Sickness & Psyche
Illness as Metaphor.
by Susan Sontag.
Farrar, Straus & Giroux. 88 pp. $5.95.
Are we responsible for the illnesses from which we suffer? Do the most serious of our illnesses reveal moral and psychological truths about ourselves which we would rather keep hidden? Do they, in fact, reveal those truths precisely because we have attempted to hide them? In her new book, Susan Sontag utters a heartfelt No in answer to these questions, especially insofar as they are asked about what she calls the “master illnesses” of the last two centuries, tuberculosis and cancer:
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. . . . Such preposterous and dangerous views manage to put the onus of the disease on the patient and not only weaken the patient’s ability to understand the range of plausible medical treatment but also, implicitly, direct the patient away from treatment. Cure is thought to depend principally on the patient’s already sorely tested or enfeebled capacity for self-love.
This seems to me one of the clearest, strongest, and (notwithstanding the reservations I shall have to make about it) most sympathetic utterances in the book. However, the reader will have noticed that by using a term like “modern diseases,” and by asserting that one disease can in some sense “replace” another, the author is clearly indicating that it is not illness as such, or its treatment as such, which is her subject, but rather the cultural or moral status of the illnesses she discusses: what we have made of them, or the uses to which we have put them, rather than what they actually are. Hence the book’s title. We are presented with a series of arguments designed to show why tuberculosis and cancer occupy or have occupied a special place in the minds of people living in the 19th and 20th centuries; how that status has been established; and what it reveals about the culture and society at large. In fact, one of the many (apparently unnoticed) oddities of this book is that while the author strenuously contests the idea that such diseases reveal anything other than themselves in a patient, she has no hesitation in making far-reaching diagnoses about the moral and psychological condition of society as a whole on the basis of her partial readings of the most dubious or ambiguous symptoms.
But let me try to summarize her case. Why are TB and cancer the “modern diseases,” and what are the metaphoric processes that have been attached to them? Well, TB was the Romantic disease par excellence. In the eyes of the Romantic poets and their Victorian and 20th-century successors, “the TB death . . . dissolved the gross body, etherealized the personality, expanded consciousness.” The tuberculotic was seen as someone “consumed” by ardor, by an “inward burning” of emotion which ultimately ennobled and spiritualized him even as it killed him:
It is with TB that the idea of individual illness was articulated, along with the idea that people are made more conscious as they confront their deaths, and in the images that collected around the disease one can see emerging a modern idea of individuality that has taken in the 20th century a more aggressive, if no less narcissistic, form.
As for cancer, the metaphors applied to it speak of it as an invader, an alien presence, a takeover of the body by energies running amok; and the language used about it, or its use as a symbol in other forms of discourse, has a concomitant harshness and hostility. What makes the disease a parallel or even a reciprocal case to TB, however, is that it too is seen as a consequence of disordered emotion. In the writings of people like Wilhelm Reich, Georg Groddeck, Norman Mailer, and a handful of medical investigators whose papers are quoted by Miss Sontag, the cancer patient is reputed to be a self-repressed, depressive type who is ultimately responsible for the disease from which he suffers.
Even from this summary it is clear that the evidence offered by the author for the ideas we are supposed to hold or to have held about the two diseases is of a different kind in each case. A novel or a poem is not the same thing as an utterance by Groddeck or Reich or a research paper in a journal, and its meaning can hardly be taken in the same way. This is an important point, to which I shall return. However, since so much of what I am going to say is critical of the book and its theses, I should make it plain that the idea of individual diseases having their “fates” or “cultural meanings” seems to me one well worth pursuing; and that despite my misgivings about Miss Son-tag’s manner of treating many of the topics she touches upon, there are a number of suggestive and stimulating passages in the book. Her attempt to establish the nature of the special affinity between certain modes of Romanticism and certain ways of perceiving illness—and of perceiving TB in particular—is especially interesting. So too is the observation that in some advanced circles, madness has now replaced TB as the disease which bespeaks the posssession by the sufferer of a sensibility more refined than that of the healthful, slothful mass. Another is the remark that to use the image of cancer to describe a manifestation or a group one hates (Jews, Communists, capitalists, “the white race”—the last having once been Miss Sontag’s own contribution to this elevated mode of discourse) is not only brutal and threatening as far as one’s intended targets are concerned, but is also viciously unkind to those who actually suffer from the disease.
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But the price the reader has to pay for such illuminations is a high one (and I’m not referring only to the $5.95 asked for the 80-odd small pages of which the book is composed). Intellectual boldness should not be confused with intellectual self-indulgence: Miss Sontag seems to have some trouble in telling them apart. This applies as much to her way of dealing with particular items of evidence as to her large, larger, and largest cultural formulations. Obviously I can give only a very few examples of what I mean. They range from her repeated invocation of the death of little Paul Dombey (in Dickens’s Dombey and Son) as the very type of that of the tubercular victim, to the remark quoted above that “with TB,” there was newly “articulated . . . the idea that people are made more conscious as they approach their deaths.” So much, on the latter point, for Moses in the Book of Deuteronomy; so much for Jacob in Genesis; so much for the mixture of moral uplift and ruthless political instruction with which David takes leave of Solomon.
As for Paul Dombey, the fact is that Dickens himself, for good artistic reasons, refrains from ascribing any single cause to Paul’s condition. Indeed, the argument that Paul Dombey must have been consumptive, given Dickens’s description of his mental and physical state, seems to me merely circular. All Dickens commits himself to (the Apothecary’s diagnosis) is that Paul suffers from “a want of vital power . . . and great constitutional weakness.”
In this connection, a passage from Charlotte Bronte’s novel Shirley—not a text cited by Miss Son-tag—is of considerable interest:
She [the heroine] was now precisely in the state when, if her constitution had contained the seeds of consumption, decline, or slow fever, those diseases would have been rapidly developed, and would have soon carried her from the world. People never die of love or grief alone; though some die of inherent maladies, which the tortures of those passions prematurely force into destructive action.
As a member of the unfortunate Bronte family, and as a clergyman’s daughter who did her share of visiting the sick, Charlotte Bronte probably knew as much about these subjects as any Victorian novelist; yet notice how the attempt at etiological precision here consorts with a striking diagnostic vagueness. I should add that later in Shirley the heroine does fall gravely ill—with cholera—and the language used about her then is very similar indeed to that which Miss Sontag believes to be peculiar to descriptions of the victims of TB. “She wasted like any snow-wreath in thaw; she faded like any flower in drought. . . .”
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Another example. We are told on the strength of a single quotation from a play by Goldsmith that
with the new mobility (social and geographic) made possible in the 18th century, worth and station are not given; they must be asserted. They were asserted through new notions about clothes (“fashion”) and new attitudes toward illness. Both . . . became tropes for new attitudes toward the self.
Now if one were to point out that the comedies of Shakespeare and Jonson are aswarm with overdressed upstarts seeking to impress through their newfangled clothes and styles of speech, and that this would seem to make nonsense of the author’s confident account of what was distinctive about the 18th century—then what would one be? A pedant? A kill-joy? A spoilsport? Or would one be simple-mindedly pretending that historical processes and changes in the organization of society do not affect the way in which people view themselves?
I can answer the last question, at least. Nothing of the kind. All one would be doing is insisting that literary conventions are enduring and protean, and that they have a life and a logic of their own. It is one thing to demonstrate, with some degree of success, that 19th-century literature took the ugly facts of fatal illness—not just TB—and tried to transform them into symbols of uplifting or reassuring kinds. It is quite another to ask us to believe that these metaphors and symbols were then taken literally by readers (or indeed by the writers themselves). We give our assent to literary works—longing assent, pleasurable assent, horrified assent—precisely because we know it to be provisional; and it is in that very provisionality that the greater part of their value to us is to be found. It follows that questions of what we believe when we read (or write) poems or novels, and of the kind of “truth” they have for us, are of much delicacy and complexity. We certainly cannot read off from them, as if from a series of dials, measurements which we can then confidently apply to the society as a whole, and thus find out what people in that society believed, or even wanted to believe, about themselves. Nor can we do the job in reverse, as it were, and say that here is a society with such-and-such measurements; these are bound to be repeated in petto in its works of literature.
To be fair, Miss Sontag is assailed by doubts on this very score at one stage. But she rapidly disposes of them:
One might reasonably suppose that this romanticization of TB was merely a literary transfiguration of the disease, and that in an era of its great depredations TB was probably thought to be disgusting—as cancer is now. . . . Yet all the evidence indicates that the cult of TB was not simply an invention of Romantic poets and opera librettists but a widespread attitude, and that the person dying (young) of TB really was perceived as a Romantic personality. One must suppose that the reality of this terrible disease was no match for important new ideas, particularly about individuality.
I am afraid the phrase “all the evidence” is a mere flourish; no such evidence is brought forward. Virtually every item of information we are offered about “the cult of TB” is literary: if it doesn’t come from novels and poems, it comes from the letters of novelists and poets, who are decidedly a special case. There is practically nothing from the letters, memoirs, and biographies of people who are not connected with the arts; nothing from the reports of Health Commissioners and other interested parties. So how can we possibly judge how widespread was “the cult of TB”? Are we to believe—to revert to my own earlier example—that Charlotte Bronte, who used the conventional language of snow-wreaths and flowers about her heroine’s malady, did not know perfectly well (when she wasn’t “being a novelist”) that a major symptom of cholera is uncontrolled diarrhea? Has the death in pain and confusion of myriads of men since the beginning of history ever prevented writers from giving their dying characters prophetic powers? Does my lack of sympathy (which I have in common with Miss Sontag) for the notion that the mad are wiser than the sane prevent me from accepting that Lear as madman and outcast imparts truths that Lear as king is incapable of recognizing?
But perhaps these questions are supererogatory. Perhaps all one need do is point out something the author glimpses early in the book but appears to have forgotten by the time she comes to generalizing about “widespread attitudes” and “reality [being] no match for important new ideas.” Surely it is because the terrible, omnipresent reality of the disease was only too well recognized, only too familiar, that there took place the literary and operatic romanticization of which she complains.
My own view is that, so far as a positive “cult” of illness can be said to have developed in the early years of the 19th century, it spoke chiefly of the Romantic poets’ sense of personal isolation and vulnerability—as, in a different way, did their imaginative identification with criminals, beggars, idiots, and children. Why writers began to feel, or at any rate to publicize, so deep a sense of estrangement from the sources of power in their society, and why readers found it so acceptable that they should do so, are hardly unexplored topics; at this point, words like industrialization, urbanization, the middle class, democracy, etc., begin to write themselves on the page. (Though I remain skeptical of their real power to explain changes in literary fashions and attitudes.) Rather than follow such trails, it seems more useful simply to remark that one of the great achievements of the English Victorian novelists was to marry certain Romantic strains to popular evangelical religion—a movement which Miss Sontag does not allude to, though its influence on Victorian fiction in general, and Victorian death-bed scenes in particular, was incalculable.
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Turning from history to the present period, and from tuberculosis to the second of the two great scourges that figure in Illness as Metaphor, we note, as I have said, that most of the passages quoted on the psychological origins of cancer are taken from psychologists and medical men, while the metaphors of violence and vileness come from newspapers and the literature of anti-cancer campaigns. By comparison with the section on tuberculosis, relatively little mention is made of imaginative works and little support is sought from them. We note also that there seems to be no logical or emotional “fit” between the two parts of the author’s thesis about the symbolic or moral status of cancer within our culture: between, on the one hand, the view of the disease as one of repressed feelings and, on the other, the violently punitive or warlike manner in which she claims it is always written about. That there was such a fit between the excessive “ardor” of the TB victim and the supposedly spiritualizing effects which poets and novelists ascribed to the disease was an important part of her earlier case; here, however, the two sides of the argument seem to be welded together by little more than fierce observations about “our shallow attitude toward death” and some elaborate metaphors of the author’s own devising on the supposed characteristics of an advanced capitalist economy.
As far as the psychological diagnoses of cancer are concerned, one problem for me is that the author is writing directly as an American about conditions in America: a subject on which she clearly knows more than I do. If she says the belief that cancer is a “disease of the emotions” is widespread, indeed pervasive, in her country, then I must assume there is some foundation for her assertion. True, the tiny handful of papers she quotes from are unimpressive, to put it politely; but presumably there are people who will believe anything that appears under supposedly scientific auspices. However, the fact that she also has to call repeatedly on the writings of two notorious loonies like Wilhelm Reich and Georg Groddeck might well be thought to weaken her case somewhat—how far, I wonder, has their influence actually spread in the United States, even at third and fourth hand, and how many people, outside small conventicles of their followers, owe serious allegiance to their views of the world and the human body? For myself, speaking from the other side of the Atlantic, I can say that though I have known many sufferers from cancer, some of them close friends and relations, I have not once—quite literally not once—heard them or those near to them speak of emotional disorder or distress as the cause of the disease.
For the rest, I agree with the author that a deplorably and peculiarly paranoid style is often used about cancer, whether by those who fear it, or by those who claim to be able to cure it, or simply by those who employ the term for political or racial abuse. Still, I have difficulty in following her when she begins to link these modes of speech to our “shallow attitude to death” and our “denial of death,” and “the large insufficiencies of our culture,” and the problem of “how to be severe in the late 20th century . . . when there is so much to be severe about.” Language of this kind always strikes me as our equivalent to just those modes of Victorian self-exaltation about which the author is severe enough elsewhere in the book. We may not have God, but it would seem that some of us do have amazing historical eyeglasses through which we can determine all sorts of things—even the fact that people in earlier times managed to have deeper “attitudes” toward death than we do.
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Two final points. There are scores of ancient, everyday “metaphors of illness” which are never mentioned in this book—terms like lily-livered; faint-hearted; brokenhearted; spineless; gutless; scatterbrained; swell-headed; stiff-necked; and so forth. Where questions of health and sickness are concerned, I am prepared to accept their testimony (together with at least some examples of more recent medical wisdom) that it is futile to seek for absolute or knife-edge distinctions between body and mind, flesh and spirit. That much said, however, I find it surprising that the author of this book should apparently share one major assumption with the glibly psychologizing tendencies she argues against. That is, she seems to believe that if one admits a psychological component in the etiology of cancer or any other serious disease, this must have important consequences for the manner in which the disease is treated. I do not see that this need be the case at all. Surely to deal as directly as we can with the pathogens in a man’s system is an easier, kinder, safer, more modest, and more effective way of proceeding than to try to remake that system overall, according to some inconceivable model of what it should really be or how it should really behave.
