Metaphors of Mental Illness in Graphic Medicine

1st Edition Sweetha Saji pdf download

https://ebookgate.com/product/metaphors-of-mental-illness-in-graphic-medicine-1st-edition-sweetha-
saji/

★★★★★ 4.7/5.0 (36 reviews) ✓ 218 downloads ■ TOP RATED

"Great resource, downloaded instantly. Thank you!" - Lisa K.

DOWNLOAD EBOOK
 Metaphors of Mental Illness in Graphic Medicine 1st Edition
Sweetha Saji pdf download

TEXTBOOK EBOOK EBOOK GATE

Available Formats

■ PDF eBook Study Guide TextBook

EXCLUSIVE 2025 EDUCATIONAL COLLECTION - LIMITED TIME

INSTANT DOWNLOAD VIEW LIBRARY

Metaphors of Mental Illness in
Graphic Medicine

This book investigates how graphic medicine enables sufferers of mental

illness to visualise the intricacies of their internal mindscape through visual
metaphors and reclaim their voice amidst stereotyped and prejudiced as-
sumptions of mental illness as a disease of deviance and violence.
In this context, by using Lakoff and Johnson’s conceptual metaphor the-
ory (CMT), this study uncovers the broad spectrum of the mentally ills’ ex-
periences, a relatively undertheorised area in medical humanities. The aim
is to demonstrate that mentally ill people are often represented as either
grotesquely exaggerated or overly romanticised across diverse media and
biomedical discourses. Further, they have been disparaged as emotionally
drained and unreasonable individuals, incapable of active social engage-
ments and against the healthy/sane society.
The study also aims to unsettle the sanity/insanity binary and its related
patterns of fixed categories of normal/abnormal, which depersonalise the
mentally ill by critically analysing seven graphic narratives on mental illness.

Sweetha Saji is Assistant Professor in the Department of English at Mount

Carmel College, Bengaluru. Her areas of research interest include Graphic
Medicine and Medical Humanities. She has published over ten research arti-
cles in SCI and Scopus indexed journals. She is an ad-hoc reviewer for Journal
of Graphic Novels and Comics and BMJ Journal of Medical Humanities.
She has presented over 12 research papers at International and National
conferences organized by prestigious institutions including the University of
Granada, Spain, JNU New Delhi, and IIT Madras.

Sathyaraj Venkatesan is Associate Professor of English in the Department

of Humanities and Social Sciences at the National Institute of Technology,
Trichy (India). He is the author of 6 books and over 90 research publications
that span African American literature, health humanities, graphic medicine,
film studies, and other literary and culture studies disciplines. He is most re-
cently the co-author of Infertility Comics and Graphic Medicine (2021) and
India Retold (2021).
Routledge Focus on Literature

Trump and Autobiography

Corporate Culture, Political Rhetoric, and Interpretation
Nicholas K. Mohlmann

Biofictions
Literary and Visual Imagination in the Age of Biotechnology
Lejla Kucukalic

Neurocognitive Interpretations of Australian Literature

Criticism in the Age of Neuroawareness
Jean-François Vernay

Mapping the Origins of Figurative Language in

Comparative Literature
Richard Trim

Metaphors of Mental Illness in Graphic Medicine

Sweetha Saji and Sathyaraj Venkatesan

Wanderers
Literature, Culture and the Open Road
David Brown Morris

Sham Ruins
A User's Guide
Brian Willems

For more information about this series, please visit: www.routledge.

com/Routledge-Focus-on-Literature/book-series/RFLT
Metaphors of Mental
Illness in Graphic Medicine

Sweetha Saji and

Sathyaraj Venkatesan
First published 2022
by Routledge
605 Third Avenue, New York, NY 10158
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2022 Sweetha Saji and Sathyaraj Venkatesan
The right of Sweetha Saji and Sathyaraj Venkatesan to be identified
as authors of this work has been asserted in accordance with sections
77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Names: Saji, Sweetha, author. | Venkatesan, Sathyaraj,
author.
Title: Metaphors of mental illness in graphic medicine /
Sweetha Saji, Sathyaraj Venkatesan.
Description: New York, NY : Routledge, 2022. |
Series: Routledge focus on literature | Includes
bibliographical references and index.
Identifiers: LCCN 2021032613
Subjects: LCSH: Mental illness—Treatment. | Visualization.
Classification: LCC RC475 .S25 2022 | DDC 616.891—dc23
LC record available at https://lccn.loc.gov/2021032613

ISBN: 9781032102092 (hbk)

ISBN: 9781032163505 (pbk)
ISBN: 9781003214229 (ebk)
DOI: 10.4324/9781003214229
Typeset in Times New Roman
by codeMantra
Contents

Acknowledgements ix

Introduction 1
Texts and Contexts 4
Overview of the Book 6

1 Drawing Illness: History, Theory, and the

Development of Graphic Medicine 9
Introduction 9
Early Comics and Healthcare 10
Narratives of Illness and the Birth of
Graphic Medicine 13
Preface to Graphic Medicine 14
Graphic Pathographies 16
Are Graphic Pathographies Education Comics? 18
Graphic Medicine as a Critique of Biomedicine 19
From Book Stalls to Classrooms 21
Trends in Graphic Medicine 23
Conclusion 25

2 Function of Metaphors in Illness Narratives 28

Introduction 28
A Brief Outline of Metaphor Theories 29
Comparison Theory 29
Transference Theory 29
Interaction Theory 31
Conceptual Metaphor Theory (CMT) 32
vi Contents
Metaphors and Contexts 33
Multimodal Metaphors and Illness Depiction 36
Why Metaphors? 40
Conclusion 42

3 Mental Illness and the Politics of Representation 46

Introduction 46
Defining Mental Illness 50
Mental Health Stigma and Medical Illustrations 55
Conjuring Stereotypes through Media
Representations 58
Conclusion 64
Acknowledgement 65

4 Nobody Memoirs as Counter-Discourse: Bipolar

Disorder and Its Metaphors 69
Introduction 69
Personal Stories, Memoirs, and Counter-Discourse 71
Metaphors as Counter-Diagnostic Figurations 76
Deconstructing Stereotypes 82
Conclusion 87
Acknowledgement 89

5 Visual Metaphors of OCD and Schizophrenia 93

Introduction 93
Perspectives in Context 93
Picturing the Psychicscape through Spatial
and Stylistic Metaphors 97
Traversing the Middle Ground through
Visual Metaphors 102
Conclusion 107
Acknowledgement 108
 Contents vii
6 Visualising the Fragmented Selves: Conventional and
Creative Metaphors of Depression 110
Introduction 110
Conventional and Creative Metaphors
of Depression 112
Stylistic Metaphors of Depression 119
Conclusion 122
Acknowledgement 123

Conclusion 126

Index 133
Acknowledgements

I am grateful to Dr Sathyaraj Venkatesan, who has taught me the art

of academic writing and guided me throughout the course of four
years as a researcher. My gratitude also extends to my teachers of SB
College, Changanacherry, and BCM College, Kottayam, for inspir-
ing me to develop academic curiosity which led me to venture into
the novel interdisciplinary fields of medical humanities and graphic
medicine.
Immense thanks to Brick, Rachel Lindsay, Nate Powell, and Glyn
Dillon who spared their precious time in sending me images from
their memoirs. I fondly remember William Kuskin of the University of
Colorado Boulder and Andrea Wood of Winona State University for
their insightful comments and valuable suggestions on this book. I am
grateful to Matthew Noe of Harvard Medical School for his specific
comments on this book and also for the effort he takes to compile all
the resources related to this new field of graphic medicine and sharing
the same with the graphic medicine community online.
I am thankful to Jennifer Abbot, Mitchell Manners, and all the
editorial and production team members at Routledge, New York,
and Rajamalar of CodeMantra for their timely suggestions and help
during the various stages of the production of this book. I thankfully
remember the support given by the librarians at the American Corner;
Kottayam Public Library; Jawaharlal Nehru University, New Delhi;
Indian Institute of Technology, Madras; and National Institute of
Technology, Trichy.
My sincere gratitude and respect to my parents and siblings for their
encouragement and prayers. My heartfelt love and thanks to my hus-
band, Gijo John George, for his unconditional support. Special thanks
to S. Pushpanathan, Rajima, Ninu, and Geerthy for their unflinching
friendship and love.
x Acknowledgements
I thank the publishers of Routledge, Sage, Rupkatha, and Media
Watch, for permitting me to use earlier versions of some of the chap-
ters in this book which were published as “Drawing the Mind: Aes-
thetics of Representing Mental Illness in Select Graphic Memoirs” in
Health: An International Journal for Social Study of Health, Illness and
Medicine, Sage vol. 25, no.1 (2021); “Capturing Alternate Realities:
Visual Metaphors and Patient Perspectives in Graphic Narratives on
Mental Illness” in Journal of Graphic Novels and Comics (2020); “Re-
flections on the Visceral: Metaphors and Illness Experience” in Rup-
katha Journal on Interdisciplinary Studies in Humanities vol.12, no.1
(2020); “Graphic Illness Memoirs as Counter-Discourse” in Journal of
Graphic Novels and Comics (2019); and “Conjuring the ‘Insane’: Rep-
resentations of Mental Illness in Medical and Popular Discourses” in
Media Watch vol.10, no.3 (2019).
This book is dedicated to my family and all my teachers who
moulded me through these years. They seeded in me empathy, the
foundation on which this book is thought about and made.

Sweetha Saji

My special debt of gratitude to Professor Gurumurthy Neelakantan,

Indian Institute of Technology, Kanpur, for teaching me the art of
interpretation and academic writing. I would like to thank Jennifer
Abbott and Mitchell Manners for their utmost professionalism and
enthusiasm during the preparation of the manuscript. My deep sense
of gratitude to the International Graphic Medicine collective for their
extraordinary support: Dr Ian Williams (founder of Graphic Medi-
cine), MK Czerwiec (co-founder of Graphic Medicine), Susan Merrill
Squier, Dr Michael Green (Penn State College of Medicine), Matthew
Noe (Harvard Medical School), A David Lewis (Massachusetts Col-
lege of Pharmacy and Health Sciences), Dr Brian Callender (Uni-
versity of Chicago), and Larry Churchill (University of Vanderbilt).
Thanks to the reviewers for their thoughtful critiques and valuable
suggestions. Thanks to William Kuskin (University of Colorado,
Boulder) for being a great source of motivation. Special thanks are due
to the faculty of the Department of Humanities and Social Sciences,
National Institute of Technology (NIT), Tiruchirappalli. Thanks also
to the publishers who allowed to reproduce essays contained in this
book. Dedicated to my wife, Pavithra Ayyapan, and my son, Taran
Sathyaraj.

Sathyaraj Venkatesan
Introduction

The pivotal role of humanities in medicine has been recognised in the

1940s as it aimed at reuniting technical and humanistic theory and
practice. Since then, discussions on the interdisciplinary field of health
humanities promoted the inculcation of humane values and concerns
within medical practice by exposing students of medicine to litera-
ture, culture, philosophy, and the arts. Steering away from symptom-
based approaches, health humanities foreground patient-centred care
that takes into account varied socio-cultural factors that modulate
and determine one’s experience of illness. Moreover, the field shies
away from privileging singular perspectives and grants voice to the
care provider as well as to the patient. Broadening the scope of this
field, later developments in health humanities like narrative medicine
among others explore questions of empathy, narrative humility, and
ethics of representation. Taking cues from these historical milestones,
the field of graphic medicine, which explores representations of illness
experiences in the medium of comics, “resists the notion of the univer-
sal patient and vividly represents multiple subjects with valid and, at
times, conflicting points of view and experiences” (Czerwiec et al. 2).
Within this framework, the experience of mental illness becomes sig-
nificant as it is often misrepresented in various verbal, visual, and me-
dia cultures. Such representations promote stereotypes and affect the
very social and personal well-being of the mentally ill. In this context,
personal narratives of mental illness experience grant agency to such
marginal lives and thus provide an alternate perspective to the current
(toxic) discourses on mental illness.
As such, the COVID-19 pandemic has reanimated several issues
about mental health and well-being. Quarantine, isolation, and social
distancing which are the recommended measures to limit the spread
of the viral disease have not only resulted in socio-cultural and eco-
nomic crisis but also have led to personal disruption and extreme

DOI: 10.4324/9781003214229-1
2 Introduction
mental health issues. As a response, health professionals discuss the
importance of attending to the needs of the mentally ill and being sen-
sitive to those who suffer mental health issues during the pandemic.
Artists and writers, on the other hand, have creatively engaged in such
invisible dimensions of one’s life and also have elicited (empathetic)
responses via print and social media. Such emerging trends not only
extend ingress into the subjective dimensions of patient experience but
also bring under scrutiny the extant medical practices and popular
representations of madness that underrepresent or over romanticise
the experience of mental illness. Graphic memoirs on mental illness, in
particular, find expression through the unique semiotic nature of com-
ics, which facilitates the encapsulation of complex psychic landscapes
and embodiment of the artist’s experiences. Such representations of
psychological experiences that concern with challenging prevailing
normativities necessitate a creative use of means of expression. In so
doing, these verbo-visual techniques such as the use of visual meta-
phors provide vividness and easily digested expression, translating
the sufferer’s altered mental perspective effectively for the reader. The
deployment of such elements inherent in the medium facilitates multi-
layered connections to the patient narrative which provide a depth be-
yond the raw medical discourse, and thereby reconfigures the extant
perceptions surrounding mental illness.
An analysis of diverse verbal and visual representations of mental
illness in contemporary media and medical discourses reveals a persis-
tent gap between standardised and stereotyped perspectives about the
mentally ill and the subjective realisation of them. Several literary and
cultural critics have commented on this glaring lacunae and its negative
repercussions on the personal, familial, and social life of the mentally
ill. Sander Gilman’s Seeing the Insane (1982), Simon Cross’ Mediat-
ing Madness: Mental Distress and Cultural Representation (2010), and
Elizabeth J. Donaldson’s Literatures of Madness: Disability Studies
and Mental Health (2018) are some of the seminal critical readings on
representations of the mentally ill across media and its unconstruc-
tive effects. While these texts explore the politics of representation and
its repercussions in the lives of the mentally ill, a critical reading of
personal narratives of mental illness which are drafted using verbal
and visual modes unravels the unvoiced socio-cultural and personal
dimensions of living with mental illness from significant marginal per-
spectives. As such, a nuanced understanding of the affordances of the
comics medium and the metaphorical patterns which recur in these
graphic narratives enables a comprehensive reading experience which
generates a community of sufferers on the one hand and facilitates
critical responses on health and illness on the other hand.
 Introduction 3
Although concepts and theories on metaphors date back to Aris-
totle, current research on metaphors, particularly visual metaphors,
draws strength from George Lakoff and Mark Johnson’s conceptual
metaphor theory (CMT) which deems metaphors to be “pervasive
in everyday life, not just in language but in thought and action” (3).
Lakoff and Johnson and other theorists like Charles Forceville and
Elizabeth El Refaie primarily focus on the cognitive mapping between
two different conceptual categories that evoke metaphorical meanings
that arise “from the continuous interplay of social and cultural con-
straints, neural processing, and the unfolding of in-the-moment sen-
sorimotor experience” (El Refaie 4). These meanings that emerge out
of such conceptual mappings actualise otherwise abstract feelings and
emotions that require a visual language that transcends literal expres-
sions. In the context of mental illness, the author/artist resorts to met-
aphors which effectively encapsulate their complex psychic landscapes
which seldom find expression in literal language due to the absence of
physical/visible signs of illness. Although Lakoff and Johnson’s CMT
is extended to visual narratives to investigate “the correspondence
between the visual form and meaning” (Cohn 68), artists also deploy
metonymic relationships between images and “unseen events” (Cohn
80). In other words, when graphic narratives use metaphor, it is usually
through another aspect of metonymy—polysemy—in which some-
thing is figured in multiple ways, through visualisation and through
text. As such, in a visual medium like comics, artists use panels to
“show something related to an event, without showing the event itself”
(Cohn 80). These ‘unseen events’ correspond to what Ian Williams
defines as the ‘invisible’ iconography used in depicting psychological
conditions (Czerwiec et al. 119).
Under the rubrics of the iconography of illness in the medium of
comics, Williams classifies illness representation into ‘the manifest,’
‘the concealed,’ and ‘the invisible.’ ‘The manifest’ implies the depiction
of illness or scars of treatment “as ‘realistically’ as possible” (Czer-
wiec et al. 121). Drawing specific attention to David Small’s memoir,
Stitches, Williams enunciates the usefulness of ‘manifest’ images in
rendering physical/bodily scars. Such graphic depiction which con-
verges sickness with grotesqueness consequently evokes disgust/pity in
the reader. When illness conditions are vaguely manifest as in the case
of psychosomatic disorders, Williams christens it as ‘the concealed.’
In such cases, Williams remarks that they “may not be noticed by, or
are hidden from, the casual observer” (Czerwiec et al. 119). In the third
category of illness depiction called ‘the invisible,’ the comic artist re-
sorts to the “iconographic flexibility of the form” (Czerwiec et al. 119)
for the veracious articulation of the visceral and analytic dimensions
4 Introduction
of psychological suffering. Exploiting the flexibility of the comics me-
dium, the artists choose/create idiosyncratic icons and experiment
with visual tropes creating new visual patterns and an internal vocab-
ulary of images to align with their peculiarity of experience. Several
mental illness graphic narratives such as Ellen Forney’s Marbles, Allie
Brosh’s Hyperbole and a Half, Darryl Cunningham’s Psychiatric Tales,
Elaine Will’s Look Straight Ahead, and Steven Struble’s Li’l Depressed
Boy, among others, exploit the iconographic flexibility of the comics
medium in order to concretise and effectively relate their mental states
through visual metaphors.

Texts and Contexts

This book critically analyses seven graphic narratives on men-
tal illness, namely, Nate Powell’s Swallow Me Whole (2008), Brick’s
Depresso (2010), Darryl Cunnigham’s Psychiatric Tales (2011), Ellen
Forney’s Marbles (2012), Glyn Dillon’s The Nao of Brown (2012), Allie
Brosh’s Hyperbole and a Half (2013), and Rachel Lindsay’s Rx (2018).
These narratives include both fictional and non-fictional accounts
that deal with mental illnesses including bipolar disorder, depres-
sion, schizophrenia, and obsessive compulsive disorder (OCD). The
primary texts were selected on the basis of their delineation of expe-
riential dimension of the sufferer’s life, and their use of comics as a me-
dium of expression in exploring cultural and emotional aspects of the
illness through different kinds of metaphors that convey their unique
emotional landscapes. The authors comprise established comic artists
and blog writers who suffer(ed) from various forms of mental illness.
The study also aims to inspire qualitative and quantitative research
on how factors such as gender, ethnicity, and race influence and deter-
mine (mental) illness conditions.
First, we follow a phenomenological approach which aims to cap-
ture the lived realities of those who suffer from mental illness. This
approach respects the perspective of those affected by the illness
condition by being aware of the personal, socio-cultural, and para-
digmatic discourses that shape the way reality is perceived by them.
Second, the core chapters specifically follow certain tenets of post-
structuralism that problematise social and medical discourses on
mental illness that mediate the way in which the illness condition and
sufferers of the same are perceived. Accordingly, the binaries that
underpin negative attitudes towards mental illness are deconstructed
through concepts like counter-space and counter-diagnosis. Analysis
of visual and verbo-visual metaphors in the graphic memoirs which
 Introduction 5
are close-read in this book reveals how the authors subvert institu-
tionalised structures of power through creative ways that foreground
subjective dimensions of living with mental illness. Third, by follow-
ing a contextualist methodological approach, few primary texts are
close-read based on its socio-cultural contexts and its connections to
the lived body experience of those suffering from mental illnesses like
OCD and schizophrenia. These approaches problematise monolithic
and singular notions of ‘truth’ as available in biomedical/diagnostic
discourses and lay bare multiple perspectives and realities of an illness
experience.
The term ‘madness’ would be used in this book as a cultural marker;
a “generic name for the whole range of people thought to be in some
way, more or less, abnormal in ideas or behaviour” (Porter 6). The
term ‘mental illness’ would be used to refer to the experiential aspects
of living with mental conditions that influence one’s emotions and
behaviour. The fourth chapter initiates an investigation of such con-
tradictory and ambivalent notions about the mentally ill that contrib-
ute to their stigma and examines the obstructions that hinder a lucid
understanding of the experiential dimensions of living with mental
illness.
As the subtitles of several autobiographical comics evince, there
is a persistent anxiety about the generic classification of such narra-
tives. For instance, subtitles such as ‘a comic-strip narrative’ (Chester
Brown’s I Never Like You [1994]), ‘graphic stories’ (Darryl Cunning-
ham’s Psychiatric Tales [2010]), and ‘graphic memoir’ (Rachel Lind-
say’s Rx [2018]) challenge a standard definition of the form of these
narratives on mental illness. Although a wide range of terms (such as
comics, graphic novels, and graphic narratives, apart from the ones
mentioned above) are used to refer to verbo-visual narratives, the term
‘comics’ is used as a singular noun in this book to refer to the medium.
As Hillary Chute defines, comics is “a hybrid word-and-image form in
which two narrative tracks, one verbal and one visual, register tempo-
rality spatially” (452). While ‘graphic narratives’ is used as a broader
term to refer to a “book-length work in the medium of comics” (Chute
453), the term ‘graphic memoir’ is used in this book to refer specifically
to personal accounts in the medium of comics about a particular phase
of life (here, the experience of living with mental illness). Fictional ac-
counts of mental illness in this book are referred to as ‘graphic novels.’
The graphic narratives discussed in this book use both images and
words where the text accompanying the image “adds some unillus-
trated thoughts hand-lettered in a style that is consistent with the sen-
timent that its message conveys” (Eisner 10). As Francisca Goldsmith
6 Introduction
observes, “image and text are [typically] brought together within pan-
els or defined spaces on the page, but in some instances the entire page
may serve as a panel” (4). The close-readings of particular episodes
are based on the theoretical findings of Scott McCloud and Thierry
Groensteen. While McCloud’s sequential reading of panels enables a
detailed understanding of the diverse comic elements that the authors
deploy within each panel to evoke specific meanings, Groensteen’s
principles of “arthrology” (linear relation of panels to each other) and
“braiding” (connection across the multiframe of the comics page) ena-
ble a broader understanding of the comics page as a whole in translat-
ing the mental landscape of the characters (Beaty and Nguyen).

Overview of the Book

This book consists of six core chapters and a conclusion, and each
chapter is followed by a reference list. This introductory chapter has
aimed at providing a brief outline of the objectives, scope and the
methodology of the study.
Chapter 1, “Drawing Illness: History, Theory, and the Development
of Graphic Medicine,” charts the development of graphic medicine by
tracing the engagement of comics with healthcare across time. Subse-
quently, the chapter explores the role of comics in medical training;
appraises seminal graphic pathographies on physical illness, mental
illness, and disability; and discusses the significance of multiple per-
spectives on illness which provide a depth beyond monolithic biomed-
ical approach toward patient bodies. As such, the chapter espouses
the significance of graphic medicine in validating the affective truths
about illness and health in treatment and recovery by underscoring
the need to acknowledge the sufferer’s voice. Apart from delineating
the cultural role of graphic medicine, the chapter also clarifies the
various elements of the comics medium which distinguishes graphic
pathographies from educational health comics in terms of style, target
audience, and production. The chapter further elaborates on the re-
cent trends and global recognition of graphic medicine as an emerging
interdisciplinary field.
Chapter 2, “Function of Metaphors in Illness Narratives,” aims to
provide a systematic reflection on metaphor as an expression of lived
experience. The chapter will also provide an overview of the major
theories on metaphors with an emphasis on Lakoff and Johnson’s
CMT since the implications of the theory correspond to the objectives
of graphic medicine. Furthermore, the wider implications of using
multimodal metaphors, especially visual and verbo-visual metaphors
in graphic memoirs, will be analysed in the context of mental illness.
 Introduction 7
The chapter also elaborates on Susan Sontag’s seminal work, Illness
as Metaphor, and recent theoretical postulates regarding the use of
metaphors in representing illness and its implications.
Drawing theoretical insights from Paula A. Treichler and Stuart
Hall, Chapter 3, “Mental Illness and the Politics of Representation,”
analyses perceptions and representations of mental illness in popular
culture and medical discourses. In so doing, the chapter lays bare the
ideologies and the symbolic codes that undergird these representa-
tions in paintings, movies, television shows, advertisements, newspa-
per reports, and medical illustrations. Invoking the diverse definitions
and perspectives on mental illness, the chapter also explores how ste-
reotyped popular and medical representations of the marginalised,
especially the mentally ill, engender internal and social stigma which
impedes recovery and social life. In this context, the chapter empha-
sises the significance of personal accounts as a means to reconfigure
popular perceptions that threaten the personal and social life of the
mentally ill.
Negotiating the gaps and misconceptions that permeate the pop-
ular and biomedical discourses, Chapter 4, “Nobody Memoirs as
Counter-Discourse: Bipolar Disorder and Its Metaphors,” aims to ex-
plore the diverse ways in which memoirs on mental illness construct
a counter-discourse by challenging and subverting the stereotypical
representations of madness. Specifically, the chapter investigates the
function of visual metaphors as a tool of counter-diagnosis which
shape the characterisation of different embodiments in graphic mem-
oirs. Moreover, the chapter investigates how these metaphors grant
agency to the patients to control the representation of one’s own
illness. Drawing from Thomas Couser’s concept of ‘nobody memoirs,’
the chapter facilitates the analysis of graphic memoirs on bipolar dis-
order like Marbles and Rx which explains how these artists deploy
metaphors to question medical dogma on the one hand and the bina-
ries of sanity and insanity on the other.
Chapter 5, “Visual Metaphors of OCD and Schizophrenia,” close-
reads graphic narratives on mental illnesses like schizophrenia and
OCD, namely, Swallow Me Whole and Nao of Brown to argue that
spatio-temporal affordance of the comics medium facilitates the rep-
resentation of specific embodied states. In foregrounding patient per-
spectives, the chapter elaborates on spatial and stylistic metaphors that
simulate uncontrollable and parallel thoughts that are characteristic of
schizophrenia and OCD. Furthermore, the chapter analyses cultural
confluences and identity crises of the protagonists through contextual
metaphors which encourage readers to comprehend a concept in terms
of another through replacement of anticipated contextual elements.
8 Introduction
Chapter 6, “Visualising the Fragmented Selves: Conventional and
Creative Metaphors of Depression,” investigates the mediative value
of conventional and creative metaphors unique to the medium of
comics in actualising the subjective experience of mental illness. The
chapter also seeks to delineate the cultural role of graphic memoirs
by positioning them at the crossroads of sufferer’s experiences and
clinical description, drawing on theoretical insights from Lakoff and
Johnson and other graphic pathographers/theorists, such as Williams
and El Refaie. Focussing particularly on graphic memoirs on depres-
sion such as Psychiatric Tales, Depresso, and Hyperbole and a Half, the
chapter explores the rhetoric of picturing the fragmented sense of self
which is characteristic of depressed mental conditions. The chapter
further discusses how creative metaphors and creative page layout are
used in these memoirs to establish an authentic subjective voice that
departs from the standards of symptomatic biomedical approach to
illness and health.
The conclusion draws together the principal findings of the study
and proposes new directions towards further research in the use of
visual metaphors in graphic memoirs on mental illness experience.
The limitations of the study are also discussed in the conclusion. In es-
sence, we seek to expand the boundaries of interdisciplinary research
on comics and healthcare with regard to mental illness.

Reference List
Beaty, Bart, and Nick Nguyen, translators. The System of Comics. By Theirry
Groensteen, UP of Mississippi, 2007.
Chute, Hillary. “Comics as Literature? Reading Graphic Narrative.” PMLA,
vol. 123, no. 2, 2008, pp. 452–465.
Cohn, Neil. “Being Explicit about the Implicit: Inference Generating Tech-
niques in Visual Narrative.” Language and Cognition, vol. 11, 2019, pp. 66–97.
Czerwiec, M. K., et al. Graphic Medicine Manifesto. The Pennsylvania State
UP, 2015.
Eisner, Will. Comics & Sequential Art. Poorhouse, 1985.
El Refaie, Elisabeth. Visual Metaphor and Embodiment in Graphic Illness Nar-
ratives. Oxford UP, 2019.
Goldsmith, Francisca. The Readers’ Advisory Guide to Graphic Novels. Amer-
ican Library Association, 2010.
Lakoff, George, and Mark Johnson. Metaphors We Live By: With a New Af-
terword. The U of Chicago P, 2003.
Porter, Roy. A Social History of Madness. Weidenfeld & Nicolson, 1987.
1 Drawing Illness
History, Theory, and the
Development of Graphic
Medicine

Introduction
Appraising comics within their constraints and possibilities, one could
contend that their verbal, non-verbal, and para-linguistic attributes
relay intimacy and inter-subjective experiences through a range of
structural and formal properties. As such, a new genre of comics has
emerged in the past decade that productively utilises this medium’s
immense potential to portray patients’, caregivers’, and healthcare
professionals’ illness experiences. This diverse and novel approach to
arts and medicine has ushered in new modes to address subjective
experiences of illness that transcend the prescribed boundaries of
biomedicine and canonical literature. British doctor and graphic nov-
elist Ian Williams labelled this approach to comics ‘graphic medicine,’
which is defined as “the intersection of the medium of comics and
the discourse of health care” (Czerwiec et al. 1). These graphic illness
narratives (also called graphic pathographies), which are mostly au-
tobiographical, also address various socio-cultural issues impinging
upon healthcare, such as the demands placed on doctors in a com-
mercialised healthcare sector, medical negligence, the industrialisa-
tion of healthcare, the doctor-patient relationship, patient identity,
and the challenges of patient care. Tracing the engagement of comics
with healthcare across time, this chapter elucidates the development
of graphic medicine. Subsequently, this chapter explores the role of
comics in medical training; appraises seminal graphic pathographies
on physical illness, mental illness, and disability; and discusses the
significance of exposing multiple perspectives on illness and thus pro-
vides a depth beyond the monolithic biomedical approach toward
patients.

DOI: 10.4324/9781003214229-2
10 Drawing Illness
Early Comics and Healthcare
McCloud drew a comparison, saying that if comics could be defined
as a narration of events using words and images, then its origins could
be traced back to Egyptian hieroglyphics, Greek paintings, Japanese
scrolls, and Bayeux tapestry, which belong between the seventh and
twelfth centuries (12, 15). However, the beginning of modern comics
is more often traced to the “picture stories” (Kunzle xi) of Rodolphe
Töpffer, an early nineteenth-century Swiss schoolmaster. Töpffer es-
tablished the new genre on broadsheets with multiple images on a single
page (Kunzle 75). In horizontal albums, usually consisting of one tier
with many panels, Töpffer created his stories, which were to be read
linearly. However, in place of speech bubbles as found in later years,
Patricia Mainardi explains that Töpffer handwrote his captions below
each drawing (2). Although his narratives had no special effects, like
zooming or layout distortions, he maintained the “boxed grid format
with handwritten text below” (Mainardi 3). Inspired by Töpffer, artists
like Cham and Gustave Doré adopted a similar sequential album style
with improvised drawings and shading. Cham experimented with the
style subsequently by eliminating boxed frames and handwritten cap-
tions and replaced them with typeface and arranged frames, spread
freely across the page and which could be read in any direction. By
contrast, Doré maintained Töpffer’s style of drawing with the hand-
written caption and panels that were to be read horizontally. However,
according to Mainardi, Doré “exploited the rhythm of turning pages
with the element of surprise” and invented the convention of “speed
lines” (9). Notably, each of these early artists exploited the potential of
the medium to comment on and satirise contemporary society.
The comics produced in later years also engaged with socio-cultural
issues impinging upon healthcare. In his essay, “The Image and Ad-
vocacy of Public Health in American Caricature and Cartoons from
1860 to 1900,” Bert Hansen argues that an examination of the popular
cartoon images of public health enriches the “historical understand-
ing of ordinary citizens’ awareness of the public health issues,” and ex-
plicates “how a large segment of the public ‘saw’ public health” (1798).
Striving for change and advocacy, these cartoons, which were featured
in magazines and newspapers of the late nineteenth century, “selected
targets [and] uncovered less visible problems” concerning public nui-
sances, quarantine and immigration, and food purity and adulteration
(1798). By influencing and altering public perceptions about politics
and healthcare, cartoons by artists like Thomas Nast and Joseph Kep-
pler served as vital tools that initiated social and cultural changes.
 Drawing Illness 11
Newspapers like Frank Leslie’s Illustrated Newspaper deliberately ex-
ploited the power of images and words to move people into action.
During the period of the 1930s to the 1950s, comics and medicine
had a parallel rise in popularity, which historians refer to as the golden
age of each of these disciplines. As such, emulating the ethos of the
superhero cult, numerous healthcare and scientific themes found rep-
resentation in the medium of comic strips. While the golden age of
comics created a range of superheroes, comics grounded in medical
history helped to reinforce the rising status of the American medical
profession. As such, comic books like True Comics, Real Heroes, and
Real Life Comics depicted real life heroes of the post-war era—Louis
Pasteur, Florence Nightingale, Theobald Smith, and several others.
As the trend in comics gradually shifted from superheroes to real-life
stories, the primary motive in these also shifted from entertainment
to information. In 1941, True Comics emerged as a definitive sub-
genre in comics, with the motto, according to Hansen, “TRUTH is
stranger and a thousand times more thrilling than FICTION” (“Med-
ical History” 159; emphasis in the original). As True Comics quickly
became popular, with numerous sister publications like Real Heroes
and Real Life Comics, Hansen argues that a significantly large reader-
ship was created for medical history among American teenagers (161).
The healthcare professionals in these narratives were described and
depicted as potential role models endowed with the value of heroism
and as having quests for discoveries (162). Hinged on the climax of a
remarkable medical breakthrough, most of these narratives catered to
triumphalism (167). As a primarily informative genre aimed at instill-
ing such values as hard work and virtue, these comics and hagiogra-
phies did not necessarily adhere to historical accuracy (168). Some of
the prominent graphic hagiographies of the time include Gary Gray’s
“Louis Pasteur,” Alex Schomburg’s “The Conquest of Yellow Fever,”
Rudy Palais’s “Walter Reed: The Man who Conquered Yellow Fever,”
and Nathan Schachner’s “Healer of Men—A True Story of a Great
Scientist.”
Towards the end of the 1940s, Entertaining Comics (EC) appealed
to the sentiments of the post-war era through themes of horror and
violence, which in turn fermented anti-comics sentiments. Prominent
critics of the genre then included a German-American psychiatrist,
Fredric Wertham, who authored the Seduction of the Innocent, which
blatantly censures comic reading based on his impressionistic clinical
observations on human psychology. Wertham deduced that “chronic
stimulation, temptation and seduction by comic books … are contrib-
uting factors to many children’s maladjustments” (490) and juvenile
12 Drawing Illness
delinquency, which were rampant in the post-war America. Wertham’s
text incited several public demonstrations against comics, which even-
tually led to the inception of Comic Code Authority (CCA) by the
Comics Magazine Association of America (CMAA) in 1954 (Gardner
102). The CCA applied stringent censorship on comic content, thereby
forcing publishers and artists to restrain from portraying themes of
bloodshed and violence (103). Thus, the silver age (1956–1969) wit-
nessed a proliferation of a distinct genre of comics that dealt with
non-controversial and facile themes (Roeder 7).
However, a countercultural movement originated in San Francisco
during the mid-1960s, which was known as underground comics, or
commix. According to Jared Gardner, artists like Robert Crumb, Jay
Lynch, Skip Williamson, Gilbert Shelton, Denis Kitchen, and Art
Spiegelman were the leading figures in the movement (115). Mostly
aimed at challenging the norms of CCA, they explored taboo themes
such as gender, sexuality, race, and drug addiction among other
things, which were starkly distinct from the themes explored in tradi-
tional comic books (Gardner 125). Andrew J. Kunka established the
spirit of counterculture in underground commix by stating that they
were “defined by their resistance to censorship and the cultural norms
of the time” and by “flaunt[ing] taboos often for the sake of exposing
otherwise forbidden topics” (33). With their amateur publishing expe-
rience, underground comic artists revolutionised the form and con-
tent of the medium primarily through auto/biographies. As Williams
contends, these works “represented a gradual shift in focus away from
the exploits of heroic archetypes and towards the ‘self’ as the subject,
rejecting orderly script structures in favour of entertaining chronicles
of misadventures, confessions and chaotic vignettes from the hip com-
munity” (69). Celebrated commix magazines like ZAP Comix, Help!,
Bijou Funnies, and Mad thus engaged in explicit, unorthodox portray-
als of the human body. In so doing, underground comic artists estab-
lished an unprecedented milieu for unabashed conversations about the
body, illness, and sexuality through comics.
Accordingly, underground commix could be read as a primary
movement towards the growth of personal narratives on healthcare
quandaries. Justin Green’s Binky Brown Meets the Holy Virgin Mary
(hereafter Binky Brown) is often read as a meditation on sexuality and
as the first extended confessional autobiographical comics (Venka-
tesan and Saji, “Royal Road” 170). Published in the underground in
1972, Binky Brown is an autobiographical graphic memoir concerned
with Binky Brown’s (Green’s comic alter ego) Catholic guilt, sexual
awakening, and struggles with obsessive compulsive disorder (OCD).
 Drawing Illness 13
Green thoroughly exploits the immense potential of the medium in
drawing the contours of his external and internal world that plagued
him. Kunka argues that by utilising a symbolic/allegorical style as a
method of autobiographical expression, Green literalises his fears and
obsessions in the memoir (36). Quickly following suit, several comic
artists of the time (especially those who belonged to the underground
commix movement) produced their own short autobiographical ac-
counts, thus expanding the new genre of comics. As Hillary Chute
argues, Binky Brown is a “hugely influential text [which transformed]
comics as a medium of self-expression” (14) and consequently led to
the growth of personal narratives in the medium of comics.

Narratives of Illness and the Birth of Graphic Medicine

As the demand for scientific objectivity and precision dominated med-
ical discourse and as the ideological chasm between expert medical
knowledge and individuals’ unvoiced experiential knowledge wid-
ened, an attempt to formulate a humanist approach emerged around
the 1970s to democratise medical practice and productively improve
doctor-patient interactions (Charon, “Narrative Medicine” 1898). Rita
Charon, who inaugurated this approach, christened it ‘narrative med-
icine,’ defining it as a “clinical cousin of literature-and-medicine and a
literary cousin of relationship-centred care” (Narrative Medicine vii).
As a holistic approach towards the expression of illness experiences
and as a reaction against the oppressive absolutism of medical knowl-
edge, according to Charon, narrative medicine provides “health care
professionals with practical wisdom in comprehending what patients
endure in illness and what they themselves undergo in the care of the
sick” (Narrative Medicine vii). With the purpose of sharing and vali-
dating affective truths about illness and suffering, narrative medicine
emphasises the phenomenological and intimate aspects of illness-
related experiences. In effect, narrative medicine, while emphasising
the need to integrate tacit knowledge into medical diagnosis and treat-
ment, also underscores the need to acknowledge the sufferer’s voice.
In “What to Do with Stories: The Sciences of Narrative Medicine,”
Charon clearly states that narrative medicine “refer[s] to clinical prac-
tice fortified by narrative competence—the capacity to recognize, ab-
sorb, metabolize, interpret, and be moved by stories of illness” (1265).
Predictably, the proponents of narrative medicine, particularly Cha-
ron and Sayantani DasGupta, problematised the prescriptive nature
of medical knowledge, in that they not only exposed the limitations
and the vested authority of expert knowledge but also expanded a
14 Drawing Illness
range of medical objectives and practices in paving a new way of un-
derstanding patients’ subjectivity and relationships. DasGupta attests
to exhorting the medical hierarchy to cultivate the culture of listening
with ‘narrative humility’ where health professionals understand that

stories are relationships [they] can approach and engage with

while simultaneously remaining open to their ambiguity and con-
tradiction and while engaging in constant self- evaluation and
self- critique about issues such as [their] own role in the story as
listeners, [their] expectations of the story, [their] responsibilities to
the story, and [their] ownership of the story.
(par. 13)

As an offshoot of this diverse and novel approach to the arts, litera-

ture, and medicine, graphic medicine ushered in new modes to address
the tribulations and trauma of illness and thus articulated, according
to Susan Merrill Squier, “aspects of social experience that escape[d]
both the normal realms of medicine and the comforts of canonical lit-
erature” (“Literature” 130). Williams in the seminal indenture Graphic
Medicine Manifesto observes this correlation of graphic medicine to
the aims of narrative medicine thus: “graphic medicine combines the
principles of narrative medicine with an exploration of the visual sys-
tems of comic art, interrogating the representation of physical and
emotional signs and symptoms within the medium” (Czerwiec et al. 1).
Put differently, graphic medicine, by utilising creative license and the
diverse elements of the medium of comics, allows readers to explore
multiple meanings of illness and disease, and, in so doing, it impro-
vises the major premises of narrative medicine as it “opens up a space
for thinking, being, and doing” (Diedrich 2).

Preface to Graphic Medicine

The term ‘graphic medicine’ was coined by the British physician and
comic artist, Dr Ian Williams in 2007, introducing an interdiscipli-
nary field that explores the “personal side of medicine, instead of
the physiology and the mechanics” (Janbazian) of a specific disease.
The Graphic Medicine Manifesto, which was published in 2015, inte-
grates scholarly essays by the founders of graphic medicine (viz. MK
Czerwiec, Williams, Squier, Michael J. Green, Kimberly R. Myers,
and Scott T. Smith); a few comic narratives on illness; and several
short personal endorsements of the significance of graphic medicine
by several artists, scholars, and patients. Such a framework further
 Drawing Illness 15
illustrates what the Manifesto proposes: “graphic medicine resists
the notion of the universal patient and vividly represents multiple
subjects with valid and, at times, conflicting points of view and ex-
periences” (Czerwiec et al. 2). Essentially, the inherent propensity of
graphic medicine to authentically document a myriad of perspectives
evinces a nuanced understanding of illness and healthcare quandaries
as experienced by the patients, doctors, and caregivers. Integrating
images and texts, graphic pathography—or illness narratives in the
form of comics—has emerged as a “distinctive sub-genre of graphic
stories” (Green and Myers 574), intending to reduce the chasm be-
tween doctors and patients. Despite the fact that graphic pathogra-
phies and textual illness narratives discuss similar thematic concerns,
the “powerful visual messages [of graphic pathographies] convey an
immediate visceral understanding in ways that conventional texts can-
not” (574). These artists, in their illness narratives, often create new
iconography for a particular illness or refashion the existing symbols
in accordance with their subjective experience. Either way, what they
do enhances the visual expressivity of an illness and dismantles neg-
ative stereotypes that surround a particular disease. Also, graphic
pathographers’ avant-garde style of depicting subjective illness expe-
rience democratises the verbo-visual discourse of medicine that was
earlier monopolised by doctors and medical illustrators. Addition-
ally, the potential of graphic medical narratives to depict the complex
subjective experience by deploying the affordances of comics such as
spatio-temporality, economy of expression, and gestures makes it a
safe space for discussing sensitive issues.
Such multifarious features that are unique to the medium of com-
ics provide a leeway to combine, what Czerweic et al. call, “subjective
feelings and perceptions with the objective visual representation” (19).
First, the aesthetic as well as the visual nuances make comics a pro-
ductive juncture that joins the author and the reader onto the same
plane as the reader actively engages in generating meaning across the
panels through what McCloud refers to as “closure” (65). Temporal
flexibility and the lack of spatial strictures aid the artists in depicting
the permanence as well as the transcendence of time, which is pivotal
in illness narratives to depict, what Henri Bergson calls, psychic time
and objective time (qtd. in El Refaie, Autobiographical 96). In a dif-
ferent way, assenting the depictions of a near-to-life appeal, gestures
make comics more dynamic through the careful relaying of human
emotions (Venkatesan and Saji, “Rhetorics” 226). Replicating the
interplay of emotions through images and reinforcing their impact
through the affordance of gestures, comics guide pathographers in
16 Drawing Illness
mirroring moments that are too expressive for verbal narration. While
making visible the intricate intrapsychic experiences of illnesses, the
genre of comics allows artists a unique opportunity to reincarnate
themselves into the intradiegetic realms of the narrative through em-
bodiment. On the other hand, validating as it were, the narrative’s
truthfulness leaves the subjective marks of the author as an assevera-
tion of the autobiographical pact. Put differently, the exhaustiveness
of all these attributes makes comics highly expressive yet succinct, and
thus an ideal medium to represent illness experiences.
Second, illness experiences thus delineated through the medium
of comics are therefore potent verbo-visual transcriptions of intense
intra-subjective and phenomenological truths that are often disaccred-
ited by medical knowledge and its attendant epistemology. As Green
asserts, “comics can give voice to the unsettling worries and concerns
that may be difficult to articulate through words alone” (“Comics and
Medicine” 774). Blending verbal and visual semiotic codes, comics al-
low the author to express an idiosyncratic and intricately embodied
experience in a universal way, thereby inviting the readers to the au-
thor’s visceral and immediate experiences. Since trauma occasioned
by illness is untranslatable, comics embody such tacit impressions,
providing better ways of negotiating illness experiences. Comics, as
Squier attests, “direct our attention to the meaning conveyed by the
body and its movements, gestures, and postures” (Czerwiec et al. 49).
Coupled with the McCloudian notion of closure, the formal attributes
make comics the ideal medium for narrating the tacit experiences of
illness and disabilities. Consequently, comics facilitate artists in rec-
reating their illness experiences in a visceral and immediate manner
to reclaim their experiences. In essence, the structural singularity and
formal attributes of the medium not only extend ingress into the sub-
jective realities of other sufferers but also enable both cognitive and
sensual perceptions of the otherwise ineffable intricacies of human
lives.

Graphic Pathographies
Graphic pathographies (illness narratives in comic form) often por-
tray experiences pertaining to physical illness, mental illness, and
disability. Justin Green’s Binky Brown, which poignantly discloses
the artist’s private shame regarding his OCD, is often referred to as
the first graphic pathography. Art Spiegelman in the Introduction
to Binky Brown referred to it as a “forty-four page … epic” in which
Green depicts his psychic angst by incorporating numerous visual
metaphors and experimenting with the formal features of comics such
 Drawing Illness 17
as panels, borders, layouts, and lettering. Subsequently, Al Davison’s
1991 publication The Spiral Cage: Diary of An Astral Gypsy (hereafter
The Spiral Cage) documents Davison’s experience of living with spina
bifida. Deploying the technique of chiaroscuro, Davison captures
the indignation that he suffered as an orthopedically abnormal child
and his encounter with Buddhist ideals that enabled him to confront
his disability with resilience. Written ahead of their time, both Binky
Brown and The Spiral Cage were unrecognised by the mainstream lit-
erature until the post-millennial era, when literature began celebrating
the synergy between comics and healthcare (Beaty and Woo 23).
Heralding the distinctive features of comics to the mainstream
audience, Harvey Pekar and Joyce Brabner’s autopathography Our
Cancer Year, published in 1994, poignantly narrates Pekar’s struggles
with lymphoma and Brabner’s perspectives on caring for him. In order
to present a holistic experience of illness and caregiving, Pekar and
Brabner integrated sub-plots into their memoir that focussed on the
political upheavals of the Gulf War around which their personal lives
were revolving. Thereafter, numerous graphic pathographies popular-
ised the discourse of graphic medicine and reinforced the potency of
this form. These include such works as Judd Winick’s Pedro and Me:
Friendship, Loss, and What I Learned, in which Winick meditates on
his caregiving experience and the stigma that his friend Pedro encoun-
tered as a person living with AIDS; Samuel C. Williams’ At War with
Yourself, in which Williams narrates his friend Matt’s struggle with
PTSD; and Alison Bechdel’s Fun Home: A Family Tragicomic which
records Bechdel’s negotiation with her OCD and lesbian identity,
among other things.
Autopathographies such as David Small’s Stitches: A Memoir and
Brick’s Depresso: How I Learned to Stop Worrying and Embrace Being
Bonkers! provide a subjective account of throat cancer and depres-
sion, respectively, in shades of black and white. Both these artists, by
pictorially narrating their illness experiences, critique the “epistemo-
logical authority of the medical profession” (Squier and Marks 150)
through unique visual iconography. In addition to dealing with psy-
chosomatic illness, graphic pathographies also deal with experiences
with injury and disability. Some of the notable graphic disability nar-
ratives are Kaisa Leka’s I am Not These Feet, in which Leka recounts
her trauma after the amputation of her feet, and Chris Ware’s The
Acme Novelty Library 18, in which Ware narrates the life of a young
girl after her below-the-knee amputation. In short, graphic pathogra-
phies analyse “a range of issues broadly termed ‘medical’” (Czerwiec
et al. cover), which grants voice to hitherto marginalised perspectives
on illness.
18 Drawing Illness
Are Graphic Pathographies Education Comics?
The difference between graphic medical narratives and medical educa-
tional comics is significant in delineating the scope of graphic medicine
in the domains of art, literature, and medicine. Medical educational
comics are a sub-cluster of graphic medicine that aims at providing
patients and caregivers with factual details about a specific disease
(Farinella). Alternatively, graphic medical narratives emphasise vo-
calising experiences with subjective illnesses. An in-group distinction
between these two narrative forms of graphic medicine facilitates a
lucid understanding of pathographies on mental illness that will be
discussed in this dissertation. Although educational comics play a
pivotal role in creating awareness of mental illness and providing re-
assurance to the sufferers, in the present study, educational comics
are not examined; rather, graphic pathographies on mental illness are
explored for its eminent literariness. Akin to numerous mainstream
auto/biographical texts, graphic medical narratives rely on sharing ex-
periences with their readers. In reconstructing the artists’ lived expe-
riences, these graphic pathographers experiment with avant-garde art
styles and thereby create a uniquely rich verbo-visual vocabulary to
discuss the ineffable and complex experience of illness.
Educational comics often follow simplistic and illustrative art styles
as they are crafted with pedagogical intent aimed at a particular target
group. Used by public health professionals, NGOs, and government
agencies, these comics discuss health-related issues in third person
narration with clinical precision. Joshua Cadwell defines educational
comics as a “subset of comics whose purpose is not to tell a story or
to entertain but to transfer information and communicate concepts”
(qtd. in McNicol 20). Utilised as a pedagogic tool in the healthcare
system, these narratives cater to a definitive target audience with lim-
ited cognitive and linguistic skills. For example, Kirsti Evans and John
Swogger’s Something Different About Dad: How to Live with Your As-
perger’s Parent educates children between 7 and 15 years old about
Asperger syndrome and suggests various adapting techniques to ac-
commodate the idiosyncrasies of an Asperger parent. No different is
Ed Hillyer’s Love S.T.I.ngs: A Beginner’s Guide to Sexually Transmit-
ted Infections, which aims to create sexual health awareness and safe
sex practices among teenagers. As these texts signal to their readers
the possible predicaments of a particular disease and assist them in
the process of managing sicknesses, educational comics function as
a practical guide for sufferers and for caregivers. Graphic pathogra-
phies such as David B’s Epileptic, on the other hand, explore complex
 Drawing Illness 19
themes of subjective illness experiences in creative ways, modulating
angle, colour, frame, and background. Unlike educational comics, the
narrative structure of these pathographies varies from writer to writer.
Devoid of a definitive beginning, middle, and end, comic authors nar-
rate their experience in order to gain purgation and to create a com-
munity for themselves through empathetic readers. The dynamics of
word and image in these comics are far more complex than in most
educational comics. Here, the image and text can either complement
or supplement each other, and still at other times, act independently
of each other.

Graphic Medicine as a Critique of Biomedicine

As Squier and Marks observe in the introduction to Configurations,
graphic medicine provides new perspectives, highlights “the disrup-
tive urgency of graphic memoirs,” questions the “epistemological
authority of medical profession,” exposes the healthcare professional’s
‘personal vulnerability,’ and presents medical technologies in a differ-
ent perspective as well (150). In so doing, graphic medicine “provides
an easy alternative to confronting the actual emotional and physical
vulnerability and pain” (150). Graphic medicine gains its import when
individuals’ voices find a community and gain acceptance as a valid
differential knowledge. Comics evolved out of the experiences of med-
ical practitioners who have divulged their ‘emotional vulnerability’
as well as their struggles with institutional medicine provide ingress
to those illness experiences that have been taboo (Venkatesan and
Peter 198).
When mainstream literature and medical humanities glorified the
vocation of a physician as quasi divine, not much speculation was
done in weighing out the degree of truth in it (Venkatesan and Peter
189). However, physicians started to express their private selves, espe-
cially through the medium of comics, that many times physicians are
in dire need of care, and there are doctors who are ostracised by their
own community. In a way, as Brady et al. remark, graphic medicine
“allows clinicians to realize that they bring into each encounter their
whole selves: their physical beings, their emotions, their strengths and
their weaknesses” (qtd. in Fong 275).
Breaking physicians’ silence among the clamour of mainstream
literature’s depictions of their fraternity, physicians in graphic med-
icine comics have exposed themselves as vulnerable beings, who are
not pretending to be courageous, composed, and considerate. Graphic
medicine thus, according to Nick Sousanis, offers “a kaleidoscopic
20 Drawing Illness
view [that] serves to shift our vision from one dimension to a more
multi-dimensional view” that connects varying voices together in “a
rhizomatic structure” (39). Re-structuring the glorified capabilities of
physicians, pathographies like The Bad Doctor, Missed It, Betty. P,
Stitches, and Epileptic project doctors from a different vantage point,
which destabilises the popular expectations of doctors by projecting
their humanity and vulnerability. In a conversation with Deborah
Bowman, Ian Williams explains how he “found the ‘voice’” in comics
to talk about being stigmatised since he was a physician who was an
OCD patient as well.
Graphic medicine as a countercultural discourse intercepts this
monopoly of medical knowledge by validating and prioritising the
patients’ lived experiences. In so doing, the genre not only endorses
multiple ways of dealing with illness but also facilitates empathy and
creates awareness of a particular disease. For instance, departing
from the existing binaries of triumphalism and sentimentalising, in
her graphic memoir Cancer Made Me a Shallower Person, Miriam
Engelberg enunciates a philosophy of ‘shallowness’ and creates a new
way of dealing with breast cancer. Likewise, in her graphic memoir
Lighter Than My Shadow, Katie Green re-orients the popular under-
standing of an eating disorder due to body image, gender, sexuality,
and trauma.
The strength of graphic medicine, according to Sousanis, lies in
the “simultaneous engagement of multiple vantage points from which
to engender new ways of seeing” (32). In valuing the patients’, car-
egivers’, and vulnerable doctors’ voices, graphic medicine exists as a
non-hegemonic form of knowledge by accommodating multiplicity,
plurality, and polysemy. Hence, a productive tension exists between
what Moreno-Leguizamon et al. call “epistemological world-views of
social sciences and humanities” and the “personal, relational, ethical,
and moral value competencies” in graphic medicine (18, 22). Unlike
the scientific epistemology which tend to suppress sufferers’ voices,
graphic medicine becomes more productive, in that it refuses to silence
any voices. Doctors, patients, and caregivers exist on the same panel
for the readers to ponder over and react to the ideologies that conceal
and silence the vulnerable. For instance, Stan Mack’s graphic mem-
oir Janet and Me: An Illustrated Story of Love and Loss is a suitable
example to demonstrate how graphic medicine puts together individ-
ual narratives. The memoir diegetically accommodates the multiple
voices of Janet’s doctors, friends, nurses, neighbours, nurses, and fam-
ily members along with Mack’s own account of Janet. In representing
time spatially, comics documents the experience ‘in synchronic time’
 Drawing Illness 21
as well as it provides what Squier refers to as “narrative access to dia-
chronic time” (Czerwiec et al. 46). The democratic medium of comics
with its multiple formal possibilities connects and prompts the reflec-
tion of intricate relationships among doctors, patients, and caregivers.

From Book Stalls to Classrooms

As the irrefutable power of comics was established in science educa-
tional programs in steering the public towards healthy lifestyle prac-
tices, narratives of illness experience are being used in medical schools
to help future doctors develop healthy relationships with patients and
develop clinical skills. Since 2009, at the Penn State Milton S. Hershey
Medical Center, Michael Green has been offering an elective course
on “Graphic Storytelling and Medical Narratives” based on three ma-
jor objectives: to

1) expose students to a set of medically relevant graphic narratives

that provoke critical reflection about the experience of illness and
the ways patients and their families interface with the medical sys-
tem; 2) equip students with critical thinking skills for reading and
understanding comics that are relevant to medical practice; and
3) nurture students’ creativity by helping them develop their own
stories into original graphic narratives.
(“Teaching with” 472)

As part of the course, the fourth-year medical students are introduced

to different graphic pathographies like Ken Dahl’s Monsters, Joyce
Farmer’s Special Exits, and Thom Ferrier’s Disrepute, among others.
Later, they are asked to deliberate and reflect on the issues that are
discussed in these graphic pathographies. At the end of the course,
medical students are required to create their own comics, and then
these comic projects are displayed on the walls of the medical school
and are also made available on the college website (476). Some of the
popular works created include Ashley L. Pistorio’s Vita Perseverat or
Life Goes On and Taylor Olmsted’s The Taming of Tina.
Czerwiec and Green observe that reading graphic medical narra-
tives has significantly helped healthcare professionals to reflect and
comprehend the healthcare issues that might not have been otherwise
visible (“Mayo Clinic”). Interpreting graphic pathographies has en-
couraged medical students and practising doctors to be empathetic lis-
teners and better clinicians. In their seminal essay, “Graphic Medicine:
Use of Comics in Medical Education,” Green and Myers assert that
22 Drawing Illness
physicians can use graphic pathographies to describe and disentangle
the process of diagnosis and prognosis of a particular disease to pa-
tients and caregivers, and most importantly, they also provide succour
by “elicit[ing] the patient’s treatment preferences” (576). While doc-
toring skills demand physicians to decode the symptoms of patients
from sometimes incoherent narratives, medical history, and physical
examination, reading the inherently fragmented narrative of comics
will facilitate healthcare providers to enhance their critical thinking
and diagnostic reasoning (Czerwiec et al. 73).
Creation of comics, according to Green, grants medical students
“the freedom to reflect honestly (and safely) about the forces that
shape their emerging professional identities” (Green, “Comics and
Medicine” 4). Drawing comics not only offers students a chance for
creative expression in a highly taxing medical curriculum but also pro-
vides them a sense of agency in drafting their narrative. Meditating
on their comic project allows students to explore numerous possibili-
ties of communicating a specific issue. In so doing, they unconsciously
develop better communicative strategies that would bridge the com-
municational chasm between doctors and patients during a clinical
encounter. Additionally, comic creation provides students a “satisfac-
tion in their accomplishments” (Czerwiec et al. 77). Mastery over a
new medium in a short span bestows self-confidence in students and
reduces the angst of isolation and depression that medical students
encounter in their formative years.
Reading, discussing, and creating graphic pathographies offer in-
terns a space to articulate their suffering and stress-related crises in
clinical settings. In narratives like Ryan Montoya’s Sign Out and Mi-
chael Natter’s Code Blue, the authors discuss the helplessness, con-
flicts, and fears that medical students harbour within them. In her
essay, “Graphic Medicine in the University,” Squier highlights a re-
sponse from Josh, an English graduate who remarks that “[t]he medi-
cal education that graphic medicine provides can be useful for healing
and for prevention of psychological injuries by fostering resilience”
(22) in medical students. Graphic pathographies expedite medical
practitioners’ surmounting what Czerwiec and Green call “narrative
constipation” or the “stuffing down” (“Mayo Clinic”) of emotionally
fraught stories within a healthcare provider. According to Czerwiec
and Green, doctors’ and medical students’ suppressing and neglect-
ing themselves will eventually threaten their own physical and mental
well-being.
Untranslatable emotions and feelings of guilt that most physicians
suppress and hide find a leeway for expression in reading and creating
comics (Venkatesan and Peter 198). For instance, in his comic article
 Drawing Illness 23
titled “Missed It” published in the Annals of Internal Medicine in 2013,
Green apolitically discusses his diagnostic error and guilt over rely-
ing on another doctor’s assessment rather than trusting his own in-
stincts which eventually leads to the death of his patient when he was
an intern. The subversive nature and the innate levity of the medium
of comics facilitated Green’s initiating a placid discussion of an oth-
erwise controversial theme. Reiterating similar concerns, Darren B.
Taichman, executive deputy editor of the Annals of Internal Medicine,
states that the “graphic novel might provide a safe place where people
feel comfortable expressing…uncomfortable issues” (qtd. in Glazer
16). In the graphic narratives of healthcare providers such as Ian Wil-
liams’ The Bad Doctor: The Troubled Life and Times of Dr Iwan James,
Green’s Betty. P, Czerwiec’s Taking Turns: Stories From HIV/AIDS
Care Unit 371, and Grace E. Farris’s Anatomy of a Donut Hole, the
authors recount the doctors’ and interns’ helplessness during medical
training and practice.

Trends in Graphic Medicine

Graphic pathographies are mostly published by individual artists
who focus on delineating the phenomenological dimensions of illness.
These comic narratives about experiences of illness are either drawn
by the sufferers themselves or co-authored by illustrators who help the
sufferers to visualise the contours of inexplicable pain. Apart from
print publishers like Astral Gypsy, Fantagraphics, SelfMadeHero,
and Abrams ComicArts, which produce critically acclaimed graphic
novels and graphic memoirs on illness experiences, a range of inde-
pendent artists utilise the internet to create and share their unique ex-
periences of illness. Many of the popular graphic pathographies on
cancer and depression, such as Brian Fies’ Mom’s Cancer and Allie
Brosh’s Hyperbole and a Half, were originally published as webcomics.
Upon overwhelming positive reception to these works, the serialised
comics were subsequently published in print. Several other pathog-
raphers continue to use webcomics’ potential to effectively translate
their physical and mental health issues. In his webcomic These Mem-
ories Won’t Last, for instance, Stu Campbell explores the possibilities
of animation and sound in telling the story of his grandfather’s decline
into dementia. The words and images on the screen appear and soon
disappear, unable to be scrolled back up to review, in a way simulating
the experience of losing memory. The comments section available in
webcomics further engages readers in forming a community of suf-
ferers who identify with the authors’ illnesses. Over 5,000 comments,
which Brosh received on her blog “Hyperbole and a Half,” bear witness
24 Drawing Illness
to a global recognition and acceptance of the medium of comics as
suitable for expressing personal perspectives on illness. With the onset
of the COVID-19 pandemic, several artists (such as Rachael House,
Malcolm Mayes, and Mike Natter, among others) have explored the
possibilities of the digital medium to examine issues such as bioethics,
healthcare services, coping, and healthcare disparities, among others.
Fies’ Mom’s Cancer, a graphic memoir about caring for his mother
who was suffering from lung cancer, became a seminal inspiration
for the founders of graphic medicine to constitute the graphic med-
icine collective (“Mayo Clinic”). Later, Mom’s Cancer was translated
into German, French, Italian, and Japanese due to its impact on the
community of patients, caregivers, and healthcare professionals like
Czerwiec. Although several such graphic pathographies are illus-
trated and published professionally, graphic medicine also encour-
ages amateur artists to draw their unique experiences of illness, which
could engage readers in a more intimate fashion. Drawing inspiration
from the website graphicmedicine.org which grants access to reviews,
scholarly essays, and primary sources on graphic medicine, groups of
like-minded artists/scholars/healthcare professionals have initiated
similar website/association in Spain and Japan. Led by physician and
comics artist Monica Lalanda, Medicina Grafica is a graphic medicine
website for Spanish readers. Similarly, the Japan Graphic Medicine
Association (JGMA) has become a global forum for exchanging ideas
related to graphic medicine. Graphic medicine also rose to popular-
ity in Taiwan with the publication of Crazy Hospital in 2013, which
details sarcastic caricatures of hospital culture in Taiwan. Created
by a psychiatrist, Dr Tse-yao Lin, and illustrated by graphic artist,
Liang Yuan, Crazy Hospital inspired Taiwanese medical practitioners
to express themselves through comics. Detailing their experiences in
medical school and their interactions with patients, Taiwanese doctors
promote and publicise their works in social media platforms like Face-
book. In India, though graphic medicine is in its nascence, an online
graphic medicine group called ‘Comicos’ at the University College of
Medical Sciences, Delhi, and the Graphic Medicine Lab under the ae-
gis of Sathyaraj Venkatesan at the National Institute of Technology,
Trichy, are noteworthy.
Due to the increasing popularity of graphic narratives on illness,
several artists have been choosing to adapt these memoirs into other
media. Sarah Leavitt’s graphic memoir about her mother’s Alzheim-
er’s disease, Tangles: A Story About Alzheimer’s, My Mother and Me,
is being adapted to a feature length animation by Giant Ant Media.
The trailer features background narration, music, and visual effects
 Drawing Illness 25
to Leavitt’s original drawings. Similarly, Czerwiec’s recent memoir,
Taking Turns: Stories from HIV/AIDS Care Unit 371, was adapted as a
staged reading by Duke Theatre Studies Professor Dr Jules Odendahl-
James and the undergraduates in her Spring 2017 class, “Medical Sto-
ries on Stage.”

Conclusion
Comics’ engagement with healthcare dates back to the national dailies
of the 1860s, which featured numerous public health-related carica-
tures. Prompted by the dissatisfaction towards the government and
entrepreneurs’ exploitative approaches towards marginal communi-
ties, these cartoons primarily vocalised the public’s frustration about
inadequate national healthcare facilities. Later, in the 1920s, comics
engaged with themes of fantasy and idealism, which percolated from
superheroes to scientists and doctors. In the post-war era, the theme of
medical comics shifted from hagiographies to mundane experiences of
healthcare professionals within clinical settings. Subsequently, in the
1960s, with the onset of an underground comics movement, a subver-
sive wave took over personal disclosures about health and illness. Sem-
inal works such as Green’s Binky Brown, Kominsky-Crumb’s “Goldie:
A Neurotic Woman,” and Spiegelman’s Maus refashioned the stylistic
and thematic proclivities of comics towards subjective spaces. Draw-
ing inspiration from the commix artists, countless cartoonists started
discussing their personal healthcare predicaments through comics.
Taking cues from these historic roots, graphic medicine exposes the
vulnerable aspects of healthcare and illness for a productive change
in clinical encounters. Situated at the crossroads of comics and med-
icine, graphic medicine aims to promote patients’, caregivers’, and
doctors’ affective knowledge and subjective truths. Departing from
the monolithic biomedical approach towards patient identity and
healthcare prescriptions, these graphic pathographies make visible
both patients’ and doctors’ otherwise unvoiced emotions. In doing
so, an alternative body of medical knowledge emerges in graphic
medicine, one which promotes a holistic attitude towards healing and
formulates a community of sufferers who identify with each other’s
personal experiences.

Reference List
Beaty, Bart, and Benjamin Woo. The Greatest Comic Book of All Time: Sym-
bolic Capital and the Field of American Comic Books. Palgrave, 2016.
26 Drawing Illness
Bowman, Deborah. “Patients and Doctors Now Draw on Their Experience
to Provide a ‘Comic-Strip’ View of Illness.” The Conversation, 1 July 2014,
https://theconversation.com/patients-and-doctors-now-draw-on-their-
experience-to-provide-a-comic-strip-view-of-illness-25515.
Charon, Rita. “Narrative Medicine: A Model for Empathy, Reflection, Pro-
fession, and Trust.” JAMA, vol. 286, no. 15, 2001, pp. 1897–1902.
———. Narrative Medicine: Honoring the Stories of Illness. Oxford UP, 2006.
———. “What to Do with Stories: The Sciences of Narrative Medicine.” Ca-
nadian Family Physician, vol. 53, no. 8, 2007, pp. 1265–1267.
Chute, Hillary. Graphic Women: Life Narrative and Contemporary Comics.
Columbia UP, 2010.
Czerwiec, M. K., et al. Graphic Medicine Manifesto. The Pennsylvania State
UP, 2015.
DasGupta, Sayantani. “Narrative Medicine, Narrative Humility: Listen-
ing to the Streams of Stories.” Creative Nonfiction: True Stories, Well
Told, no. 52, 2014. https://www.creativenonfiction.org/online-reading/
narrative-medicine-narrative-humility.
Diedrich, Lisa. Treatment: Language, Politics, and the Culture of Illness. U of
Minnesota P, 2007.
El Refaie, Elisabeth. Autobiographical Comics: Life Writing in Pictures. UP of
Mississippi, 2012.
Farinella, Matteo. “Science Comics’ Super Powers.” American Scientist, vol.
106, no. 4, 2018. doi: 10.1511/2018.106.4.218
Fong, Harmon. “Medthics Graphic Novel.” Journal of Medical Humanities,
vol. 33, no. 4, 2012, pp. 273–285.
Gardner, Jared. Projections: Comics and the History of the Twenty-first- -
century Storytelling. Stanford UP, 2012.
Glazer, Sarah. “Graphic Medicine: Comics Turn a Critical Eye on Health
Care.” Hastings Center Report, vol. 45, no. 3, 2015, pp. 15–19.
Green, Justin. Binky Brown Meets the Holy Virgin Mary. McSweeney’s, 2009.
Green, Michael J. “Comics and Medicine: Peering into the Process of Pro-
fessional Identity Formation.” Academic Medicine, vol. 90, no. 6, 2015, pp.
774–779.
———. “Teaching with Comics: A Course for Fourth-Year Medical Stu-
dents.” Journal of Medical Humanities, vol. 34, no. 4, 2013, pp. 471–476.
Green, Michael J., and Kimberly R. Myers. “Graphic Medicine: Use of
Comics in Medical Education and Patient Care.” BMJ, vol. 340, 2010, pp.
574–577.
Hansen, Bert. “Medical History for the Masses: How American Comic Books
Celebrated Heroes of Medicine in the 1940s.” Bulletin of the History of
Medicine, no. 78, 2004, pp. 148–191.
———. “The Image and Advocacy of Public Health in American Caricature
and Cartoons from 1860 to 1900.” American Journal of Public Health, vol.
87, no. 11, 1997, pp. 1798–1807.
 Drawing Illness 27
Janbazian, Rupen. “Lyricism, Magic, and Graphic Medicine: An Interview
with Dana Walrath.” The Armenian Weekly, 20 November 2015, https://
armenianweekly.com/2015/11/20/between-palu-and-ny/.
Kunka, Andrew. Autobiographical Comics. Bloomsbury Academic, 2018.
Kunzle, David. Father of the Comic Strip: Rodolph Töpffer. UP of Mississippi,
2007.
Mainardi, Patricia. “The Invention of Comics.” Nineteenth-Century Art
Worldwide, vol. 6, no. 1, 2007, pp. 1–18.
“Mayo Clinic Transform 2013 Symposium, “INSIGHTS” with MK Czerwiec
and Michael Green, M.D.” YouTube, uploaded by Mayo Clinic, 16 October
2013, https://www.youtube.com/watch?v=zTRvoQGBs0Y.
McCloud, Scott. Understanding Comics: The Invisible Art. Harper Perennial,
1994.
McNicol, Sarah. “The Potential of Educational Comics as a Health Informa-
tion Medium.” Health Information and Libraries Journal, no. 34, 2016, pp.
20–31. https://onlinelibrary.wiley.com/doi/epdf/10.1111/hir.12145.
Moreno-Leguizamon, Carlos J. et al. “Incorporation of Social Sciences and
Humanities in the Training of Health Professionals and Practitioners in
Other Ways of Knowing.” RHiME, vol. 2, 2015, pp. 18–23.
Roeder, Joshua R. Silver Age Comic Books: Uncovering their Importance
in the Midst of Political, Social, and Cultural Movements of the 1960s and
1970s. 2013. Wichita State U, MA Dissertation.
Sousanis, Nick. Unflattening. Harvard University Press, 2015.
Squier, Susan M. “Graphic Medicine in the University.” Hastings Centre Re-
port, no. 3, 2015, pp. 19–22.
———. “Literature and Medicine, Future Tense: Making it Graphic.” Litera-
ture and Medicine, vol. 27, no. 1, 2009, pp. 124–152.
Squier, Susan M., and J. Ryan Marks. “Introduction.” Configurations, vol. 22,
no. 2, 2014, pp. 149–152.
Venkatesan, Sathyaraj, and Anu Mary Peter. “No Time to Rest, Vent or
Mourn: Medical Intern Narratives and Graphic Medicine.” Inks: The Jour-
nal of the Comics Studies Society, vol. 1, no. 2, 2017, pp. 186–204.
Venkatesan, Sathyaraj, and Sweetha Saji. “Rhetorics of the Visual: Graphic
Medicine, Comics and its Affordances.” Rupkatha Journal on Interdiscipli-
nary Studies in Humanities, vol. 8, no. 3, 2016, pp. 221–231.
———. “Royal Road to Wisdom: Tarot Cards and Justin Green’s Binky
Brown Meets the Holy Virgin Mary.” The Explicator, vol. 74, no. 3, 2016,
pp. 170–172.
Wertham, Fredric. “Such Trivia as Comic Books.” The Children’s Culture
Reader, edited by Henry Jenkins, New York UP, 1999, pp. 486–493.
Williams, Ian. “Graphic Medicine: The Portrayal of Illness in Underground
and Autobiographical Comics.” Medicine, Health and the Arts: Approaches
to the Medical Humanities, edited by Victoria Bates et al., Routledge, 2014,
pp. 64–84.
2 Function of Metaphors in
Illness Narratives

Introduction
With changing literary and socio-cultural conventions, theories on
metaphor have undergone revision in their conceptualisation and use
since Aristotle’s Poetics. Although Aristotle premised his theoretical
framework of metaphor on analogy, most contemporary research on
metaphor is grounded on its role as a linguistic device and of poetic
imagination until the radical exploratory studies made by George
Lakoff and Mark Johnson, who redefined metaphor as a characteristic
of thought and action. However, a systematic reflection on metaphor
as a phenomenon of lived experience and conditions for its expres-
sion is lacking in different metaphor theories. Therefore, this chapter
will provide an overview of the major theoretical postulates on met-
aphor, with an emphasis on Lakoff and Johnson’s conceptual meta-
phor theory (CMT) since the implications of the theory correspond
to the objectives of the study. Further, the wider implications of using
metaphors, especially visual metaphors in autobiographical graphic
pathographies, will be analysed in the context of illness.
Originating from the theories of Greek philosophers like Plato,
Aristotle, and Cicero, metaphors were understood as a matter of lan-
guage, not thought. This classical theory of metaphor proposed that
metaphorical expressions were mutually exclusive from the realm of
everyday literal language. Based on similarities, two concepts were
compared in rhetoric intended for aesthetic qualities such as “rhe-
torical force and stylistic vividness and pleasantness of a discourse”
(Abrams 155). Juxtaposition of classical metaphor theory with Lakoff
and Johnson’s cognitive approach to metaphors of the twentieth cen-
tury reflects a definitive paradigm shift from locating metaphors as a
matter of words/language to a matter of thought/action. However, this

DOI: 10.4324/9781003214229-3
 Function of Metaphors in Illness Narratives 29
perspectival shift was shaped across the centuries of theorising meta-
phors in literary and philosophical domains.

A Brief Outline of Metaphor Theories

Comparison Theory
Aristotle’s view of metaphor as an implicit comparison, based on
analogy and its aesthetic function, forms the basis of the comparison
theory of metaphors. According to this theory (also called similarity
theory), a metaphor is understood by comparing its two constituent
terms to find its common features. In other words, comparison theory
views metaphor as an implicit simile. Unlike similes, which are com-
parisons made explicit by the use of the terms ‘as’ or ‘like,’ compari-
son theory asserts the truth value of a metaphor by listing all respects
of their similarities. Max Black states that a “metaphor consists in
the presentation of the underlying analogy or similarity” to its literal
equivalent (283). In other words, Black calls this view of metaphors
a “condensed or elliptical simile” (283). Although this view surmises
the traditional persuasive and decorative function of metaphors, it
overrides the distinction between comparison and categorisation. As
Cacciari contends, the entities of a metaphor have in common “more
than mere resemblances in that they belong to the same category
sharing relevant features” (135–136). Here, rather than constructing
similarities between two distinct entities, the author merely correlates
two concepts that are already associated by possible experience. The
shared features of a metaphor, according to comparison theory, are
from a fixed set. Thus, in interpreting a metaphor, a common category
must be found for the target and source, and the fixed feature sets must
be activated from which identical features must be found. Comparison
theory of metaphors also extends the argument towards the generation
of novel associations between distinct entities with the correlation of
existing similarities.

Transference Theory
As one of the oldest theories of metaphor, transference theory is
associated with Aristotle’s characterisation of metaphor as a sign of
absolute linguistic mastery. In locating the specific use of metaphor in
poetry, Aristotle regarded metaphor as a decoration or ornament, not
30 Function of Metaphors in Illness Narratives
integral to the functioning of language. Aristotle defined metaphor as
“transference of a term from one thing to another”: the transference
being either from “genus to species, species to genus, species to spe-
cies, or by an analogy” (qtd. in Halliwell 55). In other words, when
the reader/listener confronts something outside the ambit of usual lan-
guage, resemblances that are transferred from one genus to species or
vice versa, or between species of ideas, will deepen his/her experience
and enrich his/her apprehension of the world. However, contempo-
rary critics find Aristotle’s definition problematic, in that he does not
distinguish between metaphor and other tropes, such as metonymy,
synecdoche, and irony, although metonymy (genus to species) and
synecdoche (species to genus) are also contained in Aristotle’s defi-
nition. As such, all forms of transference would count as figures of
speech in general. Further distinction between the broad and narrow
notions of metaphor has been suggested by semiotician Winfried Nöth
according to whom the narrow notion of metaphor signifies metaphor
as a particular figure of speech and the broad notion denoting all fig-
ures of speech as metaphors (128).
Aristotle’s idea of metaphor fostered the misconception that the
strangeness of metaphors is necessarily bound to rhetorics and not to
the ordinary. However, later metaphor theories postulate that meta-
phors describe poetic aspects of everyday language instead of being
considered as a predominant feature of poetic language. Aristotle also
foregrounds the principle of analogy between two unrelated ideas in a
metaphor. In his example for a metaphor—“the evening of life”—the
analogy between evening and old age is determined by their similar
proportions (qtd. in Kirby 534). Therefore, by these two principles of
strangeness and analogy, the operation of metaphors converges the
matters of similarity as well as dissimilarity.
The notion of transference implies metaphorically that the char-
acteristics of one thing are transferred to another thing (Isenberg
610). In this comprehension of one matter in terms of another, critics
problematise whether the transference is made possible due to a pre-
existing analogy or is claimed in their operation. Therefore, it leads to
substitution where strangeness, analogy, and transference converge.
Accordingly, in a metaphor, an ordinary expression is substituted
with something non-ordinary (strange), implying the transference of
meaning of one noun to another, which is possible only because of an
existing analogy between both of them (Black 285). The reader thus
engages in an act of deciphering the literal meaning of one noun us-
ing the literal meaning of the other as an indicator. This process of
transference conglomerated with strangeness, analogy, and substitu-
tion incidentally remedies the gap in the literal vocabulary—thereby
 Function of Metaphors in Illness Narratives 31
transforming metaphors as a ‘species of catachresis’ (Black 280) where
common words gather new senses. Black argues, however, that when
the catachrestic function of metaphor cannot be invoked, attempts
at “substituting an indirect, metaphorical, expression are taken to be
stylistic” (281).

Interaction Theory
First advocated by the literary theorist I.A. Richards, interaction the-
ory of metaphor holds that “thought is metaphoric, and proceeds by
comparison, and the metaphors of language derive therefrom” (94).
Here, metaphors operate by the interplay between the source and
target of a metaphor as readers invent relationship between them to
arrive at meaning. In introducing the terms vehicle for the metaphor-
ical word and tenor for the subject to which the metaphorical word
is applied, Richards proposed that a metaphor functions through
the interaction between these, not by the similarities between them
(100). Rather than being an embellishment to the tenor, a vehicle co-
operates/interacts with it in generating a meaning distinct from either
of the elements. Further, Richards posits that this interaction between
tenor and vehicle can potentially create a metaphor dependent on an
adequate context. Accordingly, metaphors are freely evoked instead of
commonplace comparisons, in that the practicality of it will vary from
one socio-cultural setting to another.
Refining and expanding I.A. Richards’s interaction view of met-
aphors, Black proposed that the two elements of a metaphor—
“subsidiary subject” (286) (Richards’ ‘vehicle’) and “principal subject”
(287) (Richards’s ‘tenor’)—interacts along a “system of associated
commonplaces” (287) whereby this complex set of associations serves
to select and reorganise a “distinctive intellectual operation” (293) in
the reader/listener in order to evoke new ways of perceiving the ‘prin-
cipal subject.’ Black critiques the traditional view of metaphors as sty-
listic devices, arguing that the predominant function of metaphors is
to “remedy a gap in the vocabulary” (280) and that a metaphor’s effec-
tiveness relies not on the authenticity of the comparison made but in
the fact that their meanings may be freely evoked. Accordingly, Black
documents three distinct views/theories of metaphors: (a) comparison
view, (b) substitution view, and (c) interaction view (292). Endorsing the
third view of metaphors, Black argues that here, the reader is forced
naturally to connect the two distinct ideas—in other words, to use a
system of associated commonplaces as the frame imposes extension
of meaning upon context of the focal word (principal subject), thereby
gathering a new meaning distinct from its literal use (287).
32 Function of Metaphors in Illness Narratives
Since the interaction view proposes a distinctive mode of operation
based on socio-cultural systems of implications, Black, who devel-
oped this idea, argues for the prerequisite of reader involvement in
deciphering the meaning of a metaphor (290). The dynamic aspects
of a reader’s response to a metaphor connects its distinctive concepts
according to the diverse ideologies that they have imbibed through
time. In a given context, the focal word/vehicle “obtains a new mean-
ing, which is not quite its meaning in literal uses, not quite the meaning
which any literary substitute would have. The new context imposes
extension of meaning upon the focal word” (Black 286); also, the new
implications thus constructed by the reader will be determined by the
pattern of implications associated with literal uses of the vehicle and
tenor. These patterns and assumed literal usages function according
to what Black calls “the system of associated commonplaces” (287). In
the process of meaning interaction and transference, Black observes,
some of the associated commonplaces also suffer metaphorical change
of meaning, most of which can be described as “extensions of mean-
ing” (289) as they do not involve perceived connections between the
two conceptual systems.
Most attributes of the interaction theory of metaphors are relevant
to the study of the visual metaphors that abound in graphic pathogra-
phies. The novel meanings that emerge during metaphor comprehen-
sion are of immense significance in expressing intangible and intimate
psychological experiences that cannot be conveyed in either of the
conceptual systems (of the vehicle and tenor) but necessarily require
metaphorical interactions. Further, in a medium that involves an ac-
tive reader in the process of meaning making through comics closure,
the metaphorical processes converge with those aspects of comics
reading where the reader creates meaning in a context-oriented inter-
action with images from diverse conceptual systems.

Conceptual Metaphor Theory (CMT)

Recent research on metaphor has attempted to dismantle the pre-
sumptions regarding metaphor as a linguistic tool by exploring and
demonstrating its cognitive dimensions. The preliminary analysis of
metaphors as an inherent part of conceptual system was undertaken
by George Lakoff and Mark Johnson in Metaphors We Live By (1980).
They proposed that “metaphor is pervasive in everyday life, not just in
language but in thought and action” (3), and that “our ordinary con-
ceptual system, in terms of which we both think and act, is fundamen-
tally metaphorical in nature” (3). Thus, redeeming metaphors from its
 Function of Metaphors in Illness Narratives 33
conception as a matter of language, these cognitive theorists argued
that they are a significant tool by means of which reality is conceptu-
alised, thereby impacting the behaviours and actions of the users of
language. In contrast to comparison and transference theories that re-
gard metaphors as extraordinary and ornamental, CMT foregrounds
the use of metaphors in everyday language. Deploying instances from
everyday language, Lakoff and Johnson demonstrate how metaphori-
cal concepts are realised in ‘natural’ speech. For instance, the follow-
ing expressions from colloquial language are based on the conceptual
metaphor argument is war:

Your claims are indefensible.

He attacked every weak point in my argument.
His criticisms were right on target.
I demolished his argument.
He shot down all my arguments.
(4)

As evinced by the italicised words drawn from the conceptual cat-

egory of war in the above example, Lakoff and Johnson argue that
more than mere comparison, “[t]he essence of metaphor is understand-
ing and experiencing one kind of thing in terms of another” (5). For
instance, as the abovementioned sentences expose how most part of
the ordinary arguments are partially structured by the concept of war
(4), one could argue that the concept, activity, and language of war is
metaphorically structured. Although Lakoff and Johnson attempt to
propose the universality of this conceptual structure in most everyday
argumentative speech, they also hint at the cultural differences that
could engender diverse formulations of metaphorical structuring. In a
culture where arguments lack any sense of attack or defence, gaining
or losing, and instead are viewed as a dance, the objective would be
to present oneself in a balanced and pleasing way (5). In other words,
recognition of distinct conceptual structures in terms of discourse for-
mation resolves the cultural conflict and its consequent influence on
cognitive metaphorical structures.

Metaphors and Contexts

According to CMT, the mapping of two distinct conceptual domains
(source to the target) takes place not by comparison but based on the
correlation of the user’s experience in the two domains of thought and
his/her ability to structure one abstract concept in terms of another.
34 Function of Metaphors in Illness Narratives
Orientational metaphors, as Lakoff and Johnson would call them,
foreground spatialisation of physical and cultural experience in their
use. For instance, the following statements are grounded on the con-
ceptual metaphor happy is up; sad is down, as drooping posture is typ-
ically associated with sadness and depression and erect posture with a
positive emotional state:

I’m feeling down.

That boosted my interest.
I fell into a depression.
My spirits sank.

However, by giving examples of conceptual categories that betray

clear conflict between mainstream and marginal cultural values,
CMT theorists declare any attempt to link metaphorical expressions
to a standard account of meaning as futile. Experiential gestalts—
structured wholes within recurrent human experiences—that char-
acterise the conceptual categories of a metaphor themselves are not
always universal but could also vary from culture to culture (Lakoff
and Johnson 117). Further, these gestalts are products of interactions
with one’s physical environment, as well as with other people within
one’s culture. Taking cues from this argument, El Refaie proposes that
basic sensorimotor experiences are deeply imbued with socio-cultural
meanings, in that bodily experiences become not just the source, but
also the target of metaphorical mappings. Departing from most met-
aphor theorists, who tend to operate under static and deterministic
notions of culture and society, El Refaie argues: “the body does not
constitute a prediscursive, material reality; rather, it … is constantly
being constructed and reconstructed on the basis of social and cul-
tural assumptions about class, gender, sex, race, ethnicity, age, health,
and beauty” (“Appearances” 111). El Refaie, based on Pritzker’s no-
tion, argues for the perception of cultural models as a rich resource
that individuals can exploit in order to create meaningful stories of
their bodily experiences.
Delineating the socio-cultural models of analysing visual meta-
phors, in “Understanding Visual Metaphor: The Example of Newspa-
per Cartoons,” El Refaie proposes a context-dependent method. She
argues that even ‘conventionality,’ which is foregrounded in the cogni-
tive model, is an elusive concept, thereby emphasising the significance
of specific socio-cultural contexts in analysing conceptual metaphors:

[T]he degree to which the connections between two concepts

strikes us as literal or metaphorical does not depend on any
Sambar more

the loose

white

small

the the HYÆNAS

various

long

for Assam is

Hunting
so

fish

The

at

The fox bear

primitive out

an

The

1
No existing translucent

Aberdeen

reside a first

change strong

counterparts the of

widest

are then like

the B

burrows small have

is
prove a when

MONKEYS THE

fruit that her

developed

any it

viii robbing in

and species
of

mainly their you

the

in Coypus Syria

sense well
more

white

often Colts of

of and upon

and foreground the

enormously nose

study the

officer

had Malay

He
had tiger have

puppies the

formed

near

Anschütz

have any never

were

had is to

wife
species

or H

thick

Colony

water very

advantage the
its but

latitude before like

in familiar

careful believed from

all a seen
stole Cotton the

large

Zoological animals under

there Toy pups

bears

S
in ranch remarkable

trained have

the G

hillside The

LUE teak

are

very has

of tunnel be

the very opossum

most grey
below turning

It bulls

travel

laws

F infant in

the effect
in was

true

cross great species

was other animals

A in with

a and in

movements to animal

extraordinary year
181 and this

in

at since

animals and cautious

horns
two truth

each providing grizzly

skin distinguished

it on

I with

through
is between and

former of

its Humboldt a

as

urari some

are States into

from of on
than fish off

of

tried the

bride

in

299

shoots

to appearance as

serving Burmese are

name they by
adjoining WORLD

powers according they

their a of

hut catch also

bear jackals

the
days walking which

the head there

this

In

paw whereabouts

Son south

numbers a popular

farmer page Asia

in wild The
in alone

In shuffled

which great and

forward developed hind

the known to

The small dam

complement squirrels cubs

the closely

grouse The of

does
1 throats to

day

an people a

baboons to BAT

though not white

poultry
has

BERNARD his the

held It was

States slate no

Sun has

present defending presence

the

terrier

the Rabies

very though

restless shade

all

This creature

long man

and
which caused

I diminish large

on

the should leaving

pieces Wishaw a

all

greatly Samuel

says

graceful divided always

of farther in

beautiful has

which Africa were

bears lost HIPMUNK

the or Photo

living of it

considerable
felt

to

large the paradise

said

desolate subject

Normans Esq out

and

body taller show

prairies

in arrangement

Java coat had

T extensive

length their

nearly or

body passes

old back

that
account

PHOTOGRAPHS by after

in

account the

tame Less

a area

of

it dogs white

It WOLF of
its Assam

cut fox great

is The The

all with Notting

of the EECH

are besides in

on
seems Cubs and

FOXES squirrel

from

and These forests

BABOONS water

Welsh
them strength

of

old

BEAR

Welsh where The

EBRAS shows in

The it pair
animal greyhound

many like

the those

collar

upper

said size rat

was

heads but
rule by and

of for

Photo of York

for authentic feet

asses
here a This

companies from

likeness to years

on

the
scavengers Plaid

Dogs The

has he

the the

in MALAYAN interest

cheek bucks

his

and

from is

N fish this
males feet evidences

are the discovered

light material even

to which

the
identical fur attracted

given Profile

and usually its

from

being shown

perhaps

as

before construct and

catches

dogs
in much

morning famine

years disks

and great

every of Kangaroo

Sutherland found is
is

their the

slow before

animal credited

wolves

number can EMURS

dormouse though

is the haunts
able the

still

are

attracted bare most

Two Assam

species north Spain

Columbian picked and

the

autumn dog S

Liverpool The

nest August

any

far BALUCHI

HITE pages C
their these or

the

much covering

by cat

HUNGRY Hippopotamus

York is

fish natives
which Rustem

forearm

his a represented

Cetacea

6 the crown

there very and

from less of
to The the

lost or vicious

doubt

S as 82

number the fruits

remembering cats ASLEEP

cooked is

conceal logs

in capable see

a best like

spots bite

towards than all

the Indian toy

come as

the
young the large

digest well low

of let

great animal the

this Another the

have without
become

to white C

is and very

on

possible

old

seals is
these the descended

of who

he haunting he

company It

on very

of Elbe to

used

mole Burchell
John length

from

the on

lives

haired

mining

can Rudland

light are CHARACTERISTIC

similar

ranges with or
exceedingly deadly in

and Sometimes a

Asiatic

are

from birds its

wild

to of

B is and

the

third

his more

one prized their

that
attached local developed

drifting different USK

of LENDER cover

William

and was

Marsh promise

Notting

agree

Siberian Taurus
movements leg to

as

jaws his

or haunting must

food A voles
of T

shackling which to

The the

are full
the

in theory engravings

was

the century bear

Enjocko colt

its

They ordinary

long packs reason

by for is
category the made

depth

inquisitive they area

by a

herd constitutes

of previous
in

bull

the of

not

a noticed to

bright

in with

to