[In the following essay, Jelly argues that modern fiction has become increasingly concerned with portraying characters who are afflicted with disease.]

It probably began because Flaubert's father was Resident Surgeon at the Rouen Hospital, which may not constitute all the cause but makes a convenient start for what is now a universal condition: the fiction of the world is full of sickness. This might be thought inevitable amidst the general introspection of our time if we were not bound by the honour due to prophets to think that fictional introspection should precede, not follow, its public appearance. If this is so, then the European attitude to illness will deteriorate further unless these novelist-seers prove wrong; and this is possible because such prophecy is only worked out by hindsight. For example, Stendhal gave his forecast that the released bourgeois energy of his day, fortified with their youth and excellent education, would in no time control the professions, administration, universities, churches and academies, while the appreciation of art would remain in the hands of the elegant relics of the ancien regime. This worked out pretty accurately for an important part of the century's French culture and Daumier shows the fact by drawing the patron erect and cavalry and the painter tuberculous. True, the emerging class produced their own Balzacian crust but there was an equally powerful clique which kept aesthetics an acquired taste which only the initiates could share. Such an exclusive attitude was exemplified by the Goncourts, Flaubert himself and, amongst others, Degas, Proust and Gide; none of them were absolute aristocrats, but all were of independent means, quintessential, representing a type of metropolitan amateur who is almost absent today, that is, extinguished within half a century of his peak.

Just as the fiction of this group had a weakness for the bedside, so Madame Bovary, one of their products, is the archetype of the clinical novel and it is necessary to emphasise the following facts in this side of its construction. First, and only to be expected, its clinical detail is extremely accurate; secondly, Flaubert makes full use of the clinical incidents to influence the reader; thus, the clubfoot tragedy makes Charles a fool while the hysteria and ultimate suicide of Emma destroy any sympathy the reader may still feel for her; thirdly, the clinical features are unobtrusive although so important, and Flaubert could have easily raised a defence against these charges. For all that, he undoubtedly set a fashion in the matter and earlier novels had very rarely been clinical; Werther is not, in spite of a suicide climax, nor is Wilhelm Meister, and although Stendhal is self-clinical in his journal he is much less so in the novels. But after Madame Bovary it is hard to find a major novelist who is not also a clinician, some, like Proust, more obviously so than others. Much of this clinical writing is extremely skilful and Svevo's Confessions of Zeno is a masterpiece of the genus. Supposedly written to the request of the narrator's psychiatrist Svevo allows himself fair comment on his master's works of reference, from Trieste in the early 'twenties; psychoanalysis is 'not difficult to understand, but very boring'. He is even more cunning than Flaubert in concealing sickness but a masterly description of Basedow's disease (exophthalmic goitre) can be pieced together and how glad this makes the writer that he married the other sister. Lawrence was also a good and careful clinician and with him Ford Madox Ford springs to mind, extending the scale in Last Post by laying down the ageing Tietjens after a stroke which has left him with understanding but no speech, an ingenious solution to the problem of providing a critical eye without the active liability of belonging to a partaking character.

More modern novelists have transgressed this technical and unobtrusive use of malady and it is the dangers of the present licence which need review. Requiring that all deal with people, novels otherwise whittle down into essays of either thought, word or deed, and on each of these primary elements the influence of sickness can now be seen.

Novels of thought set out to illuminate a human aspect or situation and it is remarkable to realise that what is agreed or accepted in the sphere of invalid morality has arrived in our society through the gates of fiction or drama: for there are simply no other moral rules of sickness available. The Christian faith lays down no law on the matter but blows with the vogue, breezy and muscular fifty years ago, subconscious and psychosomatic today; doctors themselves have always funked the issue and when they get moral they turn to hieratics (Hippocrates), Christianity (Thomas Browne) or animal urge (the modern psycho-social-behaviourists). A code of invalid conduct is springing up from the tall pot of national administration but it is a grasping, material code, strengthening the courage perhaps but not the will to get well. So, rightly or wrongly, fiction has moulded our attitude to illness more than anything else over the last hundred years. Pictorial art began to enter the field as a rival but luckily desisted after realising it could only end in pathos while fiction and drama with their slower evolvement and less instantaneous use of contrast have fattened, or fastened, nicely on the problem.

Fastening is more apt than fattening but not wholly so because novels while getting thinner have not always shown more grip on the invalid situation. To this there are exceptions and, using the world of the T.B. sanatorium as a constant, it is profitable to judge Thomas Mann's The Magic Mountain against two modern novels on the same theme, The Rack (A. E. Ellis) and The Vodi (John Braine).

The Magic Mountain was published in 1924, although it refers to events up to 1914; it has therefore a pointed reference to the sick society of Europe as well as the sick individuals within the cover. As a document of illness it is unsurpassed and it should be compulsory reading for all medical students in the West, all officials, voluntary or paid, in the Health Service, and indeed a film of it should be made for everyone else in 'British Health' who cannot ride its 700 pages. Almost every aspect of the invalid problem is studied, with the appropriate emphasis that each has a different meaning for the hale spectator (reader), the professional attendant, and the patient. For clarity, the tradition of European thought is sharply divided by Mann through the use of two bitter opponents: first, Settenbrini, Italian, freemason, liberal, humanist and classic, with the key words of Renaissance, Risorgimento, reason, enlightenment, democracy (nationalism), and progress; and against him Naphta, Pauline, Jew, Jesuit, proselyte, fanatic, and scholastic, with the key words of Spirit, Faith and Passion.

Invalid morality is only one of the themes this book approaches but it is a recurring motif throughout and can be traced as follows. The first reference comes from the young hero, Hans Castorp, who has found himself in the sanatorium more or less by accident. He expresses amazement that his fellow guests, or patients, can be stupid as well as ill. This is something he cannot understand: surely the process of being ill is a refinement to the individual. Settenbrini explains that there is no logical reason why illness should bring refinement or intelligence, except the relic of old superstition that infirmity carries a pass to heaven and well-being comes from the devil. This point is extraordinarily important and Mann is wise to clarify it at the outset; of course the superstition remains as it was and both the later writers, Ellis and Braine, and Gide before them, fall cellar-steps through the hatch.

To return to The Magic Mountain; Settenbrini is allowed full control for the first half of the book while the hero becomes an accepted patient and falls silently in love with another inmate. He listens to an analyst's lecture, disease is love transformed; he wonders if physicians can still be physicians if they are themselves ill, if their spiritual mastery can be retained; and he begins to realise that disease makes men more physical and leaves them with nothing but body: but these are sidelines to the Settenbrini doctrine. Hans is confined to bed when the humanist arrives and characteristically floods the room with electric light. He chides Hans and hints that he has been fooled by the medical management. Hans tackles the progressive; do you believe in science, are there spots on your own x-ray plate, are you really ill yourself? At this Settenbrini stays silent, allowing Hans to air his anxiety on the materialism of Hamburg, his native city, on his own weakness to this materialism, and his own early introduction to death; he is an orphan. Settenbrini is now released again, death must not be divorced from life in any way; severed from life death becomes a spectre, death must have no separate reverence, nor must illness, as he had previously explained to his pupil.

Hans takes his time to accept this and keeps making allowances for his fellow patients, whose behaviour is not gilded in the print. Settenbrini tells him not to listen to them; they have no right to imagine themselves entitled to pity. But they are ill, says Hans. Disease is depravity, he is told, but he tries his best to avoid this conclusion: surely illness may be a consequence of depravity, or an excuse for depravity, but depravity itself, never. Settenbrini tells him again not to defend illness, but Hans parries that the analyst too has told him that disease is a secondary phenomenon. Settenbrini scoffs, how pure is that kind of idealism, and goes on to divide psychoanalysis itself, good as an instrument of enlightenment or destructor of conviction but bad, very bad as it stands in the way of will and action. The Italian is largely having his own way but keeps floundering into this dilemma of modern medicine: what is good and what is bad about it, why has progress to carry its own degeneration? He can only be horrified by his attitude to his own illness, and to its effect on him, that he can be prevented by his physical or animal nature from indulging in services to reason. This is his horrible dichotomy, that he has to honour the body as the vehicle of beauty, freedom, joy and desire, yet despise it as representing the inescapable principle of disease and death. Ultimately Hans accepts most of this and the book's halfway is marked by his first bold conversation with the beloved, a flighty Russian. Her contribution to this true European is the claim that it is her illness which gives her liberty. Unshaken, Hans makes his declaration on the purest Settenbrini principles; body, love and death are one.

Naphta now appears, well heeled and provided by his Order, redolent, his coat of mink lining contrasting with Settenbrini's mangy specimen. They fall on each other, arguing, scratching, biting, and finally fighting a ridiculous duel when Naphta's fanaticism slips the bond of sanity. Legitimately enough he shoots himself once Settenbrini has aimed and fired at the sky. So far as this is a solution, it means presumably that medievalism is dissolved but enlightenment as aerial as ever.

And indeed, the forty odd years since The Magic Mountain have shown that the rationalist's victory was pretty thin, and that his scorn for the reverence of illness has not been supported, as he hoped it would, by his admiration of health (though ill himself) nor by his incorporation of death into his conception of life.

Nor has he had any more luck with the idea that sympathy for the sick from the fit is an impossible transference, because the sick at once adjust themselves to their state and do not feel a corresponding jealousy for the healthy. Western development on this matter seems to have identified the healthy and sick with a mutual reverence for each other and any idea of death has been excluded from either side; in fact the kindest thing which has appeared about death during these last forty years is the recognition that when it approaches by age or illness it brings its own calm which the victim enjoys but his relations, attendants, and his earlier self are quite incapable of recognising.

And it is on these lines of thought that the second pair of books must be judged because in each case the hero is established solely on the fact of his phthisical crisis. Settenbrini would have gustily condemned this at the outset as being invalid, and the feature does veer to the religiosity of Naphta who was prepared to see a good in illness, a good in torture, and a good in corporal or capital punishment, each and all condemned by Settenbrini. The modern attitude is a flagrant compromise, with all sides trying to patch up with the rest, and it is difficult to find the fallacy, although it is obvious that in conditions of ethical parity between the sick and well it is the latter who will suffer, however much the first may gain. Moreover, this modern compromise is a firm and productive union: Settenbrini welcomed medical progress although professing to despise illness, ultimately hoping to eradicate it, while Naphta called medical progress bourgeois materialism, all very well but opposed to Faith and Spirit; it is the wedding of these two views, the worship of medical progress and the retention of Faith and Spirit, together and in the same breath, that has produced the palpable result before us, that medical progress has created more illness, not less.

In such a balanced atmosphere it is not surprising that Braine and Ellis have produced a very similar hero in the throes of tuberculosis. True to the clinical doctrine that well or ill the patient has this for life, neither book reaches a firm conclusion, each hero being left with his worst disease but deprived of his best girl. Both books are medically accurate but Ellis spends more time on the technical side, to the finick of being documentary, apart from the careless spelling. By inflicting more pain on his hero in this way he sets out to produce more emotion and succeeds in doing so. Braine's hero leaves his bed for long spells to hobnob with some gipsy Vodi (Aunt Nelly and Co.) or to go on nostalgic Sergeants' Mess outings to the next pubs.

Both books survive or die on whether the crisis of illness is a fair plank for a fictional hero, and if this is accepted then the next stage must also be accepted, that of the real-life invalid cashing in on his illness, by writing it up. It is worth while repeating that Settenbrini would have condemned both ventures utterly and to add that Naphta must have accepted them. Does this mean that Naphta should have won the duel? But not by Settenbrini committing suicide?

Clinical infiltration into the novel of words is a less universal problem but interesting in the annals of letters. Word-spinners must find metaphor and the number of sources is not infinite. Most are obvious and already overplayed, any of the arts, for example, and most of the activities, preferably stirring and dangerous. Novelists are using technical metaphor more and more, including medical feature and colour. The modern monarch of word and phrase, Joyce, reveals a memory full of medical student talk, particularly the lurid Burke and Hare variety. Two typical examples concern Bishop Arius and judicial hanging. The first is ready-made for Joyce, a fellow heretic of lengthy argument, and any account of Arius gives the manner of his death which occurred in the private part of a public place from fulminating rectal haemorrhage, with 'clotted buttocks', which is Joyce's finis to the heresy. The medical effect of hanging was even more attractive, and Joyce grabbed the priapism, with its hideous symbolism; for biologically the male sex act must be deemed akin to if not accompanied by death, as it is in some forms of life, and here was a manmade parody of the fact.

This comparison between overdrawing a medical event and using a medical event to overdraw provides a natural bridge to the next genus, the novel of deed. Medical incident has long been of the highest use in narrative and it is a pity that rules for its fair employment have never been laid down. Overcharging is again the common crime and as Braine's Vodi has been mentioned on a big issue perhaps it is excusable to quote a detail. His hero is on the crest of his easy wallowing days, just engaged to a suitable fast girl; he has to be deflated and his author chooses that night to pronounce the malignant doom of his mother: that seems overcharged. Inaccuracy is also reprehensible; as a rule the masters are careful but here is a blatant blunder of 1960, in a very high place: 'she [the wounded woman] would be drinking blood through the eye of a silver needle. Drop by drop it would be passing into the median vein, heart beat by heart beat.' This is a rich transfusion: 'drinking blood', hardly, but excusable on a poet's licence; 'the eye of a silver needle', the eye of a needle is never lengthwise, nor can a needle be made of silver, but admittedly it may be silver in appearance; the eye of this silver needle then means the lumen (channel) of either a steel needle or a silver cannula. 'Heart beat by heart beat', whose heart? Some pump is clearly envisaged, but even arterial transfusion has a pump of its own, and so did the old direct transfusion. 'Drop by drop it would be passing into the median vein', this much is accurate.

The most virile novel of deed is still criminal and it is obvious how much this type of tale owes to medicine, all the way from its professional prototypes, Doyle, Holmes and Watson, to its advanced propounders of toxicology, traumatology, and forensic problems. Less obvious is the trick perfected by one of its outstanding performers, Simenon, who can be called the modern master of minor illness. In the first place Simenon appears to be personally conditioned to minor malady. On receiving literary 'annunciation' he makes plans for 'accouchement'. The first person summoned is his doctor, to assure the author that he has no illness upon him which might interfere. Not only is the author examined, but his family and servants too; there must be no colds, sick attacks, influenza, and the like. If there is anything lurking through the house, 'labour' is postponed by tranquillisers: once the work is under way no interference is allowed until it is finished. Not content with encouraging minor malady to emphasise his own situation Simenon uses it freely in his constructed circumstances, as punctuation and heightening. The bond of sympathy between reader and character is at once tightened if they are both capable of the same sensation. It is very effective to drop some criminal on a Western air-mac, and describe not the objects around but the blinding headache he has; we know at once that is just how we should feel ourselves. In the same way the judge who is struck with grippe during the hearing of a murder trial at once 'overhears' the evidence and passes on these overtones; moreover the duration of the grippe laces up the length of the procedure and the case clears with the judge's temperature. There is hardly a Simenon novel without this clinical bracing; it is skilful, masterly, and probably subliminal to most readers.

Apart from Conan Doyle and his First Detective, novelists from the medical profession have not been very much responsible for these invalid introductions to modern fiction. When they do write medical novels they tend to write more about their colleagues and other internal professional relations than about the effect of illness or medicine on their patients. Curiously too, Somerset Maugham, who is characteristically footsure at all levels of society and in all parts of the globe, can falter at the bedside. It seems that experience as a patient or spectator is more productive to a novelist than any training as a doctor, and this supports the earlier claim that this infiltration of sickness into European fiction was not medical propaganda but dated from Flaubert and was nourished by the fastidious amateurs who went on appearing until the First War. Those gentlemen were as fussy on their health as they were about their lovely hand-made boots, so that whether they were really crocks, like Proust, or not, like Gide, they were bound to be taken up by the influence of illness on the individual. As well as being obsessional on this matter, these practitioners were also men of independent means, at a time when both illness and health were very easy if you were lucky, and appalling if you were not. Now it is a fact that the society which can see the horror of sickness can best see the advantage of health and unfortunately any depression of the former detracts equally from the latter. It is this visible example of a class which cleverly learnt to disregard the distinction between illness and health which has helped to alter our views. Thomas Mann at least faced the dilemma and went some way to solving its morality, even if he avoided its economy by restricting his remarks to people who could afford to be ill, but Gide gybed the sail, and this is what he said in his Journal: 'I have never met one of those who boast of never having been ill who was not in some way or other a bit stupid; like those who have never travelled; and I remember P. very prettily called illnesses the poor man's travels.'

This depressing opinion does not even level the well with the ill but loads sickness to defeat health. Obviously that is wrong, and society will soon become unworkable if invalids transcend sympathy and score heroics from their sick state.