Images of Illness

I

In Death in Venice passion brings about the collapse of all that has made Gustav von Aschenbach singular—his reason, his inhibitions, his fastidiousness. And disease further reduces him. At the end of the story Aschenbach is just another cholera victim, his last degradation being to succumb to the disease afflicting so many in Venice at that moment. When in The Magic Mountain Hans Castorp is discovered to have tuberculosis, it is a promotion. His illness will make Hans become more singular, become simply more than he was before. In one fiction, disease (cholera) is the penalty for a secret love; in the other, disease (TB) is its expression. Cholera is the kind of fatality that, in retrospect, has simplified a complex self, reducing it to a sick environment. The disease that individualizes, that sets a person in relief against the environment, is tuberculosis.

What made TB seem so “interesting”—or, as it’s usually put, romantic—throughout the last and well into this century also made it a curse and inspired special dread. In contrast to the great epidemic diseases of the past (plague, typhus, cholera), in which each person is stricken as a member of an afflicted community, TB was understood as a disease that isolates one from the community. However steep its incidence in a population, TB—like cancer today—always seemed to be a mysterious illness of individuals, a deadly arrow that could strike anyone, that singled out its victims one by one.

As after a cholera death, for a long time it was common practice to burn the clothes and other effects of someone who died of TB. “Those brutal Italians have nearly finished their monstrous business,” Keats’s companion Joseph Severn wrote from Rome on March 6, 1821, two weeks after Keats died in the little room on the Piazza di Spagna. “They have burned all the furniture—and are now scraping the walls—making new windows—new doors—and even a new floor.” But TB was frightening not only as a contagion, like cholera, but as a seemingly arbitrary, uncommunicable “taint.” And people could believe that TB was inherited (think of the disease’s recurrence in the families of Keats, Trollope, the Brontës, Thoreau) and also believe that it revealed something singular about the person afflicted. In a similar way, the evidence that there are cancer-prone families and, possibly, a hereditary factor in cancer can be acknowledged without disturbing the belief that cancer is a disease that strikes each person, punitively, as an individual.

That consumption is induced by the foul air of houses is now certain,” Florence Nightingale declared in 1861. Yet however much TB was blamed on poverty and unsalubrious surroundings, it was still thought that a certain inner disposition was needed in order to contract the disease. Doctors and laity believed in a TB character type—as now the belief in a cancer-prone character type, far from being confined to the backyard of folk superstition, passes for the most advanced medical thinking. In contrast to the modern bogy of the cancer-prone character—someone unemotional, inhibited, repressed—the TB-prone character that haunted imaginations in the nineteenth century was an amalgam of two different fantasies: someone both passionate and repressed.

That other notorious scourge among nineteenth-century diseases, syphilis, was at least not mysterious. Contracting syphilis was a predictable consequence, the consequence, for example, of having sex with a carrier of the disease. So among all the guilt-embroidered fantasies about sexual pollution attached to syphilis, there was no place for a type of personality supposed to be especially susceptible to the disease (as was once imagined for TB and is now for cancer). The syphilitic personality type was someone who had the disease (Oswald in Ibsen’s Ghosts, Adrian Leverkühn in Doctor Faustus), not someone who was likely to get it. In its role as scourge, syphilis implied a moral judgment (about off-limits sex, about prostitution) but not a psychological one. TB, once so mysterious—as cancer is now—suggested judgments of a deeper kind, both moral and psychological, about the ill.

The speculations of the ancient world made disease most often an instrument of divine wrath. Judgment was meted out either to a community (the plague in Book I of the Iliad that Apollo inflicts on the Achaeans in punishment for Agamemnon’s abduction of Chryses’ daughter; the plague in Oedipus that strikes Thebes because of the polluting presence of the royal sinner) or to a single person (the stinking wound in Philoctetes’ foot). The diseases around which the modern fantasies have gathered—TB, cancer—are viewed as forms of self-judgment, of self-betrayal.

One’s mind betrays one’s body. “My head has made an appointment with my lungs behind my back,” Kafka said about his TB in a letter to Max Brod in 1922. Or one’s body betrays one’s feelings, as in Mann’s late novel The Black Swan, whose aging heroine, youthfully in love with a young man, takes as the return of her menses what is actually a hemorrhage and the symptom of incurable cancer. The body’s treachery is thought to have its own inner logic. Freud was “very beautiful…when he spoke,” Wilhelm Reich reminisced. “Then it hit him just here, in the mouth. And that is where my interest in cancer began.”¹ That interest led Reich to propose a most influential theory about the relation between a mortal disease and the character of those it humiliates.

In the premodern view of disease, the role of character was confined to one’s behavior after its onset. Like any extreme situation, dreaded illnesses bring out both people’s worst and best. The standard accounts of epidemics, however, are mainly of the devastating effect of disease upon character. The weaker the chronicler’s preconception of disease as a punishment for wickedness, the more likely that the account will stress the moral corruption made manifest by the disease’s spread. Even if the disease is not thought to be a judgment on the community, it becomes one—retroactively—as it sets in motion an inexorable collapse of morals and manners. Thucydides relates the ways in which the plague that broke out in Athens in 430 BC spawned disorder and lawlessness (“the pleasure of the moment took the place both of honor and expedience”) and corrupted language itself. And the whole point of Boccaccio’s description in the first pages of the Decameron of the great plague of 1348 is how badly the citizens of Florence behaved.

In contrast to this disdainful knowledge of how most loyalties and loves shatter in the panic produced by epidemic disease, the accounts of modern diseases—where the judgment tends to fall on the individual rather than the society—seem exaggeratedly unaware of how poorly many people take the news that they are dying. Fatal illness has always been viewed as a test of moral character, but in the nineteenth century there is a great reluctance to let anybody flunk the test. And the virtuous only become more so as they slide toward death. This is standard achievement for TB deaths in fiction, and goes with the inveterate spiritualizing of TB and the sentimentalizing of its horrors. Even the ultra-virtuous, when dying of this disease, boost themselves to new moral heights. Uncle Tom’s Cabin: Little Eva during her last days urges her father to become a serious Christian and free his slaves. The Wings of the Dove: after learning that her suitor was a fortune-hunter, Milly Theale wills her fortune to him and dies. Dombey and Son: “From some hidden reason, very imperfectly understood by himself—if understood at all—[Paul] felt a gradually increasing impulse of affection, towards almost everything and everybody in the place.”

For those characters treated less sentimentally, the disease is viewed as the occasion finally to behave well. At the least, the calamity of disease can clear the way for insight into lifelong self-deceptions and failures of character. The lies that muffle Ivan Ilyich’s drawnout agony—his cancer being unmentionable to his wife and children—reveal to him the lie of his whole life; when dying he is, for the first time, in a state of truth. The sixty-year-old civil servant in Kurosawa’s film Ikiru (1952) quits his job when he learns he has terminal stomach cancer and takes up the cause of a slum neighborhood against the bureaucracy he had served. With one year left to live, Watanabe wants to provide something that is really needed (a playground for the children), wants to redeem his wasted life.

II

Disease occurs in the Iliad as super-natural punishment, as possession, and as the result of natural causes. For Homer, disease can be gratuitous or it can be deserved. With the advent of Christianity, which imposed more moralized notions of disease, as of everything else, a closer fit between disease and “victim” gradually evolved. The idea of disease as punishment yielded the idea that a disease could be a particularly appropriate and just punishment. Cressid’s leprosy in Henryson’s Testament of Cressid and Madame de Merteuil’s smallpox in Les Liaisons dangereuses show the true face of the beautiful liar—a most involuntary revelation.

In the nineteenth century the notion that the disease fits the patient’s character, as the punishment fits the sinner, was abandoned for the notion that it expresses the character. It is product of will. “The will exhibits itself as organized body,” writes Schopenhauer, “and the presence of disease signifies that the will itself is sick.” Recovery from a disease depends on the healthy will assuming “dictatorial power in order to subsume the rebellious forces” of the sick will. One generation earlier, a great physician, Bichat, had used a similar image: “Health is the silence of organs. Disease is their revolt.” In other words, their language. In disease the will speaks, through the body. Illness is understood to be a language for dramatizing the mental; it is a form of self-expression. And the evolution of this way of understanding disease—the modern metaphors of illness—is inseparable from the evolution of modern ideas of expressiveness.

In the premodern ideal of a well-balanced character, expressiveness is supposed to be limited. Behavior is defined by its potentiality for excess. Thus when Kant makes figurative use of cancer, it is as a metaphor for excess feeling. “Passions are cancers for pure practical reason and often incurable,” Kant wrote in Anthropologie (1798). “The passions are…unfortunate moods that are pregnant with many evils,” he added, evoking the ancient metaphoric connection between cancer and a pregnancy. When Kant compares passions (that is, extreme feelings) to cancers, he is of course using the premodern sense of the disease and a preromantic evaluation of passion. Soon, turbulent feeling was to be viewed much more positively. “There is no one in the world less able to conceal his feelings than Emile,” says Rousseau—meaning it as a compliment.

As excess feelings become positive, they are no longer analogized—in order to denigrate them—to a terrible disease. Instead, disease is seen as the vehicle of excess feeling. TB is the disease that makes manifest intense desire; that discloses, in spite of the reluctance of the individual, what the individual does not want to reveal. The contrast is no longer between moderate passions and excessive ones but between hidden passions and those which are brought into the open. Illness reveals desires of which the patient probably was unaware. Diseases—and patients—become subjects for decipherment. And these hidden passions are now considered as a source of illness. Blake gives as one of his Proverbs of Hell: “He who desires but acts not, breeds pestilence.”

The early romantic sought superiority by desiring, and by desiring to desire, more intensely than others do. And the inability to realize these ideals of vitality and perfect spontaneity was thought to make someone an ideal candidate for TB. Contemporary romanticism starts from the inverse principle—that it is others who desire intensely, and that it is oneself (the narratives are typically in the first person) who has little or no desire at all. We can find precursors of the modern romantic egos of unfeeling in nineteenth-century Russian novels; but Pechorin in Lermontov’s A Hero of Our Time, Stavrogin in The Possessed, are still heroes—restless, bitter, self-destructive, tormented by their inability to feel. (Even their glum, merely self-absorbed descendants, Roquentin in Sartre’s Nausea and Meursault in Camus’s The Stranger, seem bewildered by their inability to feel.) The passive, affectless anti-hero who dominates contemporary American fiction is a creature of regular routines or unfeeling debauch; not self-destructive but prudent; not moody, dashing, cruel, just dissociated. The ideal candidate, according to contemporary mythology, for cancer.

Ceasing to consider disease as a punishment which fits the objective moral character, making it an expression of the inner self, might seem less moralistic. But this view turns out to be just as, or even more, moralistic and punitive. With the modern diseases (once TB, now cancer), the romantic idea that the disease expresses the character is invariably extended to assert that the character causes the disease—because it has not expressed itself. Passion moves inward, striking and blighting the deepest cellular recesses.

“The sick man himself creates his disease,” the German psychologist Georg Groddeck wrote. “In him are to be found the causae internae; he is the cause of the disease and we need seek none other.” “Bacilli” heads Groddeck’s list of mere “external causes”—followed by “chills, overeating, overdrinking, work, and anything else.” He insists that it is “because it is not pleasant to look within ourselves” that doctors prefer to “attack the outer causes with prophylaxis, disinfection, and so on” rather than address the real, internal causes.²

Such preposterous and dangerous views manage to put the entire onus of the disease on the patient and deprive the patient of the means for understanding the range of plausible treatment. Cure is thought to depend principally on the patient’s already sorely tested or enfeebled capacity for self-love. A year before her death in 1923, Katherine Mansfield writes in her Journal:

A bad day…horrible pains and so on, and weakness. I could do nothing. The weakness was not only physical. I must heal my Self before I will be well…. This must be done alone and at once. It is at the root of my not getting better. My mind is not controlled.

Mansfield not only thinks it was the “Self” which made her sick but that she has a chance of being cured of her hopelessly advanced lung disease if she could heal that “Self.”

Both the myth about TB and the current myth about cancer propose that one is responsible for one’s disease. But the cancer imagery is far more punishing. Given the romantic values in use for judging character and disease, some glamor attaches to having a disease thought to come from being too full of passion. But there is mostly opprobrium attached to a disease thought to stem from the repression of emotion—an opprobrium echoed in the view of cancer propagated by Reich, and the many writers influenced by him. Reich’s view of cancer as a disease of the failure of expressiveness condemns the cancer patient: expresses pity but also conveys contempt. The theory also contributes to making cancer shameful, and to making cancer patients feel, consciously or unconsciously, guilty for getting cancer.

By vitalist standards, the cancer personality is one of life’s losers. Napoleon, Ulysses S. Grant, Robert A. Taft, and Hubert Humphrey have all had their cancers diagnosed as the reaction to political defeat and the curtailing of their ambitions. And the truly great, those—like Freud and Wittgenstein—whose lives can by no means be called a defeat, have had their cancers diagnosed as the gruesome though stoically endured penalty they had to pay for a lifetime of renunciation. In contrast, there never seems any ground for condescension about the disease that claimed the likes of Keats, Chekhov, Simone Weil, Emily Brontë, and Poe.

III

Cancer is generally thought an inappropriate disease for a romantic character, in contrast to tuberculosis, perhaps because unromantic depression has supplanted the romantic notion of melancholy. “A fitful strain of melancholy,” Poe wrote, “will ever be found inseparable from the perfection of the beautiful.” Depression is melancholy minus its charms—the animation, the fits.

Supporting the theory about the emotional causes of cancer, there is a growing literature and body of research: and scarcely a week passes without a new article announcing to some general public or other the scientific link between cancer and painful feelings. Investigations are cited—most articles refer to the same ones—in which out of, say, several dozen or several hundred cancer patients two-thirds or three-fifths report being depressed or unsatisfied with their lives, and having suffered from the loss (through death or rejection or separation) of a parent, lover, spouse, or close friend.³

But it seems likely that of several hundred people who do not have cancer, most would also report depressing emotions and past traumas: this is called the human condition. And the case histories are recounted in a particularly forthcoming language of despair, of discontent about and obsessive preoccupation with the isolated self and its never altogether satisfactory “relationships,” which bears the unmistakable stamp of our consumer culture. It is a language many Americans now use about themselves.⁴

Investigations carried out by a few doctors in the mid- and late-nineteenth century showed a high correlation between cancer and that era’s complaints. In contrast to American cancer patients, who invariably report having feelings of isolation and loneliness since childhood, Victorian cancer patients described overcrowded lives, burdened with work and family obligations, and bereavements. These patients don’t express discontent with their lives as such or speculate about the quality of its satisfactions and the possibility of a “meaningful relationship.” Physicians found the causes or predisposing factors of their patients’ cancers in grief, in worry (noted as most acute among businessmen and the mothers of large families), in straitened economic circumstances and sudden reversals of fortune, and in overwork—or, if the patients were successful writers or politicians, in grief, rage, intellectual overexertion, the anxiety that accompanies ambition, and the stress of public life.⁵

Nineteenth-century cancer patients were thought to get the disease as the result of hyperactivity and hyperintensity. They seemed to be full of emotions that had to be damped down. As a prophylaxis against cancer, one English doctor urged his patients “to avoid overtaxing their strength, and to bear the ills of life with equanimity; above all things, not to ‘give way’ to any grief.” Such stoic counsels have now been replaced by prescriptions for self-expression, from talking it out to the primal scream. In 1885, an American doctor advised “those who have apparently benign tumors in the breast of the advantage of being cheerful.”⁶ Today, this would be regarded as encouraging the sort of emotional dissociation now thought to predispose people to cancer.

Modern researchers into the psychic aspects of cancer like to cite old authorities, such as Galen’s observation that “melancholy women” were more likely to get breast cancer than “sanguine women.” But the meanings have changed. What Galen (AD 130-200) meant by melancholy was a physiological condition with complex characterological symptoms; we mean a mere mood. In 1870 Sir James Paget declared that “mental depression is a weighty additive to the other influences favoring the development of a cancerous constitution.” What a nineteenth-century physician meant by “mental depression” was a passionate state (mainly grief), something close to our manic-depressive syndrome.

Grief and anxiety,” said the English surgeon Sir Astley Cooper 150 years ago, are among “the most frequent causes” of breast cancer. The same theory, put in the same terms, had long been in circulation for TB. In his Morbidus Anglicus (1672), Gideon Harvey declared “melancholy” and “choler” to be “the sole cause” of TB, for which he used the metaphoric term “corrosion.” In 1881, a standard medical textbook gave as the causes of tuberculosis: hereditary disposition, unfavorable climate, sedentary indoor life, defective ventilation, deficiency of light, and “depressing emotions.”⁷ The entry had to be changed for the next edition, for in 1882 Robert Koch had published his paper announcing the discovery of the tubercle bacillus and demonstrating that it was the primary cause of the disease.

The modern work on the psychological causes of cancer finds its true antecedent and counterpart in the large nineteenth-century literature on the causes of TB. (Not in that small body of medical work from the last century on the emotional causes of cancer.) Applied to TB, the theory that emotions cause diseases survived well into this century—until, finally, it was discovered how to cure the disease. The theory’s fashionable current application—which relates cancer to feelings of isolation and depression—is likely to prove no more tenable than did its application to tuberculosis.

In the plague-ridden England of the late sixteenth and seventeenth centuries, it was widely believed that “the happy man would not get plague.”⁸ The fantasy that a happy state of mind would fend off disease probably flourished for all infectious diseases, before the nature of infection was understood. Theories that diseases are caused by mental states and can be cured by will-power are always an index of how much is not understood about the physical terrain of a disease.

Moreover, there is a peculiarly modern predilection for psychological explanations of disease as of everything else. Psychologizing seems to provide control over the experiences and events (like grave illnesses) over which people have in fact little or no control. Psychological understanding undermines the “reality” of a disease. That reality has to be explained. (It really means; or is a symbol of; or must be interpreted so.) For those who live neither with religious consolations about death nor with a sense of death (or of anything else) as “natural,” death is the obscene mystery, the ultimate affront, the thing that cannot be controlled. It can only be denied. A large part of the popularity and persuasiveness of psychology comes from its being a sublimated spiritualism: a secular, ostensibly scientific way of affirming the primacy of “spirit” over matter. That ineluctably material reality, disease, can be given a psychological explanation. Death itself can be considered, ultimately, a psychological phenomenon. Groddeck declared in The Book of the It (he was speaking of TB): “He alone will die who wishes to die, to whom life is intolerable.”⁹ The promise of a temporary triumph over death is implicit in much of the psychological thinking that starts from Freud and Jung.

At the least, there is the promise of a triumph over illness. A “physical” illness becomes in a way less real—but, in compensation, more interesting—so far as it can be considered a “mental” one. Speculation throughout the modern period has tended steadily to enlarge the category of mental illness. Indeed, the denial of death in this culture has led to a vast expansion of the category of illness as such.

This expansion proceeds by means of two hypotheses. The first is that every form of social deviation can be considered an illness. Thus, if criminal behavior can be considered as an illness, then criminals cannot be condemned or punished but must be understood, treated, cured.¹⁰ The second is that every illness can be considered psychologically. Illness is interpreted as, basically, a psychological phenomenon, and people are encouraged to believe that they get sick because they want to, and that they can cure themselves by the mobilization of will; that they can choose not to die. These two hypotheses are complementary. As the first seems to relieve guilt, the second reinstates it. Psychological theories of illness are a powerful means of placing the blame on the ill. Patients who are instructed that they have, unwittingly, caused their disease are also being made to feel that they have deserved it.

(This is the second part of a three-part article.)