Music to accompany the entry: Frisell, Carter & Motian "Worse and Worse"
For some decades, I have been confounded by the irrationality and viscosity of medical diagnosis-making, at least in some cases. Once a diagnosis is made, no matter how groundless, it tends to persist and any reasonable doubts are then erased from human consciousness. Thus, it becomes a delusion.
The current definition of delusion, now enshrined in DSM–5, can be traced back to Jaspers and his General Psychopathology (1913). His famous three ‘criteria’ – falsity, certainty and incorrigibility – form its core. He also stressed the element of sheer impossibility at the heart of it. I would argue, however, that of these three, it is certainty and incorrigibility that are the principal components of delusion. Scientists (and doctors, in their medical capacity, should normally belong to this group) often form false judgments, but as long as they are prepared to review them and be self-critical, such judgments are not delusions. The advice of Sherlock Holmes is invaluable in the art of deductive reasoning: firstly to exclude the impossible and then deal with the improbable. What is conspicuously missing in delusion is doubt; delusion is fuelled by some insatiable and unrealistic desire for absolute certainty.
Any diagnosis of syphilis made before the pathological agent had been discovered and specific tests for it had been designed, carries the risk of being delusional, unless it is doubted and remains only a hypothesis. The cause of syphilis was not discovered until 1905, when Schaudinn and Hoffmann identified Treponema Pallidum as necessary to its aetiology. This was the first scientific step towards finding a cure for this much feared disease. Some dangerous substances such as arsenic and mercury had been used as a treatment, but these created more problems than they solved. Penicillin, discovered by Fleming in 1928, made all the difference. It came into clinical use in 1942 and changed the syphscape almost instantly. Until then, syphilis had been described by many as the Great Imitator of all diseases. Undoubtedly, this was due to the ignorance of its aetiology, which led to many conditions being misdiagnosed as syphilis. As Quétel (1990) has aptly commented, this illness was more of a cultural than a medical phenomenon. Europe was in the grip of syphilophobia, which was only mirrored by a syphilomania in diagnosing the condition!
My first important encounter with a ‘delusional diagnosis’ was when I became interested in Nietzsche the philosopher and Nietzsche the man. I was struck by the sheer impossibility of dementia paralitica (tertiary syphilis), a diagnosis which he received from a doctor at the nursing home to which he was admitted in early 1889, following his total mental collapse in Turin. Ironically, the doctor was called Dr Wille (German for “will”). He was blissfully unaware that Wille zur Macht (“will to power”) was one of Nietzsche’s cardinal ideas; he hardly knew who Nietzsche was. This diagnosis, which was prevalent in nineteenth century mental asylums throughout Europe, lived on for more than a hundred years, repeated ad nauseum by all his commentators and biographers. Even Jaspers, who of all psychiatrists and Nietzsche scholars should have known better, joined the chorus of deluded diagnosticians. Astonishingly, Nietzsche never had a single sign or symptom of syphilis as I have discussed in my paper The Madness of Nietzsche: A Misdiagnosis of the Millennium? (2000). He often stressed that the search for truth was never to be the search for certainty, an imperative that was blatantly ignored by his biographers and scholars for over a century. The above case study has lead me to unexpected findings, which I have explored in my various publications.
My second compelling encounter with ‘delusional diagnosis’ concerns Schubert. Syphilis is mentioned as the tag word every time anyone speaks about the composer, and this sadly includes the BBC. I would like to ask these people: what is the relevance of syphilis to Schubert's music? Does his music sound syphilitic? British broadcaster, Sara Mohr-Pietsch, cannot resist the compulsion of syphilomania each time she talks about Schubert on BBC Radio 3. And some years ago, Raymond Tallis, a professor of geriatric medicine and a self-styled philosopher, was interviewed on Desert Island Discs. He requested that Schubert’s String Quintet in C Major be played and commented that it made him humble to think that the composer wrote it as he lay dying of syphilis. I can tell you, almost certainly Schubert did not die of syphilis! The basis of the diagnosis for his six-year illness was made by his cataloguer, a certain Herr Deutsch, who had read the available correspondence related to Schubert. Apparently, he read ‘between the lines’. One could only wish that he had read the lines and thought critically about the impossible and the improbable. If a professor of medicine repeats the “diagnosis” of an amateur diagnostician and accepts it as given, then others have little chance to challenge the delusion. However, during a Schubert-themed week on BBC Radio 3, a couple of years ago, Professor Robert Winston was the only scientist-doctor who refused to believe in the diagnosis of syphilis for Schubert. I take my hat off to him! In Schubert’s case, the only symptom on which the diagnosis of syphilis hangs is the rash he developed on his scalp (as enshrined in a letter from his friend). But there are 28 causes of scalp rash listed on Healthline, among them Lupus Erythematodes, Hashimoto’s disease, Crohn’s disease and hypopituitarism. None of these conditions were diagnosable during Schubert’s lifetime. The description of a typical syphilitic rash on the palms of his hands, soles of his feet or his thorax was conspicuously missing. To make a viable diagnosis of any condition, one must know the pathogenic factor and perform appropriate tests. No doctor of a sound mind would have diagnosed syphilis today without this process. And no doctor of a sound mind should speak of a disease that cannot be proven on a patient who has been dead for well over a century! What cannot be considered, proved or disproved must be passed by in silence, as Wittgenstein advised.
In his Pensées, Blaise Pascal discerned three sources of belief: reason, custom and inspiration. Inspired by this great scientist and philosopher, I would suggest that the sources of delusional diagnosis are ignorance, the need for certainty and the drive to appear clever. Even professors, scholars and BBC commentators fall into the trap of unreason and vanity. Or perhaps there is another reason for this unreasonable attitude – seeking sensation and having ‘one up’ on a genius. And it feels safe to hide behind the “authority” of the herd. Nobody has suggested that the alleged syphilis had any influence on Nietzsche’s or Schubert’s creativity. So why not claim that he had a more banal disease such as chicken pox or measles? Because the zeal for sensationalism would remain unfulfilled, a zeal which, to many envious commentators, seems more important than simply appreciating and admiring the works of a great man.
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