It’s Never Just Heart Disease …And Rarely Just Illness

How to Read Literature Like a Professor - Thomas C. Foster 2003

It’s Never Just Heart Disease …And Rarely Just Illness

ONE OF MY VERY FAVORITE NOVELS is a gem of narrative misdirection by Ford Madox Ford called The Good Soldier (1915). Its narrator is more fallible, more consistently clueless, than any narrator you’re ever likely to meet in all of fiction; at the same time he’s completely believable and therefore pathetic. He is part of a pair of couples who meet every year at a European spa. During all these years, and quite unbeknownst to him, his wife, Florence, and the husband of the other couple, Edward Ashburnham, carry on a passionate affair. It gets better: Edward’s wife, Leonora, knows all about it, and in fact may have stage-managed its beginning to keep the chronically straying Edward out of a more disastrous relationship. The success of this strategy must be questioned, since the relationship eventually manages to destroy, by my count, six lives. Only poor cuckolded old John Dowell remains ignorant. Consider the possibilities for irony. For an English professor, and for any avid reader, having a blithely ignorant (and only recently clued-in) husband narrate the saga of his wife’s longtime infidelity is about as good as it gets.

But I digress. Why, you ask, are they habitués of the spa? Florence and Edward are ill, of course.

Heart trouble. What else?

In literature there is no better, no more lyrical, no more perfectly metaphorical illness than heart disease. In real life, heart disease is none of the above; it’s frightening, sudden, shattering, exhausting, but not lyrical or metaphorical. When the novelist or playwright employs it, however, we don’t complain that he’s being unrealistic or insensitive.

Why? It’s fairly straightforward.

Aside from being the pump that keeps us alive, the heart is also, and has been since ancient times, the symbolic repository of emotion. In both The Iliad and The Odyssey Homer has characters say of other characters that they have “a heart of iron,” iron being the newest and hardest metal known to men of the late Bronze Age. The meaning, if we allow for some slight variations of context, is tough-minded, resolute even to the point of hard-heartedness—in other words, just what we might mean by the same statements today. Sophocles uses the heart to mean the center of emotion within the body, as do Dante, Shakespeare, Donne, Marvell, Hallmark …all the great writers. Despite this nearly constant use over at least twenty-eight hundred years, the figure of the heart never overstays its welcome, because it always is welcome. Writers use it because we feel it. What shapes were your Valentine’s cards in when you were a kid? Or last year, for that matter? When we fall in love, we feel it in our hearts. When we lose a love, we feel heartbroken. When overwhelmed by strong emotion, we feel our hearts are full to bursting.

Everybody knows this, everybody intuitively senses this. What, then, can the writer do with this knowledge? The writer can use heart ailments as a kind of shorthand for the character, which is probably what happens most often, or he can use it as a social metaphor. The afflicted character can have any number of problems for which heart disease provides a suitable emblem: bad love, loneliness, cruelty, pederasty, disloyalty, cowardice, lack of determination. Socially, it may stand for these matters on a larger scale, or for something seriously amiss at the heart of things.

We’re not just talking classic literature here. When Colin Dexter decides to kill off his recurrent detective Morse in The Remorseful Day (1999), he has a number of options. The chief inspector is a genius at solving crimes and crossword puzzles, but like all geniuses, he has flaws. Specifically, he drinks too much and remains a complete stranger to physical fitness, so much so that in novel after novel his Thames Valley Police superiors mention his excessive fondness for “the beer.” His liver and digestive system are seriously compromised, to the point where he is hospitalized for these problems in a previous Morse novel. In fact, he solves a century-old murder from his hospital bed in The Wench Is Dead (1989). His major problem, though, is loneliness. Morse has spectacularly bad luck with his women; several wind up as either corpses or culprits in his various adventures, while others just don’t work out. Sometimes he’s too needy, other times too unbending, but time after time he loses out. So when the time comes for him to collapse amid the spires of his beloved Oxford University, Dexter gives him a heart attack.


We’re into the realm of speculation here, but this is how it strikes me. To have Morse succumb to cirrhosis of the liver turns the whole thing into a straightforward piece of moralizing: see, we told you drinking too much is bad for you. Morse’s drinking would go from being a quaint idiosyncrasy to something from one of those old school-guidance films, and that is not what Dexter wants. Of course excessive drinking is bad for you—excessive anything, including irony, is bad for you—but that’s not the point. But with a heart attack, the connection to an overfondness for drink is still there if that’s what some readers want to see, but now the ailment points not toward his behavior but toward the pain and suffering, the loneliness and regret, of his sad-sack love life, that may well be causing the behavior. The emphasis is on his humanity, not his misdeeds. And authors, as a rule, are chiefly interested in their characters’ humanity.

Even when the humanity isn’t very humane, or the heart ailment a disease. Nathaniel Hawthorne has a great short story called “The Man of Adamant” (1837). As with a number of his characters, the man of the title is a committed misanthrope, absolutely convinced that everyone else is a sinner. So he moves into a cave to avoid all human contact. Does it sound like a “heart” problem to you? Of course it does. Now the limestone cave he chooses has water, a little drip of water, that’s just stiff with calcium. And moment by moment, year by year, the water in that cave seeps its way into his body, so that at the end of the story he turns to stone, or not him entirely, just his heart. The man whose heart was figurative stone at the outset has his heart turn to literal stone at the end. It’s perfect.

Or take the case of Joseph Conrad’s Lord Jim. Early in the novel, Jim’s courage has failed him at a crucial moment. His strength of heart, both in terms of bravery and of forming serious attachments, is in question throughout the narrative, at least in his own mind, and at the end he misjudges an enemy and his miscalculation causes the death of his best friend, who happens to be the son of the local chieftain. Jim has promised this leader, Doramin, that if his plan results in the death of any of his people, Jim will forfeit his own life. When it does, he walks with great calm to Doramin, who shoots him through the chest; Jim glances proudly at the assembled crowd—See, I am both brave and true to my word—and falls dead. Conrad doesn’t perform a postmortem, but there is one and only one place in the chest where a shot results in instantaneous death, and we know where that place is. The very next comment by Marlow, the narrator, is that Jim was “inscrutable at heart.” The novel’s all about heart, really, heart in all its senses. Jim’s end, then, like the Adamantine Man’s, is perfectly apt. A man who in life has put so much stock in “heart”—in loyalty and trust, in courage and fidelity, in having a true heart—can only die by a blow to the heart. Unlike Hawthorne’s character’s demise, though, Jim’s is also heartbreaking—to the woman who is his de facto wife, to old Stein, the trader who sent him in-country, and to readers, who come to hope for something heroic and uplifting, something suitably romantic, for the incorrigibly romantic Jim. Conrad knows better, though: it’s tragedy, not epic, as he proves by that shot in the heart.

More commonly, though, heart trouble takes the form of heart disease. Vladimir Nabokov created one of the nastiest villains in modern literature in Lolita’s Humbert Humbert. His self-absorption and obsession lead him to cruelty, statutory rape, murder, and the destruction of several lives. His darling Dolores, the Lolita of the title, can never lead a psychologically or spiritually whole adult life. Of her two seducers, Clare Quilty is dead and Humbert is in jail, where he dies, somewhat unexpectedly, of heart failure. Throughout the whole novel he’s had a defective heart in the figurative sense, so how else could he die? He may or may not need to die, but if he does buy the farm, there’s only one death symbolically appropriate to his situation. Nobody had to tell that to Nabokov.

As a practical matter, then, we readers can play this two ways. If heart trouble shows up in a novel or play, we start looking for its signification, and we usually don’t have to hunt too hard. The other way around: if we see that characters have difficulties of the heart, we won’t be too surprised when emotional trouble becomes the physical ailment and the cardiac episode appears.

Now, about that irony. Remember Florence and Edward, the wayward spouses with heart trouble? Just what, you ask, is wrong with their hearts? Not a thing in the world. Physically, that is. Faithlessness, selfishness, cruelty—those things are wrong, and ultimately those things kill them. But physically, their hearts are completely sound. So why did I say earlier they suffer from heart disease? Haven’t I just violated the principle of this chapter? Not really. Their choice of illness is quite telling: each of them elects to employ a fragile heart as a device to deceive the respective spouse, to be able to construct an elaborate personal fiction based on heart disease, to announce to the world that he or she suffers from a “bad heart.” And in each case the lie is, on another level, absolutely true. As I said earlier, it doesn’t get better than that.

At the beginning of James Joyce’s wonderful story “The Sisters” (1914), the unnamed young narrator mentions that his old friend and mentor, a priest, is dying. There is “no hope” for him this time, we’re told. Already your reader’s radar should be on full alert. A priest with no hope? Not hard to recognize in such a statement a host of possibilities for interpretive play, and indeed those possibilities are realized throughout the story. What’s of immediate interest here, though, is how the priest got that way. He’s had a stroke, not his first, and it has left him paralyzed. “Paralysis” is a word that fascinates the young boy, quite apart from its meaning; he yokes it with “simony” and “gnomon” in a triad of words to obsess over. For us, however, it’s the notion of paralysis—and stroke—that intrigues.

Anyone who has ever had to watch a loved one deteriorate after a massive stroke will no doubt look askance at the very idea of such frustration and misery being in some way intriguing, fascinating, or picturesque, and quite rightly. But as we’ve seen time and again, what we feel in real life and what we feel in our reading lives can be quite different.

From this little story the condition of paralysis grows into one of Joyce’s great themes: Dublin is a city in which the inhabitants are paralyzed by the strictures laid upon them by church, state, and convention. We see it throughout Dubliners—a girl who cannot let go of the railing to board a ship with her lover; men who know the right thing to do but fail because their bad habits limit their ability to act in their own best interest; a man confined to bed after a drunken fall in a public-house rest room; political activists who fail to act after the death of their great leader, Charles Stewart Parnell, some ten years earlier. It shows up again and again in A Portrait of the Artist as a Young Man and Ulysses and even in Finnegans Wake (1939). Of course, most maladies in most short stories, or even novels, are not quite so productive of meaning. For Joyce, however, paralysis—physical, moral, social, spiritual, intellectual, political—informs his whole career.

Until the twentieth century, disease was mysterious. Folks began to comprehend the germ theory of disease in the nineteenth century, of course, after Louis Pasteur, but until they could do something about it, until the age of inoculation, illness remained frightening and mysterious. People sickened and died, often with no discernible preamble. You went out in the rain, three days later you had pneumonia; ergo, rain and chills cause pneumonia. That still occurs, of course. If you’re like me, you were told over and over again as a child to button your coat or put on a hat lest you catch your death of cold. We’ve never really accepted microbes into our lives. Even knowing how disease is transmitted, we remain largely superstitious. And since illness is so much a part of life, so too is it a part of literature.

There are certain principles governing the use of disease in works of literature:

1) Not all diseases are created equal. Prior to modern sanitation and enclosed water systems in the twentieth century, cholera was nearly as common as, much more aggressive than, and more devastating than tuberculosis (which was generally called consumption). Yet cholera doesn’t come close to TB in its frequency of literary occurrence. Why? Image mostly. Cholera has a bad reputation, and there’s almost nothing the best public relations firm in the world could do to improve it. It’s ugly, horrible. Death by cholera is unsightly, painful, smelly, and violent. In that same period of the late nineteenth century, syphilis and gonorrhea reached near-epidemic proportions, yet except for Henrik Ibsen and some of the later naturalists, venereal diseases were hardly on the literary map. Syphilis, of course, was prima facie evidence of sex beyond the bounds of marriage, of moral corruption (you could only get it, supposedly, by visiting prostitutes), and therefore taboo. In its tertiary stages, of course, it also produced unpleasant results, including loss of control of one’s limbs (the sudden, spastic motions Kurt Vonnegut writes of in his 1973 Breakfast of Champions) and madness. The only treatment known to the Victorians employed mercury, which turned the gums and saliva black and carried its own hazards. So these two, despite their widespread occurrence, were never A-list diseases.

Well, then, what makes a prime literary disease?

2) It should be picturesque. What, you don’t think illness is picturesque? Consider consumption. Of course it’s awful when a person has a coughing fit that sounds like he’s trying to bring up a whole lung, but the sufferer of tuberculosis often acquires a sort of bizarre beauty. The skin becomes almost translucent, the eye sockets dark, so that the sufferer takes on the appearance of a martyr in medieval paintings.

3) It should be mysterious in origin. Again, consumption was a clear winner, at least with the Victorians. The awful disease sometimes swept through whole families, as it would when one member nursed a dying parent or sibling or child, coming into daily contact with contaminated droplets, phlegm, blood for an extended period. The mode of transmission, however, remained murky for most people in that century. Certainly John Keats had no idea that caring for his brother Tom was sealing his own doom, any more than the Brontës knew what hit them. That love and tenderness should be rewarded with a lengthy, fatal illness was beyond ironic. By the middle of the nineteenth century, science discovered that cholera and bad water went together, so it had no mystery points. As for syphilis, well, its origins were entirely too clear.

4) It should have strong symbolic or metaphorical possibilities. If there’s a metaphor connected with smallpox, I don’t want to know about it. Smallpox was hideous in both the way it presented and the disfigurement it left without really offering any constructive symbolic possibilities. Tuberculosis, on the other hand, was a wasting disease, both in terms of the individual wasting away, growing thinner and thinner, and in terms of the waste of lives that were often barely under way.

Throughout the nineteenth and early twentieth centuries, TB joined cancer in dominating the literary imagination regarding illness. Here’s a partial list: Ralph Touchett in Henry James’s novel The Portrait of a Lady (1881) and Milly Theale in his later The Wings of the Dove (1902), Little Eva in Harriet Beecher Stowe’s Uncle Tom’s Cabin (1852), Paul Dombey in Charles Dickens’s Dombey and Son (1848), Mimi in Puccini’s opera La Bohème (1896), Hans Castorp and his fellow patients at the sanatorium in Thomas Mann’s Magic Mountain (1924), Michael Furey in Joyce’s “The Dead,” Eugene Gant’s father in Thomas Wolfe’s Of Time and the River (1935), and Rupert Birkin in Lawrence’s Women in Love. In fact, Lawrence encodes his illness into the physiognomy, personality, and general health of his various alter egos. Not every one of these was labeled “tubercular.” Some were “delicate,” “fragile,” “sensitive,” “wasting away”; others were said to “have a lung” or “suffer from lung disease” or were merely identified as having a persistent cough or periods of low energy. A mere symptom or two would suffice for the contemporary audience, to whom the symptoms were all too familiar. So many characters contracted tuberculosis in part because so many writers either suffered from it themselves or watched friends, colleagues, and loved ones deteriorate in its grasp. In addition to Keats and the Brontës, Robert Louis Stevenson, Katherine Mansfield, Lawrence, Frédéric Chopin, Ralph Waldo Emerson, Henry David Thoreau, Franz Kafka, and Percy Bysshe Shelley form a fair beginning toward a Who’s Who of artistic consumptives. In her study Illness as Metaphor (1977), Susan Sontag brilliantly discusses the reasons for the disease’s popularity as a subject and the metaphorical uses to which it was put. For now, we’re less interested in all the implications she identifies, and more interested in recognizing that when a writer employs TB directly or indirectly, he’s making a statement about the victim of the disease. His choice, while no doubt carrying a strong element of verisimilitude, also very likely houses symbolic or metaphorical intentions.

This fourth consideration—the metaphorical possibilities a disease offers—generally overrides all others: a sufficiently compelling metaphor can induce an author to bring an otherwise objectionable illness into a work. A good example would be plague. As an instance of individual suffering, bubonic plague is no bonus, but in terms of widespread, societal devastation, it’s a champion. In two works written a mere twenty-five hundred years apart, plague successfully takes center stage. In Oedipus Rex Sophocles has Thebes hit by various plagues—withered crops, stillborn children, the works—but here as in general use, plague carries with it the implication of bubonic. It comes to mean what we think of as plague, in fact, because it can lay waste to whole cities in short order, because it sweeps through populations as a visitation of divine wrath. And of course divine wrath is the order of the day at the beginning of Sophocles’ play. Two and a half millennia later, Albert Camus not only uses the malady, he calls his novel The Plague (1947). Again, he is not interested so much in the individual sufferer as he is in the communal aspect and the philosophical possibilities. In examining how a person confronts the wholesale devastation wrought by disease, Camus can set his existentialist philosophy into motion in a fictional setting: the isolation and uncertainty caused by the disease, the absurdly random nature of infection, the despair felt by a doctor in the face of an unstoppable epidemic, the desire to act even while recognizing the pointlessness of action. Now neither Camus’s nor Sophocles’ use is particularly subtle or hard to get, but in their overt way they teach us how other writers may use illness when it is less central.

When Henry James has had enough of Daisy Miller and decides to kill her off, he gives her Roman fever or what we would now call malaria. If you read that beautiful little novella and neither of these names suggests anything to you, you really need to pay more attention. Malaria works great, metaphorically: it translates as “bad air.” Daisy has suffered from figurative bad air—malicious gossip and hostile public opinion—throughout her stay in Rome. As the name implies, it was formerly thought that the illness was contracted from harmful vapors in hot, moist night air; no one suspected that the problem might lie with those darned mosquitoes that were biting them on those hot, moist nights. So the notion of poisonous vapors would work nicely. Still, the older name used by James, Roman fever, is even better. Daisy does indeed suffer from Roman fever, from the overheated state that makes her frantic to join the elite (“We’re dying to be exclusive,” she says early on) while at the same time causing the disapproval of the Europeanized Americans who reside permanently in Rome at every turn. When she makes her fatal midnight trip to the Colosseum and she sees the object of, if not her affections, then at least her interests, Winterbourne, he ignores her, prompting her to say, “He cuts me dead.” And the next thing we know, she is dead. Does the manner of her death matter? Of course. Roman fever perfectly captures what happens to Daisy, this fresh young thing from the wilds of Schenectady who is destroyed by the clash between her own vitality and the rotten atmosphere of this oldest of Old World cities. James is a literary realist, hardly the most flamboyantly symbolic of writers, but when he can kill off a character in a highly lifelike way while employing an apt metaphor for her demise, he doesn’t hesitate.

Another great nineteenth-century realist who sees the figurative value of illness is Henrik Ibsen. In his breakthrough play A Doll’s House (1879), he includes a neighbor to the Helmer family, Dr. Rank, who is dying of tuberculosis of the spine. Dr. Rank’s illness is uncommon only in terms of its location; tuberculosis can settle in any part of the body, although the respiratory system is the one we always think of. Here’s the interesting part: Rank says he inherited the disease from his father’s dissolute living. Aha! Now instead of being a mere ailment, his condition becomes an indictment of parental misdeeds (a strong thematic statement in its own right) and, as we latter-day cynics can recognize, a coded reference to an entirely different pair of letters. Not TB, but VD. As I suggested earlier, syphilis and its various brethren were off-limits for most of the nineteenth century, so any references needed to be in code, as here. How many people suffer from consumption because their parents led immoral lives? Some, certainly, but inherited syphilis is much more likely. In fact, emboldened by his experiment here, Ibsen returned to the notion several years later in Ghosts (1881), in which he has a young man losing his mind as the result of inherited tertiary syphilis. Intergenerational tensions, responsibilities, and misdeeds are some of Ibsen’s abiding themes, so it’s not surprising that such an ailment would resonate with him.

Naturally, what gets encoded in a literary disease is largely up to the writer and the reader. When, in the course of Justine, the first novel of Lawrence Durrell’s Alexandria Quartet, the narrator’s lover, Melissa, succumbs to tuberculosis, he means something very different from what Ibsen means. Melissa, the dancer/escort/prostitute is a victim of life. Poverty, neglect, abuse, exploitation have all combined to grind her down, and the grinding nature of her illness—and of Darley’s (the narrator’s) inability to save her or even to recognize his responsibilities to her—stands as the physical expression of the way life and men have quite literally used her up. Moreover, her own acceptance of the disease, of the inevitability of her mortality and suffering, mirrors her self-sacrificing nature: perhaps it is best for everyone else, Darley especially, if she dies. What’s best for her never seems to enter her mind. In the third novel of the series, Mountolive, Leila Hosnani contracts smallpox, which she takes as a sign of divine judgment against her vanity and her marital lapse. Durrell, however, sees it otherwise, as symptomatic of the ravages that time and living take on us all. In each case, of course, we’re free to draw our own conclusions.

What about AIDS?

Every age has its special disease. The Romantics and Victorians had consumption; we have AIDS. For a while in the middle of the twentieth century, it looked like polio would be the disease of the century. Everyone knew people who died, or wound up on crutches, or lived in iron lungs because of that terrible, and terrifying, disease. Although I was born the year Dr. Jonas Salk made his blessed discovery of a vaccine, I can remember parents during my youth who still wouldn’t let their children go into a public swimming pool. Even when conquered, polio had a powerful grip on the imaginations of my parents’ generation. For some reason, though, that imagination did not become literary; polio rarely shows up in novels of the period.

Now AIDS, on the other hand, has been an epidemic that does occupy the writers of its time. Why? Let’s run the list. Picturesque? Certainly not, but it shares that terrible, dramatic wasting quality of consumption. Mysterious? It was when it showed up, and even now this virus that can mutate in infinite ways to thwart nearly any treatment eludes our efforts to corral it. Symbolic? Most definitely. AIDS is the mother lode of symbol and metaphor. Its tendency to lie dormant for so long, then make an appearance, its ability because of that dormant period to turn every victim into an unknowing carrier, its virtual one hundred percent mortality rates over the first decade or so of its history, all these things offer strong symbolic possibilities. The way it has visited itself disproportionately on young people, hit the gay community so hard, devastated so many people in the developing world, been a scourge in artistic circles—the tragedy and despair, but also the courage and resilience and compassion (or their lack) have provided metaphor, theme, and symbol as well as plot and situation for our writers. Because of the demographic distribution of its infection history, AIDS adds another property to its literary usage: the political angle. Nearly everybody who wants to can find something in HIV/AIDS that somehow works into their political view. Social and religious conservatives almost immediately saw the element of divine retribution, while AIDS activists saw the slow response of government as evidence of official hostility to ethnic and sexual constituencies hardest hit by the disease. That’s a lot of freight for a disease which is really just about transmission, incubation, and duration—which is what all diseases have always been about.

Given the highly charged nature of the public experience, we would expect to see AIDS show up in places occupied by other ailments in earlier times. Michael Cunningham’s novel The Hours (1998) is a reworking of Virginia Woolf’s modern classic, Mrs. Dalloway, in which a shell-shocked veteran of the Great War disintegrates and commits suicide. In the aftermath of that terrible war, shell shock was a hot-button medical item. Did it exist, were these men simply malingerers, were they predisposed to psychological unfitness, could they be cured, what had they seen that caused them but not others to succumb? Cunningham clearly can’t use shell shock and is even too far out of the Vietnam era for PTSD to have much resonance. Besides, he’s writing about the contemporary urban experience, as Woolf was doing earlier in the century, and part of that experience for him is the gay and lesbian community and part of that experience is HIV/AIDS. His suicide, therefore, is a patient with very advanced AIDS. Other than the illness that occasions them, the two deaths resemble each other greatly. We recognize in them a personal calamity that is particular to its time but that has the universality of great suffering and despair and courage, of a “victim” seeking to wrest control over his own life away from the condition that has controlled him. It’s a situation, Cunningham reminds us, that differs from age to age only in the specific details, not in the humanity those details reveal. That’s what happens when works get reenvisioned: we learn something about the age that produced the original as well as about our own.

Often, though, the most effective illness is the one the writer makes up. Fever—the non-Roman sort—worked like a charm in times past. The character merely contracted fever, took to her bed, and died in short or long order as the plot demanded, and there you were. The fever could represent the randomness of fate, the harshness of life, the unknowability of the mind of God, the playwright’s lack of imagination, any of a wide array of possibilities. Dickens kills off all sorts of characters with fevers that don’t get identified; of course, he had so many characters that he needed to dispatch some of them periodically just for housekeeping purposes. Poor little Paul Dombey succumbs with the sole purpose of breaking his father’s heart. Little Nell hovers between life and death for an unbearable real-time month as readers of the original serialized version waited for the next installment to be issued and reveal her fate. Edgar Allan Poe, who in real life saw plenty of tuberculosis, gives us a mystery disease in “The Masque of the Red Death.” It may be an encoding of TB or of some other malady, but chiefly it is what no real disease can ever be: exactly what the author wants it to be. Real illnesses come with baggage, which can be useful or at least overcome in a novel. A made-up illness, though, can say whatever its maker wants it to say.

It’s too bad modern writers lost the generic “fever” and the mystery malady when modern medicine got so it could identify virtually any microbe and thereby diagnose virtually any disease. This strikes me as a case where the cure is definitely worse than the disease, at least for literature.