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Images of Illness


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.


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.”

  1. 1

    Reich Speaks of Freud (Farrar, Straus and Giroux, 1967), p. 57.

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