Show Me Where It Hurts: Part 1

Illness, mental and physical, is arguably comics’ invisible master theme, deeply woven into their genome and shaping the stories they tell, from the earliest newspaper strips (chronic allergies in Winsor McCay’s Little Sammy Sneeze) through the rise of superhero comics (from Batman’s PTSD in 1939 through the Fantastic Four’s radiation poisoning in 1961). It is only in recent years, however, that mental and physical illness have come to the fore in graphic storytelling, together with a new field at the crossroads of narrative medicine and comics studies: graphic medicine.

Narrative medicine emerged out of the desire of practitioners and patients to push back against the seemingly inexorable drive of late 20th-century medicine to replace patient narratives with data derived from ever more sophisticated diagnostic technologies. New and increasingly more precise imaging and other diagnostic technologies, from X-Rays to MRIs, were designed to provide objective insights; at the same time, their cost and mastery demanded more and more of the time previously afforded to patient narratives. The turn of the 21st century witnessed exceptional growth in the use of imaging technologies, as CT scans doubled and MRIs tripled. As the number of “objective” images proliferated and their resolution increased exponentially, it was inevitable that the weight accorded to those images would grow accordingly. Each of these technologies required specialists not only to operate but also to read them, specialists often cloistered away from contaminating patient’s narratives. The power of new diagnostic technologies, combined with the expertise and money required to operate them, gave to these technologies and the data they produce an increasingly talismanic function in the diagnosis process. And the mounting pressures on doctors to see more and more patients (in part to pay for these technologies) has necessarily diminished time and space for patient narratives. By the early years of the 21st century, it was not simply that doctors came to see patients’ narratives as irremediably subjective and therefore imprecise and unreliable; doctors began to contend that patients compulsively, inevitably lie—as one Dr. House repeatedly reminded viewers beginning in 2004.

For doctors like Rita Charon, a founder of the narrative medicine movement, there is an urgent need to restore the balance by recovering the art of listening to patient narratives. For patients like myself and countless others, narrative medicine has served as a tool for rehumanizing our relationship to doctors often tethered to computer monitor and stopwatch—and for effectively advocating for the diagnostic authority of our stories about our bodies.

As it first emerged a few years ago, graphic medicine might have been merely a subset of narrative medicine, were it not for the unique affordances and power of this strange form—affordances that turn out to be especially powerful in communicating what Elaine Scarry identifies as that most incommunicable of understandings: pain. “Graphic medicine” was coined by Ian Williams, a doctor and cartoonist, who has been collaborating over the past several years with a group of scholars, physicians, and cartoonists to develop the practice and the field of graphic medicine. His colleagues in this endeavor include MK Czerwiec, a cartoonist and HIV/AIDS and hospice-care nurse based in Chicago, and Michael J. Green, a doctor who has integrated the making of comics into his medical school classes and brought comics into medical journals where their appearance would have been unimaginable even a few years ago. Together with Susan Merrill Squier, Kimberly R. Myers, and Scott T. Smith, this collective has recently published the Graphic Medicine Manifesto, an academic treatise told in a combination of prose and comics. In this way the manifesto puts to the test its authors’ belief in the ability of comics to forge connections—between medicine and humanities, between doctors and patients—that prose alone often makes impossible. As the lead book in the new series at Penn State Press devoted to this small but dynamic field, the goal here is to encourage other scholars, patients, doctors, and cartoonists to collaborate across these divisions in similar ways.

The manifesto puts to the test its authors’ belief in the ability of comics to forge connections that prose alone often makes impossible.

As the authors behind the Graphic Medicine Manifesto argue, the comics form that emerged simultaneously with the new imaging technologies at the end of the 19th century was in the 20th the constant subject of experiments in the relationship between two semantic systems—word and image—as they collaborated and competed to convey meaning. The highly charged relationship wherein neither text nor image conveys the truth but together succeed in saying something more
true than either could individually has been termed “the vital blend” by Robert C. Harvey.¹ This blend extends further to the relationship between creator and reader, who must, as Scott McCloud and others have argued, collaborate at every turn to make meaning by filling in the gaps of what this highly elliptical and fragmentary form necessarily leaves unwritten and undrawn.² Arguably more than any other narrative form, comics have always wrestled with the challenges of making meaning out of competing systems and storytellers, yielding something different—and, when it is done right, better—than either could tell alone.

And here is where comics can come to the rescue of medicine, as they did for this patient and for so many others over the last generation, modeling generative collaborations between image and text, data and narrative, creator and reader, and doctor and patient in the face of experiences seemingly impossible to relate. Graphic autobiography was born with an illness narrative—Justin Green’s Binky Brown Meets the Holy Virgin Mary (1972), about debilitating OCD—but it was not until the 1990s that illness memoirs began truly to proliferate in comics, with such seminal texts as Al Davison’s The Spiral Cage (spina bifida) and Harvey Pekar and Joyce Brabner’s Our Cancer Year (testicular cancer and chemotherapy). In the 21st century, narratives about mental and physical illness have emerged as the dominant form of nonfiction comics.

I want to highlight some recent additions to the growing body of graphic literature devoted to medicine, illness, and recovery. I would also encourage all interested in learning more about this topic to visit the home page of the Graphic Medicine working group. Here you will find reviews of comics about mental and physical illness as well as information about the Penn State Press series, which has followed up the Graphic Medicine Manifesto with a semi-autobiographical graphic novel, The Bad Doctor, by Ian Williams, and three additional titles. I am too close to the group to offer an objective review of what they have accomplished here, but a review in the New York Times of both the Manifesto and The Bad Doctor does a terrific job of spelling out what is so exciting about the series.

Arguably the most monumental volume of graphic medicine to appear in the last several years is Katie Green’s Lighter than My Shadow. Weighing in at over five hundred pages, the book chronicles the devastations of anorexia and sexual abuse and the pathways and processes leading toward recovery. It is also a devastatingly articulate monument to all that the cartoonist could not articulate, as she brilliantly describes in the course of the narrative, with either words or pictures alone.

Early in the volume we see a young Katie struggling to express for herself and her family the demons that are shaping her increasingly destructive relationship to food. She turns first to words, but they can convey little more than the dark self-hatred that has consumed her. She turns then to images, which prove only marginally more effective as a tool for communication and if anything seem to bring upon her even more profound torment. In the extended portrait of the artist as a young woman that the book patiently reveals, layer by layer, it is only when she finds means and mechanisms to bring both word and image together into a complex weave that she begins to take ownership of her story and her recovery. In a magnificently rendered sequence toward the volume’s end, she begins to fully embrace and care for the badly wounded younger versions of herself who trail behind her adult self like ghosts.

Lighter than My Shadow is a moving, beautiful, and at times harrowing book that somehow manages to describe an uplifting narrative of recovery without promising a Hollywood happy ending—or even an ending at all. There is no promise that any of this will ever be finally and fully consigned to the past, or that food and sex won’t forever be visited by specters of past violence. What there is, however, is the promise that Green will never again be silenced or afraid to draw and write her own pathways out of the shadows.

A very different book, both stylistically and formally, is John Porcellino’s Hospital Suite. Where Green’s page is layered, textured, often filled to overflowing with lines and ink, Porcellino’s is spare and minimalist, relying as he has throughout his long career on thin lines and the powerful negative spaces they reveal. For over 25 years Porcellino has been producing autobiographical comics in his self-published zine King-Cat, comics that, unlike many “diary comics,” are less confessional than they are lyrical, engaged with the beautiful (and sometimes devastating) pauses and silences of everyday life. But long-time readers of King-Cat know that life has not always been easy for Porcellino: financial troubles, marital heartbreak, and mental and physical health problems have routinely punctured his meditations on the search for beauty even in the darkest Midwestern winter’s day.

Long-form narrative is not Porcellino’s natural medium. Indeed, he has typically been drawn to short narratives so spare as to more closely resemble sutras or koans than short stories. Further, his serialized autobiographical comics have often reflected on a short period of recent history, as opposed to the kind of decades-long reconstruction of memory and experience called for in Hospital Suite. Porcellino adapts to long-form autobiography seemingly effortlessly, however, while maintaining the spare visual and narrative style that has long defined his pages. This new work tells the story of his struggles, first with debilitating physical illness and then, in its wake, with crippling mental and emotional illness that in many ways transformed his life and relations more fully than did the former. Like Green, he refuses pat lessons and the formulaic narrative arcs that define so many Hollywood versions of illness. Here illness is about confronting the possibilities of death and rebirth, while finding meaning in the smaller messages that lie between those two junctures, both of which remain out of reach for our narrator.

Porcellino’s story maps out the vastly underappreciated relationship between physical and mental health. Medicine “cures” him of a crisis in part one, only to leave in its wake the devastations of part two, for which Western medicine has few answers—and often little time. Indeed, this is, not surprisingly, a theme we see running through many contemporary graphic memoirs about illness: a patient knows that getting the help she needs from a doctor can mean downplaying or even silencing the depression or anxiety that is often crippling her as much as the physical symptoms brought on by an acute or chronic illness. In the graphic memoir, as modeled by pioneering works like Spiral Cage or Our Cancer Year, physical and mental health are allowed to speak their mutual story. Still, few have explored the connections in comics more fully and sensitively than has Porcellino, aided in his navigations by extensive readings in Eastern philosophies and medicine. Herein lies the ultimate “vital blend” that graphic medicine might bring us, alongside that of joining imaging and storytelling, creator and reader, patient and doctor: the dissolution of the ultimate barrier of Western medicine between mind and body.

In part two of this survey I will look at examples of medical graphic memoirs that explore this “blend” further, concluding with a short meditation on the lessons for practitioners and patients alike that emerge from a course of reading in this expanding body of graphic literature.