Nothing Becomes Something

Thomas Laqueur

  • When Breath Becomes Air by Paul Kalanithi
    Bodley Head, 228 pp, £12.99, February 2016, ISBN 978 1 84792 367 7

We live in the golden age of pathography. Before the middle of the 20th century there was very little writing devoted to the experience of living with illness. There were many reports of bodily ills in the letters and diaries of 18th-century men and women but no sustained narratives of disease. Autobiographies in the shadow of death were rare and brief. In David Hume’s six-page-long account of his life there are four sentences about his impending end: ‘I was struck with a disorder in my bowels which at first gave me no alarm, but has since, as I apprehend it, become mortal and incurable. I now reckon upon a speedy dissolution.’ Despite his physical decline, he continues,‘I possess the same ardour as ever in study, and the same gaiety in company. I consider, besides, that a man of 65, by dying, cuts off only a few years of infirmities.’ If he could choose to live a period of his life over again he might choose this one, the last. For Hume, nothing more needed to be said about waiting for death, a subject that we moderns have turned into a veritable genre.

The 19th century brought a few memoirs of invalidism, like Harriet Martineau’s Life in the Sickroom, which reports on her five-year-long retreat from an active life. And there were occasional diaries of illness: Alphonse Daudet’s In the Land of Pain, written between 1887 and 1895, two years before he died in agony from tertiary syphilis, foreshadows the rise of disease as a kind of character, an antagonist to be faced and reckoned with (‘the first moves of an illness that’s sounding me out, choosing its ground’). At about the same time, Tolstoy was creating in fiction pathography’s foundational narrative form. Memoirs of illness and dying almost always begin, as The Death of Ivan Ilyich does, at the moment when nothing – the little ache, the ordinary vagaries of living in a body – turns out to be something. Ivan bumped his side as he fell while adjusting a curtain; it hurt a bit but he continued in good health that day and the next; then one day he wasn’t. He understood now that the trite syllogism in his school logic textbook did not apply exclusively to Caius or to humans in general but to him in particular. ‘All men are mortal; Caius is a man; therefore Caius is mortal.’ Ivan tried to get back to his old self – the one that existed before universal truth became personal – but could not. Tolstoy defines the moment – the crossing of a border into the land or the dimension of mortality – that is at the heart of all subsequent writing about disease. It is an odd moment. All of us can easily look up how long the actuaries with their well-wrought life tables expect us to live. But once the disease that is the agent of our demise declares itself, it transforms everything in our world. Tolstoy also describes the great gap Ivan feels between his physicians – for whom death and disease are the substance of their profession – and himself, the dying man for whom it is everything. All the stuff of modern disease narratives is here already in the 1880s: disputes of diagnosis and treatment among the doctors; well-meaning condescension. ‘What sort of night have you had?’ his doctor asks. Ivan looks at him, ‘as much as to say: “Are you really never ashamed of lying?”’

For almost a hundred years Ivan Ilyich had few literary followers. Forty years on, in 1926, Virginia Woolf noted how astonishing it was that ‘illness has not taken its place with love and battle and jealousy among the prime themes of literature’. What could be more weighty? In illness ‘we go down in the pit of death and feel the waters of annihilation close above our heads’; ‘when the lights of health go down’, ‘undiscovered countries’ come into view. And yet, for the next fifty years there were few reports on these seemingly uncharted lands. John Gunther’s bestselling 1949 memoir, Death Be Not Proud, about the death from cancer of his brilliant 17-year-old son, is a notable exception. Then, by the end of the 20th century, book-length accounts of illness were suddenly everywhere: more than thirty accounts of Aids and more than a hundred of cancer alone were published in the United States between 1988 and 1992. Their numbers keep growing and their scope expanding. Now there is even beginning to be a serious literature on the illness and death of pets, especially dogs, through which the emotional and ethical issues around the end of life, theirs and ours, can be newly imagined.[*] The proliferation is so noticeable that writers despair of rising above cliché. In Jenny Diski’s first dispatches to the LRB from the ‘Cancer World’ that she had just entered she despairs of being able to say anything new: ‘I was handed my script, though all the lines were known already and the moves were paced out. There were no novel responses possible. Absolutely none that I could think of.’ But, as she reminds herself, she is a writer and writing is what writers do. ‘Now, cancer is what I do, too.’ And so: ‘A fucking cancer diary? Another fucking cancer diary.’[†]

I don’t mean to claim that the forty-year-old form that is now so familiar came from nowhere or from Tolstoy’s imagination. It is to some extent an expansion of those accounts of last moments and last words to which people in most literate cultures have been attracted for millennia. I think sometimes of the great French historian Marc Bloch on the brink of death: the teenage boy to whom he was handcuffed as the two were about to be executed by the SS in the summer of 1944 was terrified. ‘This will hurt,’ the boy cried. ‘No, my boy, it won’t hurt,’ Bloch is reported to have assured him. He was, in general, wrong. People have known for thousands of years that a meaningful, thoughtful, painless and even conscious death is largely the luck of the physiological draw at its most capricious. Yet we pay attention to how others have died in the hope of something better or for assurance that, since others have managed, so will we. Last words and behaviour seem irresistibly exemplary and consequential, a testimony to the truth or falseness of what we believe or live by. Dying – and last moments in particular – bears witness to what really matters. At stake in what we might think of as the ancestor of the pathography – the deathbed account – are the answers to big questions: can one die at peace without God, for example. The matter has been debated since the Enlightenment, reached a peak of public attention in battles between believers and free-thinkers in the 19th century, and remains alive in some circles today. There are many, many more obstacles to dying peacefully than an absence of faith, but, as Christopher Hitchens noted with some pleasure, there was a website that invited ‘potential punters’ to place bets on whether he would repudiate his atheism before he died or ‘take its hellish consequences’. He died an atheist.

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[*] See Jessica Pierce’s The Last Walk: Reflections on Our Pets at the End of Their Lives (2012).

[†] These pieces were published in book form as In Gratitude (Bloomsbury, 256 pp., £16.99, April, 978 1 4088 7990 0).