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BMJ. 2007 July 7; 335(7609): 49.
PMCID: PMC1910649
Between the Lines

Fish out of water

Theodore Dalrymple, writer and retired doctor

Saul Bellow's last novel, Ravelstein, is a roman à clef, Ravelstein being Allan Bloom, the literary academic and Bellow's close friend, who made a fortune towards the end of his life with his book The Closing of the American Mind and then died shortly afterwards from AIDS. Another of the characters, Radu Grielescu, is the egregious historian of religions, Mircea Eliade, who taught for many years at Chicago University and who covered up his deep support in the 1930s for—and involvement in—the genocidal Iron Guard in Romania, by means of a pipe smoking persona that implied that the religious wisdom of ages had somehow rubbed off on him. (It is astonishing how deeply postwar intellectual life in Europe and America was affected by European intellectuals who had one way or another to disguise their pro-Nazi record and who did so by muddying the philosophical waters as much as they could.)

Bellow's novel, written by an old man about a slightly younger man who had just died, has a lot about illness in it. This is not surprising, perhaps. But towards the end of the book I was delighted to meet an old friend of mine, a disease that I saw much of in the Pacific islands, hundreds of cases of which I treated but haven't seen since—namely, ciguatera fish poisoning.

The narrator goes to a French island in the West Indies and, with his young wife, eats fish at a fashionable restaurant. “The fact was that Bedier [the restaurateur] of the Forgeron [the restaurant] had infected me.”

This is not quite fair, because there is no way of telling which fish has ciguatoxin in it. (The condition becomes more common when the dinoflagellate Gambierdiscus toxicus is disturbed from the coral reef by rough seas and enters the food chain in successively larger fish.) In the Pacific islands it was believed that a coin placed on the eye of an affected fish would tarnish very quickly; a more scientific method was a bio-assay on the nearest cat. Quite often, though, people at a feast would eat a large barracuda, and 60 at once would be affected. After reading Ravelstein I got out the old records that I had kept of the cases and re-astonished myself with electrocardiographs showing heart rates that had fallen to 24 a minute and notes of excess salivation of 2 litres an hour.

The case described by the narrator was not typical. I never saw one that did not start either with severe gastrointestinal disturbance or with paraesthesiae, but in the book the first and, for a long time, only symptom is extreme tiredness.

The narrator decides to go to the doctor but doesn't expect much, because “Americans don't take much stock in foreign medicine,” and “Colonial medicine, especially in the tropics, was very chancy.”

This wasn't quite fair either, and I was faintly irritated by it. In my day the great experts on ciguatera fish poisoning in the world were the colonial French, and the principal research into the condition was conducted in Tahiti. It was they, I think, who had actually isolated ciguatoxin and elucidated its chemical structure. I had briefly considered researching the condition myself, but I realised that I had not the means to discover anything that they, the French researchers, did not already know about it.

In the book the French doctor diagnoses dengue fever, which Bellow mistakenly says is treatable with quinine. The fact remains, however, that if you have ciguatera fish poisoning the best place to have it diagnosed is on the island where you contracted it, where a doctor has seen hundreds of cases before.


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