop being a

“buttinsky.” Husbands, be warned though, signs of what was to come

are here

—

a whole chapter on “having outside interests of your own.”

Tsk, tsk.

Le Petomane, Jean Nohain and F Caradec, Sphere, 1971

A classmate of mine, Foul Bowel Bob Howell, would have had his

whole identity changed by this book. The story of the world’s most

celebrated musical anus belonging to Joseph Pujol, “a very modern

fin de siècle fellow” who could do violin, bass, and trombone recitals.

Youth and Sex.Dangers and Safeguards for Girls and Boys, Mary

Scharlieb and F Arthur Sibley, TC and EC Jack, 1914

A wise man once said that he who goeth to bed with stiff problem,

waketh with solution in hand. Dr Clement Dukes, medical officer at

Rugby School and “the greatest English authority on school

hygiene,” claims here that about "90 to 95 per cent of all boys at

boarding schools” are well acquainted with Mrs Palm and her five

daughters. Lots of early EBM here on the causes of blindness and

torpor.

Linda H Clever, editor, Western Journal of Medicine

The Plague, Albert Camus, Modern Library/Random House, 1948

This metaphor for the Holocaust applies as well to AIDS. The Nazis

were the plague; the rats were the collaborators; the physicians were

the Resistance. For once, doctors come off looking good.

Collected Poems, Emily Dickinson, Avenel Books (original, 1890,

1891, 1896; special, 1982)

Emily Dickinson captured the breeze, uncovered the soul, inflamed

the passions

—

all with a few words ingeniously placed.

The Bible, New Standard Translation

Well, why not? Great literature; great courage, hope, renewal, all the

other themes that are important to me in one handy volume.

Self-Renewal:The Individual and the Innovative Society, John W

Gardner, Norton, 1981

Still in print, this antidote to decay and pessimism shines a beacon

for wonderers and wanderers, for those who question their direction

in life and the meaning in life. Gardner, a Marine in the second world

war, a cabinet officer, and the founder of the citizens’ lobby, Common

Cause, teaches by telling lively stories that impart pure wisdom.

Lest Innocent Blood Be Shed, Philip Hallie, Harper Torch, 1985

This is the story of Le Chambon, a Huguenot village that saved Jews

in the heart of Vichy France. It is not great literature but great ethics

... that can change the way we live.

Frank Davidoff, editor, Annals of Internal Medicine

Tumbling in the Hay, Oliver St John Gogarty, Reynal and Hitchcock,

1939

Quirky, engaging, Fellini-like novel about life as a medical

student/bicycle racer in Dublin in the 1930s. It ain’t like it used to be.

The Death and Life of Great American Cities, Jane Jacobs, Random

House (Modern Library Edition), 1993

An unblinking look at what really happens on city streets and why.

The result is devastating; it turns out that the emperors of modern

urban planning had no clothes on at all. A landmark of 20th century

social criticism. Also good reading, funny; she has a very sharp

tongue.

The Language Instinct, Stephen Pinker, Morrow, 1994

Highly readable but also scholarly (Chomskian) account of the way

language really develops and is used. Punctures a number of pomp-

ous people and ideas along the way; a lot of good quotes from

Woody Allen and the like.

Landscape and Memory, Simon Schama, Knopf, 1995

Not exactly easy reading, but you’ll never look at the natural world

the same way again. You finally understand that what you see when

you look at the landscape is as much myths in your head as rocks and

the trees. Full of juicy stories about the great and not so great. Could

also pick one or another of Schama’s books, like Citizens

—

the one

about the French revolution: awesome.

The Gift. Imagination and the Erotic Life of Property, Lewis Hyde,

Random House (Vintage Books), 1983

Pulls together everything from Walt Whitman and Ezra Pound to

medical journal publishing with the common thread of gift giving.

Tony Delamothe, deputy editor, BMJ

The Autobiography of Alice B Toklas, Gertrude Stein

“What an interesting life you must have had living with me,” Stein

intimated to her partner of 25 years. “You should write your autobi-

ography.” Somehow Alice never got round to it, so Gertrude wrote it

for her. What you get is the several times larger than life Gertrude

Stein. Despite having been a star medical student at Johns Hopkins,

Stein failed her finals (in 1902)

—

“You don’t know what it is to be

bored.” Oliver Wendell Holmes had told her that a medical

education opened all doors, and it did: Stein’s fingerprints can be

found all over 20th century culture.

A Book of Common Prayer, Joan Didion

“We tell ourselves stories in order to live,” begins a collection of Joan

Didion’s essays. And all of her work, fiction and non-fiction, reminds

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1713BMJ VOLUME 315 20-27 DECEMBER 1997

us that making sense of our lives is one of the supreme human tasks.

Didion’s heroines seem perilously close to losing the plot as they

travel between California and central America, trying to impose on

events a believable narrative line.

The Undertaking: Life Studies from the Dismal Trade, Thomas Lynch

I think of undertakers as those stooges with illfitting suits and expres-

sions to match, reflecting emotions they can’t possibly be feeling,

funeral after funeral, day after day. This caricature is probably unfair to

all of them

—

it certainly is to Lynch, who has more interesting things to

say about The Really Big Issues than most writers, perhaps because

he’s so close to them, funeral after funeral, day after day.

The Reader, Bernhard Schlink

Germany is the 20th century’s “special case,” which those of us of a

certain frame of mind want to have explained for us. This initially

simple tale of a relationship between a student and an older woman

has profound things to say about the recent German past and why

humans make the choices they do.

Collected Poems, Judith Wright

South of my day’s circle, part of my blood’s country,

rises that tableland

I turn to this collection whenever my Australian roots need nourish-

ing. Wright lived on the edge of the rainforest and campaigned for

the environment and the Aborigines a generation before these were

fashionable

—

yet she was recognised as Australia’s foremost poet

within her lifetime.

Michael Farrell, consultant psychiatrist, United Kingdom

Ulysses, James Joyce

James Joyce dropped out of medical school and indicates what great

things some of you might have done if you pursued a different

career.Each chapter is focused on a particular body organ and sense,

but it will take some deciphering. The doctor’s behaviour in the book

consists of drinking and carousing. A single and complete education

in English literature.

Amongst Women, John McGahern

Finely crafted about male emotional tyranny of women

—

a suitable

reminder of all those bastard consultants who behaved intolerably to

everyone on their ward rounds.

Junky, William Burroughs

The best book by this reprobate addict describing the addict’s life. He

advises when seeking drug prescriptions: “You need a good bedside

manner or you will get nowhere with doctors.”

Diana: Her Own Story, Andrew Morton

A tragic tale, but you can learn a good bedside manner from the

Queen of Hearts.

Medical Nemesis, Ivan Illich

A flawed but brilliant critique of modern medicine that seems to

have been lost in history but is as ever relevant today.

Carlo Fonseka, professor of physiology, Sri Lanka

The Blind Watchmaker, Richard Dawkins

Best book on evolution.

The Double Helix, James Watson

Gives the lowdown on scientific research.

The Culture of Contentment, John Kenneth Galbraith

Tells why socialism should not be allowed to die.

Preparing for the 21st Century, Paul Kennedy

Relevant history on a grand scale.

Rubaiyat of Omar Khayyam, Edward Fitzgerald

Good for philosophical relaxation.

Paul Glasziou, general practitioner, Australia

The Man Who Mistook his Wife for a Hat and Other Clinical Tales, Oliver

Sacks, Harper and Row, 1987

Can stories of unusual neurological problems really be entertain-

ment? Sacks makes them so, but also poses many thorny questions

about the nature of disease and our sense of self.

Moments of Reprieve, Primo Levi

Levi has written several books about his time in Auschwitz, but this is

probably the most readable. For example, “Small Causes” tells how

his ill gotten half bowl of frozen soup leads to an illness that results

in his “abandonment” by the fleeing Nazis

—

a “mistake” which saved

his life.

How We Know What Isn’t So, Gilovich

Dr Who once said: “You humans are so good at seeing patterns that

aren’t there.” There are several good books that expand on this

insight and discuss our routine errors in thinking and judgment, but

this is probably the most readable.

The Dilbert Principle, Scott Adams, Harper Business, 1996.

This is the most amusing critique of modern non-evidence based

managerialism. Essential reading for those who want to understand

the problem, but afterwards I would then suggest Deming’s Outofthe

Crisis.

Mediterranean Light, Martha Rose Shulman, Bantam, 1989

Was there a rule against cook books? Shulman writes with such

affection and wit about this healthy and delicious cuisine. One of my

favourite books to browse at random, and the mushroom risotto is

the best I’ve tried.

Brian Haynes, physician, Canada

Candide by Voltaire and Candy by Terry Southern

To help (and amuse) all those who have trouble saying no.

The Wealthy Barber. The Common Sense Guide to Successful Financial

Planning, David Chiton, Stoddart Publishing, 1989

All people starting out in life who wanna get rich quick should read

this

—

it will help you protect yourself from yourself. (Wish I’d read it

when I was young!)

The Edible Woman, Margaret Atwood, Bantam-Seal Books

Reveals how and why women have difficulty eating meat that looks

on the plate as it is in real life

—

for example, fish

—

and how women

can overcome this.

Early books by Kurt Vonnegut Jr, especially Slaughterhouse Five

(1969), God Bless You Mr Rosewater (1965), Welcome to the Monkey

House (1950), Dell Publishing

Some of the best modern satire and insight into human nature that

Iknow.

Another Country, James Baldwin, Dell Publishing, 1960

The truth about sex, race, and society, Manhattan soul version.

Jonathan Hobson, medical student, United Kingdom

To Kill a Mockingbird, Harper Lee

I’m sure everybody knows the story; a beautiful tale of childhood and

justice in a southern town. Very emotive and a wonderful read.

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1714 BMJ VOLUME 315 20-27 DECEMBER 1997

House of God, Samuel Shem

A very cynical look at hospital medicine written by an American

intern under a pseudonym. Some great advice

—

for example, any

bodily cavity is accessible with a long enough needle and a strong

enough arm. Should probably be read by all medical students just to

show that even the annoying incidents on the wards can be humor-

ous if one is cynical enough not to get worn down.

The Ultimate Alphabet, Michael Wilkes

Written, or rather drawn, in 1986, this book features 26 paintings,

one for each letter. In each one there are thousands of objects all

starting with the same letter; the aim is to identify as many of them

as possible. Always good fun.

The Orton Diaries, Joe Orton

A great insight into the depravity of 1960s bohemian London. Very

interesting and contrasting

—

accounts of his father’s funeral on one

page, stories of his exploits in the lavatories in London on the next.

The Decameron, Boccaccio

A series of 60 or so vignettes, similar to the Canterbury Tales, set in

15th century (I think!) Italy. Good to know what really went on back

then. People from all places and all ages seem to enjoy doing the

same things, and laugh at pretty much similar humour.

Olivia Horner, medical student, United Kingdom

In the Skin of a Lion, Michael Ondaatje

I love this book. It is possibly the best book I have recently read.

The Quantum Self, Danah Zohar

Medicine revolves around the Newtonian mechanistic paradigm.

Here is an alternative philosophy, also based on science, that allows a

holistic vision of ourselves and the world. This stretched my mind

and made me excited.

Electric Kool-Aid Acid Test, Tom Wolfe

It was either this or Trainspotting. Both are about drug culture. This

one is now almost historical as it tells about acid, Ken Kesey, and

Haight-Ashbury hippy life.

Medical Nemesis, Ivan Illich

Illich dislikes the professions. He believes they decrease the control

the ordinary man has over his life. In this book he argues as to how

much modern medicine has actually achieved in making us

healthier. Very little, according to him

—

I’m not sure I totally agree

but he has made me think.

To Kill a Mocking Bird, Harper Lee

I still reread this book, and it still makes me cry.

Richard Horton, editor, Lancet

Of Human Bondage, W Somerset Maugham, Penguin

A book I read at 30, but one that I should have read at 20. It would

have saved me (and others) a great deal of irritation.

The Sportswriter, Richard Ford, Harvill

The fateful humour of an ordinary

—

though, in Ford’s hands,

extraordinary

—

life.

Long Day’s Journey Into Night, Eugene O’Neill

A torn family, frayed by illness. The hinterland, largely unexplored,

surrounding every patient.

Satan Says, Sharon Olds, University of Pittsburgh Press

Her first collection of poetry. Olds ties language into tight knots that

cut pleasurably into flesh.

The Discourses.Epictetus,Everyman

A friend to get you through long nights on call.

Zviad Kirtava, rheumatologist, Georgia

Flowers for Algernon, Daniel Kizzy

This is short story worthy of some tremendous novels for its

outstanding feeling of compassion. Reminds me of the wonderful

movie Awakenings.

The Catcher in the Rye, J D Salinger

It is too difficult for me to describe this masterpiece. One should just

read it.

The Little Prince, Antoine de Saint-Exupery

Hopefully, most medical students have already read this book, like

Beauty and the Beast, which could also be mentioned.

The Notes of the Young Doctor, Mikhail Bulgakov

Terrible notes from Russia after the revolution by a genius writer,

who like many others has been a doctor himself.

The First Garment, Guram Dochanashvili

My favourite book

—

has everything a human being needs to learn.

Carl Kjellstrand, physician, United States

Heart of Darkness, J Conrad

The best written story in English. The subject, the call to violence and

cruelty, can be seen in small children and is that which we can cover

up for a while. A good thing to know about.

The Plague, A Camus

The counterweight to the above, an immensely optimistic book, which

says that we can control these traits by human heroism. And the hero

is a physician who recognises the plague, a cover for all evil (I believe

that it was Nazism that inspired Camus to write this book). He fights

against it with his little group, who all die, apart from the physician.

“Nonetheless he knew that the tale he had to tell could not be one of

final victory. It could only be a record of what had to be done, and what

assuredly would have to be done again in the never ending fight

against terror and its relentless onslaughts, by all, who despite their

personal afflictions that enable them to be saints, still refuse to bow

down to pestilences and strive their utmost to be healers.”

The Brothers Karamazov, F Dostoyevsky

The best description of three great human characters and how

different people deal with the great catastrophes that life tosses every

one of us from time to time.

Death in the Family, James Agee

The best description of the numbing catastrophic impact of sudden,

unexpected death on a young family, complete with the problems of

communication that exist in all families. In this case it is a disagree-

ment about religion between the wife and the husband, who is killed

in an accident.

My Confession, L Tolstoy

The tale of how a young, rich, spoiled, very intelligent person works

through the superficialities of his artificial environment to find a

moral rock bottom. Every physician should do that to be able to deal

with patients a bit beyond being a slick body engineer.

Irvine Loudon, medical historian, United Kingdom

Guns,Germs and Steel.A Short History of Everybody for the last 13,000

years, Jared Diamond, Jonathan Cape, 1997

A marvellous, broad, and highly original account, of the impact of

agriculture, disease, writing, technology, and war on the develop-

ment of humanity; beautifully written and gripping. Just published.

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1715BMJ VOLUME 315 20-27 DECEMBER 1997

A Thousand Acres, Jane Smiley, Flamingo

Hearing that this was the story of King Lear set in modern rural

mid-west USA, I was doubtful at first, but I believe it to be the most

moving and memorable novel of the past 20 and more years. I have

read it three times with increasing admiration and enjoyment.

Notes from a Small Island, Bill Bryson, Black Swan (paperback)

By far the funniest, as well as one of the most sharply observed,

accounts of Britain today.

Solitude, Anthony Storr, HarperCollins

I wish this beautifully wise and readable book had been available

when I started medicine. I am sure it would have made me a more

understanding and tolerant doctor, as well as reassuring me that it is

OK to be a bit of an unsociable recluse.

Weir of Hermiston, Robert Louis Stevenson

The most beautifully written and most memorable novel I have ever

read

—

even though it was unfinished.

Nabil Nassar, physician, Lebanon

The Ascent of Man, J Bronowski

Deals with humanity through the concept of understanding the phi-

losophy of nature through “understanding human nature and of the

human condition within nature.” Doctors and the diseases they diag-

nose and treat are within nature.

Manwatching, Desmond Morris

A fascinating book on how human physical gestures transmit

messages. Some of the ideas presented and discussed never crossed

many minds, including mine. Physicians “watch” patients all the time.

Man and His Symbols, Carl Jung

As depicted in the title, the book is about symbols of man, emphasis-

ing the “language” of dreams with which the unconscious in man

communicates.It helps medical students understand the many facets

of man’s behaviour, which in essence reflects actions preconceived in

his brain while dreams are “actions suppressed.”

The Muqaddimah of Ibn Khaldun, translated by F Rosenthal

Although originally written more than six centuries ago, this book

remains a classic behavioural sociology reference about men’s physi-

cal environment and his social behaviour within this environment,

and how both influenced him and the civilisations he developed.

Roger Robinson, associate editor, BMJ

Dibs in Search of Self, Virginia Axline

A moving account of psychotherapy for an emotionally disturbed

child.

Middlemarch, George Eliot

By any standards one of the greatest novels, but nominated for its

portrait of a doctor to admire and identify with.

The Citadel,AJCronin

A compelling story which shows why Britain needed the National

Health Service (and still does).

Hall of Mirrors, John Rowan Wilson

A gripping medicopoliticolegal thriller, and a warning that the

student is not entering a profession led exclusively by saints or intel-

lectual geniuses.

Le Grand Meaulnes (The Lost Domain), Alain Fournier

Nothing medical here, but nominated for the haunting beauty with

which it evokes a sense of loss.

Jaime Sepulveda, public health director, Mexico

The Magic Mountain, Thomas Mann

Life and times of a young man with tuberculosis in the pre-antibiotic

era. A must for medical students.

The Alexandria Quartet, Lawrence Durrell

One of the most influential and seductive books I have ever read.

Under the Volcano, Malcolm Lowry

A novel on the intense life of an alcoholic British consul in Cuerna-

vaca, Mexico, during the 1930s

Confederacy of Dunces, John Kennedy Toole

Pulitzer prizewinner, one of the most hilarious books on earth.

Love in the Time of Cholera, Gabriel Garcia Marquez

Extraordinary novel on falling in love at an old age, the cholera pan-

demic existing only as a background.

Jenny Simpson, editor, Clinician in Management

Captain Corelli’s Mandolin, Louis de Bernieres, Minerva

An unputdownable tale, provoking endless reflection on the value of

a human life and the sheer madness of huge organisations.

The Diving-Bell and the Butterfly, Jean-Dominique Bauby

Compulsory reading for anyone involved in health care. I finished

this remarkable book in the course of a long night

—

it would have

been disrespectful to put it down. I emerged considering very care-

fully not only how we help those who are suddenly unable to com-

municate but also the need to appreciate each day that you are lucky

enough to possess all your faculties and reasonable good health.

The House at Pooh Corner, A A Milne

An invaluable aid to analysing the peculiar behaviour of senior col-

leagues. In the medical profession, Eeyores and Tiggers abound, and

many an otherwise upsetting encounter can be defused by

predicting the next phrase with an inward smile.

The Bridges of Madison County, Robert James Waller, Mandarin

Not only remarkable for its lovely style, this novel brings a lesson to

us all. Written by a professor of management who wanted to write

—

you can dream it, you can do it.

Notes from a Small Island, Bill Bryson

Another essential for survival in the medical profession. Our sense of

humour

—

like the rest of us

—

needs a regular workout, and Bill Brys-

on’s books provide a thoroughly and at times achingly good laugh.

Richard Smith, editor, BMJ

The Leopard, Giuseppe Tomasi di Lampedusa, Collins Harvill

Written by a Sicilian nobleman, this book includes an unequalled

account of dying and explains why people, especially Sicilians, often

don’t want to do what is “sensible.”

Anything by Anthony Trollope (most of his many novels are in Pen-

guin Classics)

I would never understand the institutions of medicine

—

like the

BMA

—

by reading the newspapers, but I do through reading

Trollope. And his books are captivating.

Middlemarch,