TB or not TB: the literature of consumption | John Self

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This article is taken from the March 2022 issue of The Critic. To get the full magazine why not subscribe? Right now we’re offering five issue for just £10.


Relax, everyone. Experts assure us that the danger has peaked, or will soon peak, and the number of new Covid novels will slowly decline. We shall move from a pandemic to an endemic phase, where fiction featuring scenes of lockdown and working from home will be no more cause for concern than another debut about a toxic relationship.

Even by the standards of our emotionally incontinent, logorrhoeic age, the Covid fiction variant has overwhelmed our bookselling services more quickly than anyone anticipated. But there is no need for drastic measures such as placing protective caps over writers’ pen nibs; the wave will pass, just as other pandemic fiction has.

Not all world-stopping diseases are equal, however. What about the others? The influenza pandemic of 1918-20, despite killing around 50 million people worldwide, has left little permanent mark on imaginative literature. Its most notable records are non-fiction, from Mary McCarthy’s Memories of a Catholic Girlhood (both her parents died of Spanish flu when she was six) to Ernest Hemingway’s Death in the Afternoon. In fiction even the surviving strains are not widely read, such as Katherine Anne Porter’s “nearly pure autobiography” novella Pale Horse, Pale Rider and William Maxwell’s novel They Came Like Swallows.

No infectious disease has left its scars on a body of literature like tuberculosis

AIDS has fared better, with big bruising writers like Alan Hollinghurst, Colm Tóibín, Anne Enright and Adam Mars-Jones all wrestling with it in fiction. But for longevity and spread, no infectious disease has left its scars on a body of literature like tuberculosis (TB).

This is, first, because rather than having a short sharp peak, like Spanish flu and Covid, TB’s reign was both long and high: it was responsible for one in seven deaths in Europe at its peak. Its main treatment was the rest cure of a sanatorium, available only to the wealthy rather than those living in the crowded conditions that were most likely to incubate it in the first place (Joseph Conrad described the popular sanatorium resort of Davos Platz as a place “where the modern Dance of Death goes on in expensive hotels”).

The second reason for its prominence is that, as well as being unignorable in society, TB caused the early deaths of many of our greatest writers, including Anton Chekhov, Franz Kafka and Katherine Mansfield. And being a chronic disease — Kafka had it for seven years before it killed him, Mansfield for 12 — it transformed their lives as well as causing their deaths; so they were able to write about it, both in fiction and in letters and diaries.

Its literary record, in other words, is as complete as we could wish. Even the common name for TB in the nineteenth century and before — consumption — has an irresistible literary flavour, so evocative and dramatic, and named for the way an advanced case of the disease eats into the bronchial passages and erodes the blood vessels.

This gave rise to the characteristic symptom which Chekhov described in a letter of 1897: “Hardly had we sat down to the table when a vigorous flow of blood started streaming from my throat.” The disease had a mythical quality: in Stendhal’s 1827 novel Armance, a character’s mother refused to say “tuberculosis”, fearing that naming it would invoke its worst effects.

It’s timely, then, that this month sees the re-issue of what might have been the last great TB novel published while the disease was still a live danger in this country: A. E. Ellis’s The Rack (1958).

Ellis was the pseudonym of Derek Lindsay, one of the last people in England to undergo the traditional sanatorium treatment for TB before antibiotics became widely available. The Rack is long, stately and evocative of the grim effects of TB on the sanatorium patients and others (even some of the doctors die): of the disease, but also of the treatment and the boredom of the rest cure.

But it is not without comedy, and the New York Times on its original publication said that “in every chapter of this remarkable book Mr Ellis has wrung music out of anguish”, while Graham Greene placed it in the company of Ulysses, Clarissa and Great Expectations.

The Rack was inspired by Thomas Mann’s monumental The Magic Mountain (1924), which remains the highest peak of the genre, but Ellis went low where Mann went high, forcing his character Paul Davenant into the bodily suffering that Mann’s dilettante Hans Castorp never endured. Castorp, like Mann himself when he contracted TB at a sanatorium his wife was attending, had a mild case: just enough to flavour the novel, as it were. Mann was more interested in the experience as an education rather than an ordeal: as his wry narrator says in the introduction to The Magic Mountain, “only thoroughness can be truly entertaining”.

The torturous nature of Davenant’s experiences in The Rack — I am not referring to the frequent passages of untranslated French, directed at a generation of readers who knew their oignons — might qualify it to be called Kafkaesque, were that word not so devalued that, as Martin Amis put it, it’s now used to “describe a train delay or a queue in the post office”.

Handily, Kafka had his own TB experience — he died from it in the year The Magic Mountain was published — which he described in letters with characteristic vim. He believed that the haemoptysis symptom (spitting blood) was an outcrop of his mental suffering — “secretly I don’t believe this illness to be tuberculosis … but rather a sign of my general bankruptcy” — and found the gruelling sanatorium treatment — of course he did — as much of a trial as the disease. “Former hangmen dislocate your arm if you resist injections.” This is a prime example of how any experience in extremis magnifies personality traits.

Similarly, the spirited Katherine Mansfield did not mince words when she recorded some of her treatment in her diary in 1919: “Saw two of the doctors — an ass and an ass.” Chekhov had TB for 20 years before it finally killed him, but he produced all his greatest work during this period of progressive ill health.

Kafka died at the age of 40, Chekhov at 44, Mansfield at 34; TB infected and killed people young. This was one factor — the glow in the cheeks as the disease developed was another — that contributed to its being seen for many years as a romantic affliction; hence the image of the “beautiful consumptive”. Charlotte Brontë wrote that “consumption, I am aware, is a flattering malady”. Mann’s Hans Castorp associated it with genius, and even its own victims such as John Keats — dead at 25 — romanticised its effects: “youth grows pale, and spectre-thin, and dies”. His friend Percy Bysshe Shelley affirmed it: “Ah, even in death he is beautiful, beautiful in death, as one that hath fallen on sleep.”

All this was at a time when the source of TB was not understood — it wasn’t until 1882 that the bacterium that causes it was discovered — and so it was seen not as an acquired disease but as an illness intrinsic to the inherent disposition of the sufferer. It is not too far a stretch, after all, to link a waifish aesthete and a wasting disease (French dandy and aesthetic provocateur Théophile Gautier said that in his youth, “I could not have accepted as a lyrical poet anyone weighing more than ninety-nine pounds”).

TB dominated illness in literature throughout the eighteenth and nineteenth centuries

TB dominated illness in literature throughout the eighteenth and nineteenth centuries, with Charles Dickens, Samuel Richardson and Elizabeth Gaskell all putting their characters through its gruelling mill. Toward the middle of the twentieth century, the novels became less frequent as TB rates began to fall.

The most famous of England’s late literary victims of TB was George Orwell, who completed Nineteen Eighty-Four when staying on the Scottish island of Jura in the late 1940s; he hoped the island would be a clean environment that would help him recover (when he was taken to hospital later, he had to have his typewriter confiscated to enforce rest).

Orwell was the first TB patient in Scotland to receive the then-new wonder drug streptomycin. But he suffered severe side effects which meant the treatment had to be discontinued. One little-read but excellent example of a late TB novel is Scarred Hearts (1937) by the Romanian writer, Max Blecher, who died of TB at the age of 29. It emphasises the community nature of the sanatorium — an enforced setting for a disparate range of characters is, of course, a kernel of good fiction — where “the patients here lead normal lives. They dress normally, go about on the streets … only they do it all lying down, that’s all …”

The sanatorium is a form of exile, but some patients succumb to a sort of Stockholm syndrome, and don’t want to leave. One woman in Scarred Hearts who is cured but still walks badly, would “prefer to remain here among the sick, where everyone has something wrong with them, than become an object of curiosity among the healthy”.

Now, in the West, TB is of literary interest only as a historical device. Linda Grant’s 2016 novel The Dark Circle — recommended as an aperitif for those who find The Rack or The Magic Mountain initially daunting — is set in an English sanatorium in the period 1949-51, when the twin-pronged approach of effective drug treatments and the new National Health Service made TB into a passing problem only.

As for A. E. Ellis, he recovered from his bout of TB and lived a long life, dying in 2000 at the age of 80. But, despite mixed success with a couple of plays in the 1970s, he never published another novel. The Rack, it seems, had consumed him.

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