The object of this essay is to illustrate, via the case of an important eighteenth-century novel, some of the peculiar ways in which literature and medicine interact in that period. In the first section I will explore some of the theoretical issues that arise as part of my attempt to explain how the disease consumption came to be represented as a glamorous Romantic malady, despite the its often horrible – and indeed terminal – reality (if one can use that word meaningfully).

As Dr Thomas Beddoes put it in his Essay on the Causes, Early Signs, and Prevention of Pulmonary Consumption at the very end of the eighteenth century :

Writers of romance (whether from ignorance or because it suits the tone of their narrative) exhibit the slow decline of the consumptive, as a state on which the fancy may agreeably repose and in which not much more misery is felt, than is expressed by a blossom, nipped by untimely frosts. Those who only see the sufferers in passing, are misled by the representation. And I have heard many persons thus prepossessed, after closely attending a sick friend, declare their surprise not less than their horror, at the unexpected scenes of varied and protracted misery which they have been condemned to witness. (Beddoes, Thomas, 1799, 6)

Consumption had become a literary disease by the late eighteenth century : novelists regularly depicted what Beddoes saw as deceptively easy and beautiful deaths by consumption, so many blossoms « nipped by untimely frosts ». Beddoes took on the role of the medical iconoclast, smashing to pieces the artistic myth so that people could be led out of ignorance, a blindness induced by foolish literary representations. Expecting a beautiful and easy death, the inexperienced carer would witness a drama of a different kind : « scenes of varied and protracted misery » that evoked surprise and horror rather than an agreeably poetic swoon.

What could lead to such an apparent gulf between representation and reality, well-structured narrative and horrific biological fact ? That is this article’s central question : how did such a killer disease come to be the object of glamorous representations in the Romantic period and beyond, and on such a large scale in Britain and America ? What was it about this condition that caused it to be so seductive to both a popular and elite readership ?

In seeking to comprehend the gulf between a murderous disease and its paradoxically glamorous – or at least positive – cultural representations, we need to make use of recent developments in the study of health and illness. « Narrative » has become a buzzword covering a multitude of perspectives in the theory and, more recently, practice of medicine, not to mention in the fields of literary and cultural studies. To cut a long and reasonably well-documented story short, recent writers on matters medical – such as Arthur Frank, Byron Good, Kathryn Montgomery Hunter, Arthur Kleinmann and David Morris – have followed the lead of linguistic philosophy and shown that our experience of health and illness alike is constructed through signs, primarily language¹. We develop stories, patterns of expectation, plots and sequences of images and metaphors, which form our perceptions of disease, pain, the importance of suffering and so on.

In this article my use of the word « narrative » is a tool to demonstrate how mythologies of illness arise partly because humans must explain disease through patterns of language : we have no choice in the matter. Susan Sontag has famously argued against the linkage of metaphor and illness but, according to our present understanding of illness, we have only language, only signs. It has been possible for consumption to become a powerful set of cultural narratives – more or less positive – precisely because the narratives we must generate about any perceived object are able to transcend or transform the physical world : even that of our own bodies. Put simply : people’s need to explain, contain, and even manipulate illness results in evolving discourses that may eventually detach themselves from what might be termed biomedical reality. What constitutes « reality » for the patient is another matter.

So – this is easy – we can happily settle into a postmodern linguistic relativism. Or can we ? According the extreme version of the linguistic turn, the body vanishes in a puff of post-structuralism ; the advance of biomedicine, which has eradicated illnesses like smallpox and found a cure for consumption itself, lies forgotten in a Derridean abyss. Having bashed the linguistically insensitive doctors, we can put the world to rights by making them read poetry and retrain in aromatherapy. Of course, if one is more sceptical about complete postmodern relativism, one might wonder about whether alternative therapies can effectively remove one’s cataract, or whether a suitably poetic surgeon might still be incompetent in her or his day-job.

In his Illness and Culture in the Postmodern Age, David Morris brings a heartening degree of common sense to the debate. Encouraged by feminist critics, who have been worried about denying the specific biological facts of maternity (for example), Morris reminds us of the existence of such things as bacteria, viruses, and disease entities – many, if not most of which, are explicable through medical science, a discipline that has made astounding progress in the last four hundred years. His mediation between the biomedical and cultural perspectives on disease calls for recognition that we are biologically grounded in bodies with certain inescapable material processes and that we express such biology through language and narrative. Representation, or story-telling, is not an added extra to our experience of health and illness, but fundamental.

The importance of Morris’ point for this study is that we need to acknowledge, not merely that consumption has been constructed or fabulated in some kind of mythical language, but that consumption has certain biological patterns that impose themselves on, and give rise to, cultural meanings of the disease. As it happens, consumption has symptoms – we might say genres or given plots of physical events – which came to be constructed through various discourses as beneficial to the recipient of the illness. Hence, this study uses that body of work (no pun intended) on medicine which has followed the importance of narrative in the famous « linguistic turn » taken by postmodernism and post-structuralism but, because consumption is a real disease phenomenon, forces a recognition that complete relativism is a throwing out of the biomedical baby with the cultural bathwater.

The methodology I employ here, therefore, acknowledges the specificity of the disease process and combines it with an analysis of that disease’s representational evolution at the level of culture. I combine a long-historical perspective with contemporary popular and specialist medical materials and relate them – symbiotically but not necessarily evenly – to literary texts. I show, to put it succinctly, how the particular medical entity in question (consumption) is a combination of narrative (the mythology of the good death, love melancholy), medical theory (the new medicine of the nerves), and biological « reality ».

Before we move to our case study, we need to fill some gaps in our history of consumption : in the Renaissance there were two crucial discourses on consumption – as the disease of love and the disease of the good and easy death, both of these necessary to explain how consumption gathered meaning and symbolic force in later periods, and indeed showing how consumption already was a significant cultural and literary factor for different social reasons.

The first discourse was that of consumption as love melancholy, as Shakespeare demonstrated in Much Ado About Nothing :

Benedick – Come, I will have thee, but by this light I take thee for pity.

Beatrice – I would not deny you, but by this good day I yield you great persuasion, and partly to save your life, for I was told you were in a consumption.

(Humphreys, (éd.), 1981, V.iv.96, p. 216)

By the time of this witty exchange, consumption was figured as the disease of love : as I will show in another study, Robert Burton and Gideon Harvey provide medical evidence, while a range of literary authors from Chaucer and Surrey to Margaret Cavendish and John Dryden demonstrate the strength of consumption’s metaphoric power even in this period.

The alternative (or even complementary) discourse of consumption described it as the disease of the good Christian death. The consumptive poet-pastors John Donne and George Herbert were described by Izaac Walton as holy sufferers of consumption as the spiritual disease while, in his Life Out of Death, A Sermon preached at Chelsey, on The recovery of an honourable Person in 1655, Thomas Fuller, a Protestant divine, offered various « Motives to patience in illness », including the following :

Secondly, consider that thy disease is far gentler and painless than what thou hast deserved, what is thy disease, a Consumption ? Indeed a certain messenger of death ; but know, that of all the Bayliffs, sent to arrest us to the debt of nature, none useth his prisoners with more civility and courtesie then the Consumption. (Fuller, 1655, 20-21)

The tradition of the ars moriendi also contributed to the popularity of consumption : Thomas Browne (in his Letter to a Friend), Thomas Fuller, Jeremy Taylor, Abraham Cowley, John Bunyan, Edward Taylor, Elizabeth Rowe, and even John Milton are all part of the lively debate about consumption’s appropriateness for the dying Christian in the literature of the Renaissance and early eighteenth century.

Coming to the period of my brief case study today, it is as well to point out that, despite being thought of as the Romantic disease nowadays, narratives of consumption were both common and powerful in the Enlightenment. The medicine of the nerves had a strong impact on representations of consumption, including on the influential image of Richardson’s dying Clarissa, who combines a good death and the typically female death of pining for a lost love object in a form of Neo-Platonic ascension from secular to religious love. Consumption becomes the physical disease of sensibility in both literature and medicine, as a number of writers, including Tobias Smollett, Anna Seward, Frances Brooke and Laurence Sterne amply demonstrate.

We commence our case study with a consideration of the medical changes which, in turn, were to affect the perceptions and narratives of consumption. I begin with two quotations :

You must see that I have been consuming from day to day.

(Samuel Richardson, Clarissa ; or, the history of a young lady, 1751, vol. 7, XCVIII, 376)

I have always foretold, that these Symptoms [of nervous disease] (especially in tender, delicat, lively young Persons) would terminat in a real sensible Phthisis Pulmonum. [= Consumption].

(George Cheyne, 1742, The Natural Method of Cureing the Diseases of the Body, and the disorders of the mind depending on the body, 185-87 – « A Consumption »)

By the end of the eighteenth century, consumption is not only the symbolic disease of the lover or a desired condition for the dying Christian, but also the glamorous sign of female beauty. Thomas Beddoes, maverick but fashionable physician and husband of novelist Maria Edgeworth’s sister, complains that the female boarding school « has greatly contributed to multiply the genteel, linear, consumptive make, now or lately so much in request »². Fat is certainly out of fashion by 1799, while the consumptive look is in.

Why ? What happened in the eighteenth century – the « enlightened » age – to persuade women of all classes that they should lose their pleasing plumpness and, in a vogue which is still with us today, imitate the « linear, consumptive make » ? The answer to this question is inevitably complex, and requires a knowledge of shifting medical ideas about the body at this time. At the end of the seventeenth century new modes of medical thinking came into being, notably the partial displacement of the ancient humoural theory by a mechanistic Newtonian model and then, around mid-century, an increasingly dominant physiology of the « nerves ». The medicine of « nervous sensibility » made a powerful impact in the social and literary spheres, not only as manifested in the cult of the sentimental – in which the finer feelings of the « nervous » better sort were allowed fashionable indulgence – but also in the wider « culture of sensibility », to use Ben Barker-Benfield’s phrase³.

With these developments came a change in the status of consumption in both medicine and metaphor. Consumption was transformed from a (humoural) disease symbolising grossness and filth, to one that embodied the aesthetic and the spiritual – largely through women. In contrast with humoural theory, which had regarded the heart, liver and bowels as more « nervous » and important, eighteenth-century nerve theory substituted the brain and nervous system as dominant entities. For men too consumption became the mark of refinement, but generally of a different sort : consumptive males were to be more creative, intelligent, poetic : the shapers of representations ; women became those beautiful images. Consumption itself had been metaphorically purified as the ideal physical disease of sensibility.

Medical Perspectives : Cheyne, Nerves and Consumptions

George Cheyne was a society doctor, treating the Great and the Good for their various ailments. Striking a pose – with good reason given his astounding fluctuations in weight – as a fellow sufferer, he gained the attention, sympathy and patronage of his middle and upper-class readers, among them Samuel Richardson (who even published Cheyne’s writings), Alexander Pope, John Wesley, David Hume, Laurence Sterne and Tobias Smollett. Cheyne was therefore a conduit for medical ideas to the literary and popular culture of the eighteenth century. The fact that he himself was both a doctor and sufferer of nervous disease, as well as a good literary stylist, meant that he was able to bridge the crucial divide between the world of elite medicine, a world often mistrusted by patients – given its lack of effectiveness in treating disease – and the realm of the suffering individual. He was able to appropriate the power of both perspectives on the illness narrative for his own writing, gaining an authenticity and hence authority that other medical writers could not match. Such an advantageous cultural hybridity gave Cheyne a means to influence representations of consumption far beyond his own writings. His primary message was that the consumerism and luxurious lifestyle promoted by this new « consumer century » had deleterious effects upon the body, engendering all kinds of psychological disorders which he defined as the new English Malady. These problems of the mind in turn could generate further physical deterioration. Tea, coffee, chocolate, rich sauces, too much liquor, a sedentary or idle lifestyle : all these elements of highliving British culture contributed to a weakening of the system.

Cheyne’s Natural Method of Cureing the Diseases of the Body, and the disorders of the mind depending on the body (1742) made the crucial claim that consumption was the most significant disease affecting « the Young and Delicat » in Britain next to nervous and hysteric ones : « indeed there is such a connexion between high Hysterics with fits, and a Phthisis Pulmonum [consumption of the lungs] with Tubercles, that they generally and naturally slide into one another ; and both are the fatal Distempers, that afflict or destroy the noblest Spirits, and finest Geniuses, of this Island, as every one who has been attentive must have observ’d » (Cheyne, 1742, 185-7 – « A Consumption »). For Cheyne « great Nervous Symptoms » were « the first Stage, or Elements of a Phthisis ». He reinforced the idea that a consumption of the lungs was a disease that often struck the young, while also making a firm and newly formulated link between the English Malady (that cluster of psychological conditions arising from disorder of the nerves alternately called hysteria, hypochondria, melancholia and the Vapours) and consumption.

In the Renaissance, consumption could emanate from melancholy, but, in this new eighteenth-century context defined by Cheyne, it is not only that which causes phthisis. Here, he transformed consumption and the « nerves » into signs of greater sensibility and social distinction, even as he identified its debilitating effects. If you had consumption, he said, you were naturally likely to be a noble spirit or a fine Genius, and he made sure that his audience understood the point : « I have always foretold, that these Symptoms (especially in tender, delicat, lively young Persons) would terminat in a real sensible Phthisis Pulmonum » – if not prevented. Should his austere « cooling » regimen be applied before the disorder took too severe a hold, it would preserve « some of the noblest and brightest Spirits this Sage or Country produces » (Cheyne, 1742, 185-87).

A point to be stressed here is that, for Cheyne and others after him, thin was good, especially in women : it showed that you had a delicate sensibility, finer nerves, and appropriately unworldly, spiritualised consumptive frame. Burke’s definition of the beautiful also praised female delicacy bordering on illness.

The important progression from nervous disorder to consumptive illness was also stressed by later physicians of the nerves, such as the influential Robert Whytt. In his Observations on the nature, causes and cure of those disorders which have been commonly called Nervous, Hypochondriac, or Hysteric (1765), he specified that « a phthisis pulmonalis may also be the consequence of nervous disorders, when the morbid matter producing them falls chiefly upon the lungs » (Whytt, 1765, 237). In the same volume he also identified the possibility of « a nervous atrophy », which involved « a marasmus or sensible wasting of the body » that lacked many of the precise symptoms (such as sweating and fever) of a consumption of the lungs (Whytt, 1765, 253).

Cheyne, like the physicians before him, recognised that the passions could take their toll on the nerves. Chronic passions like « long Grief, dark Melancholy, hopeless natural Love » and religious melancholy (in which the subject became fixated on the after-life) « waste » and « wear out » the nervous system (Cheyne, 1724, 155-57). People with rigid fibres were most susceptible to slow and lasting passions, « which secretly consume them as chronical Diseases do » (Cheyne, 1724, 100). One of consumption’s defining characteristics was its lengthy course and insidious progress.

Clarissa’s Consumption

Early heroines of the novel, like Moll Flanders, could be threatened by consumption if suffering from some form of love melancholy, or at least loss of their desired object. Such descriptions of consumption and consumptive death tended to be brief, concentrating more on the emotional logic of the event rather than the aesthetics of the act itself. The death of Clarissa, the famous heroine of Samuel Richardson’s novel of the same name, expanded the possibilities of consumptive death by combining elements of the love melancholy tradition, aspects of the Protestant good and easy death, and Cheyne’s new discourse of sensibility. Clarissa would provide the template for future sentimental heroines in Europe and America, profoundly influencing representations of female consumptive death – it is difficult to overstate Clarissa’s importance – in the Romantic and Victorian periods as well as its own century⁴. By providing an extended process of aestheticised consumptive death, Richardson showed a new way of understanding the relationship between disease and gender⁵.

Clarissa’s death has been the source of much debate, resistant as it is to any scientific, twenty-first century, retrospective diagnosis⁶. I myself have previously stated that Clarissa does not die of consumption, or at least an « earthly disease » : I was wrong⁷. The medicine of the eighteenth century, as in the preceding ones, did not share our present mainstream understanding of illness as a product of purely physical disorder, despite tendencies in that direction. Nor was a disease separable from the individual’s constitution, both physical and moral : a whole complex of factors, from the hereditary to environmental, from emotional to occupational, were thought to be contributory to health or illness. Nor, as we have already seen, were diseases easy to separate from one another : one state could segue into another when the conditions were appropriate : the nerves to consumption, for example, or even different types of consumption. Consequently, attempts to pigeon-hole Clarissa’s death as a twenty-first century medical condition – such as anorexia nervosa – are doomed to failure. Clarissa’s demise is constructed through complex and highly gendered discourses of consumptive death, even though her illness is not described in a way that doctors in our present century would find satisfactory.

Various factors combine to cause Clarissa’s disease, the primary one being identified as grief by various people in the novel, including Clarissa herself : « Death from grief was, she believed, the slowest of deaths » (Richardson, 1751, vol. 7, XCVIII, 376). Consumption was perceived as chronic in its progress, a sense that its cognate « decline » echoed. Medical opinion concurs with her self-diagnosis : Goddard the apothecary states that she will recover if she wishes, but « so much grief, as you seem to indulge, is enough to impair the most vigorous health, and to wear out the strongest constitution » (Richardson, 1751, vol. 6, XCVIII, 400). Of course at this point Goddard is mistaken in his belief that his recommended regimen can cure Clarissa because he does not fully comprehend her personal situation and the power of her emotions. Belford anticipates this outcome as he warns Lovelace, the rake whose abduction of Clarissa causes the problem, of the probable effects of his actions : « what I most apprehend, is, that with her own hand, in resentment of the perpetrated outrage, she (like another Lucretia) will assert the purity of her heart : Or, if her piety preserve her from this violence, that wasting grief will soon put a period to her days » (Richardson, 1751, Vol. 4, LVI, 342)⁸. Belford shows that a cultural template already exists for Clarissa’s situation : Clarissa grieves for the illegitimate loss of her virginity, but this grief is inserted into the traditional symptoms of love and religious melancholy.

After all, she has lost the secular love relationship to which she aspired in the first place : Lovelace was once the object of her desire. Indeed her humane physician has no doubt in declaring that « her heart’s broken : she’ll die… there’s no saving her » (Richardson, 1751, vol. 7, LVII, 203). As with so many other women, once her earthly sexual goals are frustrated and her loved one removed – for whatever reason – her only respectable option is to turn to religious consolation. The Neo-Platonic tradition of secular love leading one to a love of God provides a more philosophically cogent explanation for such a transition. This displacement from secular to religious love does not evade the festering grief felt by Clarissa, however. As Cheyne put it : « long Grief, dark Melancholy, hopeless natural Love » and religious melancholy « waste » and « wear out » the nervous system (Cheyne, 1724, 155-57). Cheyne, and the physicians writing before him, assumed as a commonplace that grief and love melancholy would result in consumptions, unless the emotion was so strong that suicide cut short the process of wasting⁹.

Clarissa’s symptomatology is peculiarly suited to Richardson’s narrative requirements for his novel ; she suffers from a consumption of a certain form. In Clarissa’s death, the symptoms of the disease are minimal, although they do change the longer it progresses. The most striking initial aspect is consequent on its psychological motivation : Clarissa herself states that she has « no appetite » (Richardson, 1751, Vol. 6, XCVIII, 400). As a result, she loses weight without losing beauty ; Belford reports to Lovelace : « could she have prevailed upon herself, I know that the sight of her would have been as affecting to you, as your visit could have been to her ; when you had seen to what a lovely skeleton (for she is really lovely still, nor can she, with such a form and features, be otherwise) you have, in a few weeks, reduced one of the most charming women in the world ; and that in the full bloom of her youth and beauty » (Richardson, 1751, Vol. 7, L, 172). The paradox of the « lovely skeleton » is crucial for later representations of consumptive women : Clarissa’s beauty is partly preserved by consumption’s ability to merely thin the body ; smallpox and other like maladies would scar the skin as Lady Mary Wortley Montagu’s poem on the disastrous effects on her own beauty from smallpox shows (Montagu, 1747).

Clarissa’s moral beauty requires that no such external stigma occur, despite the fact that others in the eighteenth century had argued that the moral should be separate from the physical¹⁰. Her youth (she is nineteen when she dies) is also stressed as a component of this beauty : consumption was commonly assumed to be a disease of the young by doctors and lay people alike, especially in its relation to love. The poignant contrast of death and the bloom of youth had long been employed for its dramatic pathos as well as its role in the Christian vanitas tradition, in which the juxtaposition of life at its height with decay and death stresses the vanity of disregarding the next life¹¹. Clarissa’s instance gives a new energy to these clichés in the eighteenth century : here they are employed to illustrate the dastardly effects of rakish behaviour on a moral and « sensible » young lady, as well as lending her a further allure in her sickness.

Other symptoms hint more specifically at a consumption of the lungs. Doctor H. responds to her « shortness of breath (which she attributed to inward decay precipitated by her late harasses…) » by recommending the age-old remedy for disorders of the lungs : « go into the air ». However, because the consumption is a sign of a deeper psychological problem, both physician and patient know that this advice will do no good « in such a malady as mine » (Richardson, Samuel, 1751, Vol. 7, LXXII, 254-55). This is as technically medical as the representation of her condition is allowed to become : « shortness of breath » falls far short of many of the terrible problems that could beset those suffering from a consumption of the lungs. There is no spitting of blood, no violent coughing, no nasty matter being expectorated from the lungs, no hectic fevers and, although one could claim a « facies Hippocratica » or wasted, skeletal features for Clarissa, her beauty is not affected. What we have instead is one of the most symptomless forms of consumption ; so symptomless in fact, that a specific medical term is not used, because it would divert attention away from the emotional and spiritual focus of Clarissa’s death as well as allowing a certain latitude in Richardson’s manipulation of physical symptoms for narrative effect.

Another reason no one thinks fit to name Clarissa’s disease is because in many ways it was too obvious to her contemporaries, familiar as they were with the tradition of love melancholy described in the first chapter. J. F. Zückert, a physician writing in 1768, observed that Clarissa’s « slow consumption » is a classic example of the physical consequences of « heart-break »¹². However, it is notable that Clarissa herself is far less afraid to discuss her condition than the tactful and usually « silent » doctors within the novel (Richardson, Samuel, 1751, Vol. 7, LVII, 206). It is she who forces the physician to tell her that she has only « a fortnight or three weeks » to live (Richardson, Samuel, 1751, Vol. 7, LVII, 206), she who takes control of her own treatment, and it is she who comes closest to naming her condition technically : she tells Dr H. that « you must see that I have been consuming from day to day ; and now, if I can judge by what I feel in myself… I cannot continue long » (Richardson, Samuel, 1751, Vol. 7, LXXII, 255). No one has a better understanding of her consuming grief or her consumptive illness narrative than Clarissa herself : she knows what manner of consumption she suffers and its duration as she claims the privilege of the person of sensibility to prioritise her own experience of her body rather than the more or less « insensible » analyses of the largely helpless doctors.

To conclude in general : I hope I have shown that medicine and literature in this period are inseparable, and that there was a constant interaction between literary and medical texts and their authors, and that these texts had effects upon the general readership (as well as being affected by that popular culture of medicine). My particular point is that the popular understanding (and even experience of) consumption was generated through a network of such relationships, such narratives, and that such a network was produced over a long historical period as well as by contemporary theories of medicine.