The ideas behind this inflammatory broadside (it is only eighty-eight pages) are stated plainly on an introductory page:

My subject is not physical illness itself but the uses of illness as a figure or metaphor. My point is that illness is not a metaphor, and that the most truthful way of regarding illness—and the healthiest way of being ill—is one most purified of, most resistant to, metaphoric thinking.

This is the Puritan view—the view that got such a clouting from Ibsen in The Wild Duck. But here is Dickens expressing perfectly what happens to illness when it is used as “a figure or a metaphor.” Young Smike, of Nicholas Nickleby, is dying of TB. This is admittedly a “dread disease,” but it “refines” death’s “grosser aspect” in that “the struggle between soul and body is so gradual, quiet, and solemn, and the result so sure, that day by day, and grain by grain, the mortal part wastes and withers away, so that the spirit grows light and sanguine with its lightening load….”

Miss Sontag has made a fine collection of such repellent passages of metaphorical nonsense. They were used by the Victorians, she explains, to prettify the great killer of the nineteenth century, and there were two reasons why metaphor was particularly suited to it: first, the doctors didn’t know what it was, and so laid it open to the whims of fantasy; second, it did marvelous things (as the Dickens passage shows) to the physical crudities of man. TB is “a disease of extreme contrasts: white pallor and red flush, hyperactivity alternating with languidness,” and it gave the dying person a far more “beautiful and more soulful” appearance than he had enjoyed in his robuster days. From there, it was only a step to regarding it as “romantic,” and once established as romantic, it couldn’t fail to grow fashionable. “I could not have accepted as a lyrical poet anyone weighing more than ninety-nine pounds,” said Gautier (a novelist who was allowed to be heavier, Miss Sontag presumes). Saint-Saëns, who is also quoted, remarked Chopin’s good fortune in being “tubercular at a time when good health was not chic.” Needless to add, this “really awful disease” was good for both religion and society: it helped Little Eva, on her deathbed, to beg her father to free his slaves. Its mysterious nature left ample room for comforting illusions: Shelley was able to assure Keats that it always made a beeline for the very best poets, and even Byron, already renowned for his pallor, said that a little TB might provide added interest.

This way of seeing TB went right on into the middle of our own century, long after Koch had found that a bug was at the bottom of it. Middleton Murry found his wife, Katherine Mansfield, more beautiful on the day before her death than she had ever looked before: he wrote of her on that day in the sort of words Dickens had written of Smike. As for the ladies in general, Miss Sontag believes that their struggle to keep slim nowadays is a hangover from the great days of TB. The menfolk recovered their bulk long ago—except in the fiction of Thomas Mann and Henry James. Miss Sontag affirms sardonically that they “grew fat, founded industrial empires, wrote hundreds of novels, made wars, and plundered continents.” Here, it is possible to detect a touch of fiction.

Clearly, there was a certain sensitiveness of character that made TB interested in a person. Even the fat ones listed by Miss Sontag might have had thin TB ones inside them longing to get out. But what was generally agreed was that the character preceded the illness—that only the right type could hope to get it. TB Miss Sontag points out, stood alone in this respect: any mutt could contract syphilis—and, of course, derive neither spiritual benefit from it nor a reputation for sensitiveness—and the same went for the Black Death, ulcers, and virtually all other kinds of diseased conditions. But TB, with its emphasis on a man’s having the right character in the first place, led the way for the equally important killer that has largely replaced it.

This is cancer; and the reason why Miss Sontag has devoted so much of a very short book to TB is precisely that the two diseases are soul mates in respect to so-called characterology. This long section is without doubt the very best part of her book; it is written angrily, clearly, and expressively, and what it has to say is particularly valuable because it should have been said so long ago.

“TB, cancer…are viewed as forms of self-judgment, of self-betrayal.” But each, conveniently enough, betrays the self in the opposite way to the other. Someone who was “both passionate and repressed,” spiritual and romantic, invited TB, but the “cancer-prone character” is all of a piece, “someone unemotional, inhibited, repressed.” The TB line has more or less died out—though Miss Sontag, in a very hearty sideswipe, suggests that insanity has been made heir to its “hectic, reckless” heights of consciousness. But the cancer bequest—initiated, she believes, by Schopenhauer’s devotion to the will (“The will exhibits itself as an organized body, and the presence of disease signifies that the will itself is sick”)—became the inheritance of the mavericks of psychoanalysis, Groddeck and Reich. For Groddeck, “the sick man himself creates his disease…”; for Reich, the horrible cancer of the mouth that Freud endured so gallantly for so many years was the natural fate of a man who had a beautiful speaking voice and, thanks to being “very unhappily married,” was “very much dissatisfied genitally”—a condition he was too respectable to remedy.


Miss Sontag remarks that this view of disease is implicit in much of the writing of Freud and Jung. One might add that at the time the opinion was first put forward, psychology was emerging from the dog house like early Christianity from the catacombs. As early as the 1930s, the temptation to see everything in terms of psychology was beginning to run wild—the natural extreme to which all theories run when they find favor after long years of being eaten by lions.

Miss Sontag’s point is that what once seemed wild in ‘psychology is now the accepted “mythology of cancer.” The belief that there is a “cancer-prone character type” is not “confined to the back yard of folk superstition”; on the contrary, it “passes for the most advanced medical thinking.” The idea that “the character causes the disease” is based on the idea that it does so because the character “has not expressed itself.” Deprived of outward expression, “passion moves inward, striking and blighting the deepest cellular recesses.”

With the passing of the years, the supposedly cancer-prone type has managed to embrace many more tendencies than he enjoyed in the days of Groddeck and Reich. Among Miss Sontag’s quotations describing this wretched creature are: “prone not to be able to forgive and to hold deep-seated resentment”; “low-gear persons” with “feelings of isolation”; victims of memories of “emotional deprivation in childhood” which lead to an inability to construct a “meaningful relationship” and the “conviction that life holds no more hope.” Some two-thirds 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.” In fact, the net of character is now spread so wide that it can catch both Rimbaud and Napoleon at the extremes and most of the rest of us in between.

Miss Sontag comments on this in a fine passage:

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.

To this she adds:

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.

From there, it is only a step to regarding death itself as “a psychological phenomenon” and to Groddeck’s dictum: “He alone will die who wishes to die….”

Nearly all this makes good reading—and would make even better, as argument, if the opposition were conceded a point occasionally (e.g., Groddeck was by no means a numbskull; psychosomatic illnesses are valid as such sometimes). Miss Sontag’s neglectfulness in these matters is due in the main to the anger she feels at the way the victims of cancer are obliged to suffer not only from a cruel disease but from the shame of having incurred it by being socially undesirable people. Their shame is increased by the fact that their disease is a metaphor for anything that is incurably loathsome. Where TB could glow in an absurd radiance, cancer can only be projected in metaphors that are “an incitement to violence.” The so-called “Jewish problem” was the cancer of Nazi Germany, remediable only by remorseless surgery. Israel has been “a cancer in the heart of the Arab world” for twenty years of Arab polemics. But Miss Sontag notes that no particular party has a monopoly on cancer’s metaphorical flourishes. Trotsky used cancer to describe Stalinism; John Dean to describe Watergate. D.H. Lawrence applied it to masturbation; here, humor comes to the rescue at last.

Those who attempt to cure cancer fall into metaphorical traps that are drawn “from the language of warfare.” The body is “invaded”; the cancer cells spread and “colonize.” The doctors “bombard” the invader with toxic rays; they speak of chemotherapy as if it were poison gas; their aim is to “kill” the killer at all costs. What is called “the war on cancer” includes a whole “military rhetoric” reminiscent of the conferences of “battle-weary officers mired down in an interminable colonial war.” Cancer, in short, “is now in the service of a simplistic view of the world that can turn paranoid.”


That is often what cancer tends to do in Miss Sontag’s hands, damaging a book that is full of good things. Her stated aim is to take the myths and metaphors away from cancer and leave it purified as a thing in itself—a disease of great seriousness that must be treated truthfully, respectfully, coolly. But the violence that attends it at present is reflected in her own thinking: her “battleweary officers” fighting their “colonial” war are the very sort of metaphors she can’t abide when they are used by the other side. Similarly, her taking the onus for cancer off the patient’s personality is excellent—except that the rest of us are made to pay for it. We take a “shallow view of death”; we regard it as an “obscene” and “shameful, unnatural event”; we even avoid meeting friends who have got cancer. The “consumer society” of which we are a part helps to build up the hogwash which surrounds cancer and the falseness of its terminology. Many patients play along with the prevailing dishonesty, and so help to confirm the doctors’ insistence that dishonesty is what the patient wants.

This part of the book is not pinned together as decisively as the section on the application to cancer of the cruder sorts of psychology. It involves too many myths and metaphors that are dragged in as standard terms of radical expression—in particular, the “colonial” hangovers from Vietnam and that old standby “the consumer society.” It takes no account of the fact that we wage “war” on a hundred-and-one things besides cancer—on poverty, on racism, on drugs, sin, and pornography. But few will quarrel with Miss Sontag’s last words, which stress the overriding primacy of genuine medical research. Whatever our view of the world, we know it will still be as corrupt as ever it was when cancer has followed the Black Death and TB into that dark corner where the abuses of metaphor die their natural death.

This Issue

July 20, 1978