The Perils and Possibilities of Retrospective Diagnosis

In this post Anna Jamieson explores researchers’ urge to retrospectively diagnose historical and literary figures, outlining the dangers and possibilities of such diagnostic endeavours.

In 2001, The Atlantic published an article by Cullen Murphy examining the tendency for doctors, psychiatrists and historical researchers to get “carried away” with diagnosing medical issues of the past. Murphy critiques the ways that historical figures, long overdue their annual checkups, often become the topic of sustained historical interest, as “hobbyist detectives” take satisfaction in working out “what’s wrong” with literary characters or historical actors. Most striking is Murphy’s conclusion, which discusses an article published in the Canadian Medical Association Journal. The article takes on the ‘neurodevelopmental and psychological problems’ of A. A. Milne’s Winnie the Pooh, whose cast, it claims, are ‘Seriously Troubled Individuals’. According to the CMAJ article, Pooh suffered from ADHD, Eeyore shows signs of chronic dysthymia, Piglet clearly suffers from anxiety disorder and Tigger exhibits a recurrent pattern of risk-taking behaviours.[1] Murphy summarises that the article “recommends a variety of interventions, from methylphenidate (Pooh) to fluoxetine (Eeyore) to paroxetine (Piglet) to clonidine (Tigger).”[2]

For those familiar with the idiosyncrasies of these characters, this analysis might raise a smile. But whilst playful, Murphy’s mention of Milne’s anthropomorphic band of woodland critters and their later diagnoses reminds us of the intense historical preoccupation with this type of retrospective musing. We do not need to look far to find examples of assigning modern diseases to historical personalities: Immanuel Kant is bestowed with Alzheimers, Frédéric Chopin with cystic fibrosis, Hamlet with melancholia, Catherine the Great with syphilis, and Van Gogh with a web of psychiatric disorders that led to his suicide in 1890 — to name a few. In 1969, the dangers of projecting current medical thinking upon past individuals and their health was made clear when psychiatrists-turned-historians Ida Macalpine and Richard Hunter wrongfully diagnosed King George III with porphyria. Seeping into broader cultural discourse, this diagnosis was later used in Alan Bennett’s play, and the subsequent film, The Madness of King George (1994).[3] As historian Jo Edge described in her article for the Wellcome Collection, to make this conclusion “the authors combed the voluminous records produced by George’s physicians during his several periods of incapacity, and picked the symptoms that suited their conclusion.”[4]

Charles Turner, George III as he was in his final illness, 1820
Source: Wellcome Collection

Every few years a medical humanities article surfaces that enshrines the challenges of retrospective diagnosis and charts its dangers. Often pointing out the ways that some researchers conveniently select sources to match their hypothesis when flexing their diagnostic muscles, others look towards the pitfalls of relying on speculation to come to their conclusions. As Axel Karenberg lamented in 2009, this type of research embodies an irresolvable methodological issue through the “unlimited range of speculation” it invites, due to the fact that the patient in question can never be physically examined. Ten years later, an article published in The Lancet by Matthias Schmidt, Saskia Wilhelmy and Dominik Gross agreed that an “absence of knowledge” meant that any diagnostic endeavour was “susceptible to speculation, rumours, and conspiracy theories.”[5]

Another key issue for these writers is that “medical knowledge itself changes over time”.[6] Unpacked by Schmidt et al, critical to the attribution of any disease is the range of “customs, environment, working conditions, nutrition, medical attitudes and practices” that impacts the patient, many of which are impossible for the historical researcher to trace.[7] Highlighting the ways that diseases are impacted by their social context, moreover, emphasises the complexities of applying today’s diseases on the past. Most recently, neurologist A. J. Larner has neatly summarised this range of arguments against retrospective diagnosis, with a reliance on second hand evidence, a lack of relevant primary sources, a failure to understand an illness’s rightful context and the ethical dilemmas surrounding patient consent all coming under fire.[8]

This raft of criticism aside, these writers simultaneously admit to the potentially productive encounter that anachronistic diagnosis can allow. For the medical historian considering past patients or illnesses, the complete avoidance of any diagnostic activity is impossible. A more nuanced, creative approach might in fact prove illuminating, if researchers tread carefully across their diagnostic endeavours. As Roy Porter optimistically proclaimed, “medical sociology and anthropology can prove immensely suggestive for the historian trying to breathe life into sufferers long since dead and gone.”[9] Despite his initial concerns, Karenberg builds on Porter’s view, suggesting that we can view pathobiographies as “windows of opportunity,” as unique lenses through which to unearth past medical practices and perceptions.[10] These commentators contend that if sources are approached critically, their historical and social context taken seriously, and the quest for a static diagnosis rejected, then a more insightful, dialogical explanation might be reached.[11]

How best to proceed then, given these debates, in the diagnostic activity that much scholarship demands? Paying careful attention to place and specific symptoms is vital, enabling a malleable diagnosis that does not necessarily solidify the patient’s health condition, but provides insight into time, society, space or place. As Edge argues, the easy application of a modern medical condition onto the past serves to flatten out our understanding of contemporary life. “It’s much more interesting,” Edge writes, “to examine the cultural and social context in which these accusations arose to get a fuller picture.”[12] Schmidt, Wilhelmy and Gross agree with this, arguing that whilst it may be the task of historians to interpret the past, it is more important to uncover what “contemporaries thought about the person’s condition, how they came to their assessment, and how they dealt with the situation.”[13] Embracing a multifaceted approach, then, uniting a touch of speculation with a sustained focus on context is surely the best way forward.

An additional step in this focus is to administer self-reflexivity about our own context, along with the types of illnesses we as historians are most prone to project upon our case-studies. In my own research on the relationship between representations and lived experience of women’s mental illness in the late eighteenth and early nineteenth century, I have admittedly found myself searching records for mentions of specific symptoms that match my own diagnosis surrounding the mental health of a case study, and a disorder that I have, often subconsciously, already bestowed upon them. In a similar way that I might hunt for instances of a historical woman’s agency, power or even nascent feminism, likewise I have had to check myself when I too have got carried away when piecing together one’s psychiatric past. Thinking about our own subjective bias and unconscious attempts to frame certain individuals as patients, sufferers, agents, or survivors — all with specific conditions, disorders, and emotions in tow — allows us to uncover whether we employ various diagnoses to better suit our conclusions and politics, celebrating or rejecting specific illnesses in favour of others. Critically, being self-reflexive means that we are willing to change our minds if necessary, admitting any mistakes as we go.

As the Covid-19 crisis has highlighted, symptoms surrounding any illness might shift, develop and mutate over time. Over the last few months, attempts at self-diagnosis have been common, as emerging symptoms filter into public consciousness. Many of us have been retrospectively diagnosing ourselves, family and friends, in the absence of proper testing and as new symptoms emerge. In one way, recent events have highlighted the natural human tendency to fall into the habit of retrospective diagnosis instinctively; at the same time, our reliance on speculation, intuition and common sense over the last months align with the essential tools needed by medical researchers when attempting to increase their understanding of the past. Adopting an attitude which errs towards ethics and elasticity seems to be the order of the day.

 

References

Edge, Joanne, “Diagnosing the Past,” Wellcome Collection Blog, 26 September 2018

Karenberg, Axel, “Retrospective Diagnosis: Use and Abuse in Medical Historiography,” Prague Medical Report 110, no. 2 (2009): 140–145

Larner, AJ, “Retrospective Diagnosis: Pitfalls and Purposes,” Journal of Medical Biography 27, no. 3 (August 2019): 127—128

Murphy, Cullen, “Second Opinions: History winds up in the waiting room,” The Atlantic, June 2001

Muramoto, Osamu, “Retrospective diagnosis of a famous historical figure; ontological, epistemic, and ethical considerations,” Philosophy, Ethics and Humanities in Medicine 9, no. 10 (2014)

Macalpine, Ida, Richard Alfred Hunter, George III and the mad-business (Allen Lane: The Penguin Press, 1969)

Porter, Roy, “The Patient’s View: Doing Medical History from below,” Theory and Society 14, no. 2 (1985): 175–198

Schmidt, Matthias, Saskia Wilhelmy and Dominik Gross, “Retrospective diagnosis of mental illness: past and present,” The Lancet 7, 1 (2019): 14–16

Shea, Sarah E., Kevin Gordon, Ann Hawkins, Janet Kawchuk, Donna Smith, “Pathology in the Hundred Acre Wood: a neurodevelopment perspective on A.A.Milne,” Canadian Medical Association Journal 163,  no. 12 (2000): 1557–1559

Bio

Anna Jamieson is a PhD researcher in the History of Art department at Birkbeck College, University of London. Her work examines cultural, social and institutional responses to women’s mental illness between 1770—1830, considering the interplay between stereotype and lived experience. She is on Twitter @annafranjam

[1] Sarah E. Shea., Kevin Gordon, Ann Hawkins, Janet Kawchuk, Donna Smith, “Pathology in the Hundred Acre Wood: a neurodevelopment perspective on A.A.Milne,” Canadian Medical Association Journal 163,  no.12 (2000): 1557–1559.

[2] Cullen Murphy, “Second Opinions: History winds up in the waiting room,” The Atlantic, June 2001.

[3] Ida Macalpine and Richard Alfred Hunter, George III and the mad-business (Allen Lane: The Penguin Press, 1969).

[4] Joanne Edge, “Diagnosing the Past,” Wellcome Collection Blog, 26 September 2018.

[5] Matthias Schmidt, Saskia Wilhelmy and Dominik Gross, “Retrospective diagnosis of mental illness: past and present,” The Lancet 7, 1 (2019), 14–16.

[6] Axel Karenberg, “Retrospective Diagnosis: Use and Abuse in Medical Historiography”, Prague Medical Report 110, no. 2 (2009): 145. Osamu Muramoto, ‘Retrospective diagnosis of a famous historical figure; ontological, epistemic, and ethical considerations’, Philosophy, Ethics and Humanities in Medicine 9, no.10 (2014).

[7] Schmidt et al, “Retrospective diagnosis of mental illness: past and present.”

[8] AJ Larner, “Retrospective Diagnosis: Pitfalls and Purposes,” Journal of Medical Biography 27, no. 3 (August 2019): 127—128.

[9] Roy Porter, “The Patient’s View: Doing Medical History from below,” Theory and Society 14, no. 2 (1985): 184.

[10] Karenberg, “Retrospective Diagnosis,” 145.

[11] Karenberg, “Retrospective Diagnosis,” 145.

[12] Edge, “Diagnosing the Past.”

[13] Schmidt et al, “Retrospective diagnosis of mental illness: past and present.”

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