Axel Munthe and The story of San Michele: the perils of being a ‘fashionable’ doctor

Nowadays, most doctors are salaried, paid – directly or indirectly – by the state. Until well into the twentieth century, however, doctors earned their living from fees paid to them by patients. Those with a large wealthy clientele were commonly referred to as ‘fashionable’, a term seldom used these days.

Axel Munthe (1857–1949), a Swede who trained in Montpellier and Paris, was one such fashionable doctor. His memoir, The story of San Michele,¹ published in 1929, when he was 71, were an unlikely global bestseller. The book is a highly impressionistic, semi-fictional account of an extraordinary life, an amalgam of memoirs, personal philosophy and tall tales. Munthe describes a number of supernatural encounters with ghosts and fairy folk, yet fails to mention his two wives. His stories are far-fetched but entertaining, with a charming, whimsical portrait of peasant life in Capri. Animal lovers were entranced by Munthe's tenderness towards, and understanding of, his large menagerie, which included dogs, birds and a baboon. I suspect that the reading public of the late 1920s enjoyed the ghoulish and the grotesque: there is a touch of Poe in some of the stories, and the book has a distinctly erotic flavour.

Munthe practised initially in Paris, and subsequently in Rome; he spent his summers in Capri, where he built the eponymous Villa San Michele. Munthe was charismatic and fluent in several languages, and had an extraordinary ability to instil confidence in his patients. He had equal power over animals. Munthe was a mass of contradictions: he gladly treated the poor for free, but actively cultivated the rich and titled; he claimed to be a misanthrope (preferring animals to humans), but put his life in danger to help the victims of the cholera epidemic in Naples (1884) and the Messina earthquake (1908). He preferred simple food and clothes, yet the Villa San Michele was filled with expensive antiques. Munthe eventually became physician to the Swedish royal family, acting as full-time, personal physician to Princess (later Queen) Victoria. He was also her lover. Victoria spent several decades under Munthe's care, and appears to have been a chronic invalid, but without any convincingly specific cause for this invalidism, other than her unhappy marriage to Prince (later King) Gustaf. Munthe's chief prescription for her problems appears to have been frequent changes of scenery (conveniently apart from her husband), with many winters spent in Capri. She frequently spent days or weeks in bed. Victoria eventually died age 67, with Munthe at her side.

Munthe began his professional life in Paris, catering for the Swedish and Italian communities there. He also attracted a number of wealthy, titled patients, such as ‘the Countess’. She is beautiful, young and bored; the Count is much older and quite dull. Although Munthe does not describe her symptoms, he remarks that she had been treated for ‘appendicitis’ by her previous medical attendants. Munthe makes a diagnosis of ‘colitis’, probably meaning what we now call irritable bowel syndrome (IBS), rather than the modern meaning of the word. ‘Colitis, as this word is used now, was not known in those days.’ According to his biographer, Munthe himself suffered from IBS. Was he, I wonder, anticipating the current re-branding of IBS as a low-grade form of inflammatory bowel disease?² Soon, his waiting-room was full of fee-paying patients, anxious to find out if they too had ‘colitis’.

Munthe had first visited Capri as a tubercular teenager, and fell in love with the island. He moved from Paris to Rome, where he quickly established himself, yet again, as a doctor among the expatriate community. He spent his summers on Capri, where he built the famous villa, and became a hero to the local community, because he treated the islanders for free. His patients in Rome were mainly wealthy English and American clients, and Munthe moved easily in the highest social circles. After Princess Victoria became his patient, Munthe quit his practice to devote himself more or less exclusively to his royal patient, which he did from 1892 until her death in 1930.³

Munthe believed that he had entered a Faustian pact in order to realise his dream of the Villa in Capri; in The story of San Michele, the young Munthe is visited in Capri by a Mephistophelean spirit: ‘It shall all be yours’, he said in a melodious voice, waving his hand across the horizon. ‘The chapel, the garden, the house, the mountain with its castle, all shall be yours, if you are willing to pay the price!’ Munthe asks of the spirit what the price will be, and is told: ‘The renunciation of your ambition to make yourself a name in your profession, the sacrifice of your future.’ ‘What then am I to become?’ asks Munthe. ‘A might-have-been, a failure,’ replies the spirit. Munthe was an old man filled with regret when he wrote the book, and concluded that he had sacrificed his opportunity for the lesser prize of becoming a fashionable doctor. There is scant evidence, however, that Munthe had any great aptitude for ‘scientific’ medicine. He may have had vague notions of emulating Charcot and Pasteur, but there is no mention in his book of scientific developments, and one gets the impression that Munthe never read a journal or attended a scientific meeting after qualifying. He appears to have been more interested in literature and music. His medical talent lay in his acute insight into ‘psychosomatic’ disorders, and the book reminds medical readers that the doctor–patient interaction is still the key therapy for most problems.

Describing a colleague in Rome, Munthe wrote: ‘That I considered him an able doctor was of course quite compatible with his being a charlatan – the two go well together, the chief danger of charlatans lie there.’ Munthe could have been describing himself. He believed that the financial transaction of paying a fee corrupted the doctor–patient relationship: ‘The doctors should be paid by the State and well paid like the judges in England. Those who do not like arrangement should leave the profession and go on to the Stock Exchange or open a shop. The doctors should walk about like sages honoured and protected by all men.’ The story of San Michele is a warning against becoming a ‘fashionable’ doctor.