a sort of pidgin English

The concept of diagnosis is contingent on the concept of disease. Diagnosis is the name of a disease, just as, say, violet is the name of a flower. For example, the term "diabetes" names a type of abnormal glucose metabolism. ... Diseases (lesions) are facts of nature, whereas diagnoses (words) are artifacts constructed by human beings.
  ... Names, semanticists love to remind us, are not things. Manipulating things is difficult, sometimes impossible. Manipulating names is easy. We do it all the time. Violet may be the name of a flower, a color, a woman, or a street. Similarly a disease-sounding term may be the name of a pathological lesion or bodily malfunction, or the name of the malfunction of a car, computer, or economic system, or the behavior of an individual or a group. ... We cannot distinguish between the literal and metaphorical uses of the term "disease" unless we identify its root meaning, agree that it is the literal meaning of the word, and treat all other uses of it as figures of speech. In conformity with traditional practice, I take the root meaning of disease to be a bodily lesion, understood to include not only structural malfunctions but also deviations from normal physiology, such as elevated blood pressure or lowered white cell count. If we accept this definition, then the term "diagnosis," used literally, refers to and is the name of a disease, and used metaphorically, refers to and is the name of a nondisease.
  ... Historically, scientific medicine is based on the postmortem examination of the body. Recalling his early work as a neurologist, Freud proudly reminisced: "The fame of my diagnoses and their post-mortem confirmation brought me an influx of American physicians, to whom I lectured upon the patients in my department in a sort of pidgin-English." In scientific medicine, the pathological diagnosis always trumps the clinical diagnosis.
  The use of diagnostic terms becomes problematic when the conditions they name are not disease but merely subjective, unverifiable complaints, referable to an individual's body, behaviors, or thoughts (communications). Psychopathology is diagnosed by finding unwanted behaviors in persons or by attributing such behaviors to them. For example, the term "kleptomania" is both a phenomenon and a name; diagnosis and disease are one and the same. Once "named," the diagnosis of a mental illness validates its own disease status. Psychopathology, unlike organic pathology, can change with the nosology—changing the name can convert disease into nondisease and vice versa (for example, homosexuality into civil right, smoking into nicotine dependence). Mental diseases are, a fortiori, diagnoses, not diseases.

Thomas Szasz, Pharmacracy: Medicine and Politics in America (2001:28-30)

Cui bono?

People often assert that they are ill or that another person is sick. It is an error to believe that people say these things only because they have a disease or only because the person they call sick has a disease. People are often sick but do not say so or say so only to a few confidants, and they often assert, for a variety of reasons, that others—about whom they know next to nothing—are sick: thus, people simulate illness or malinger (to avoid military service), simulate health or deny illness (to avoid medical attention), and claim that others are sick by diagnosing them (to justify treating them as patients). These elementary truths have not been lost on artists, who provide us with perceptive accounts of the often complex and devious motives of patients and doctors.
  Having a demonstrable disease is not enough to explain why the subject asserts that he is ill (assumes the sick role) or why others assert that he is ill (place him in the sick role). To understand the myriad nonmedical meanings and consequences of illness—that is, the tactical rather than descriptive uses of terms such as "ill" and "patient"—we must, at least temporarily, ignore the pathological dimensions of the concept and instead focus on the classic problem, Cui bono? Cicero explained the importance of posing this question, primarily to oneself, as follows: "When trying a case L. Cassius never failed to inquire, 'Who gained by it?' Man's character is such that no man undertakes crimes without hope of gain."
  No man asserts that he or someone else has an illness without hope of gain. The potential gains, for oneself or others, from asserting such a claim—for example, securing medical help, monetary compensation, excusing crime, and so forth—are virtually endless. They depend on the claimant's character and motives, the social context in which the claim is advanced, and the ever-changing legal and social milieu in which medicine is practiced.

Thomas Szasz, Pharmacracy: Medicine and Politics in America (2001:6-7)

plague throughout

As a science, medicine rests on and makes use of the same methods and principles as the physical sciences. One of these principles is that the observer is a person, and the object he observes is not. Chemists and physicists observe, for example, the characteristics of various elements and classify them as helium, lithium, uranium, and so forth. The classification serves the interests of the classifiers. The objects classified have no interests.
  To understand the many conceptual, economic, and political problems that beset contemporary medical practice, that is, medicine as health care, we must distinguish between scientific medicine, whose objects of study are diseases that affect human beings, and clinical medicine, whose objects of study are persons, usually called "patients." Making this distinction does not imply that one is intellectually, morally, or practically better or more important than the other. Each enterprise has its own agenda and vocabulary.

· The aim of scientific medicine, an enterprise barely 150 years old, is to increase our understanding of the causes and cures of conditions scientifically defined as diseases. The aim of clinical medicine, which may be said to be as old as civilization, is to help persons regarded as sick recover their health.

· The practitioner of medical science seeks to understand disease. The practitioner of clinical medicine seeks to relieve dis-ease.

· Scientific medical knowledge is indifferent to individual or collective human well-being; it may be equally useful for biological warfare and the relief of human suffering. In contrast, the raison d'être of clinical medicine is the welfare of the patient.

... In the ancient world, disease was a gnostic concept, concerned with "spiritual truth," not with empirical evidence. In Biblical, Greek, and Roman accounts, disease is a holistic-theistic concept that precludes distinguishing between literal and metaphorical illnesses, between diseases of the body and diseases of the mind. There is no Latin word for our scientific concept of disease. When the Romans spoke of disease, they used the word "morbus"—the root of the English words "morbid" and "morbidity"—which also means disaster, fault, and vice; or the word "malum"—the root of such English words as "malefactor" and "malevolent"—which also means evil, harm, hardship, and punishment. The King James Version of the Scriptures uses the terms "murrain," "plague," and "pestilence," instead of the term "disease." The Revised Standard Version uses "plague" throughout. Accordingly, the act of healing entailed intermingling natural and supernatural means of influence, medical and religious methods of treating the body and the mind.
  ... Deluged by incessant advertising and propaganda about medical treatments, people forget that Christianity is not only a faith of redemption but also a faith of healing, of both body and soul. Unlike Abraham, Jesus is not only a prophet, he is also a healer, the Divine Physician, the Savior (der Heiland in German). For centuries, Christians regarded sickness as punishment for sin, curable by means of prayer, repentance, sacrifice, and the aspersion of holy water by a priest, the representative of an all-forgiving deity.
  To be plague-stricken was to be smitten by God. This put people in a bind: They believed in the theological explanation of the "plague," at least in part, because they could not get at the natural, physical cause of it, and then they refrained from trying to get at the root of the evil because they thought the evil was brought on by the hand of God. Furthermore, everyday life was replete with proof of the efficacy of miraculous cures for illnesses of all kinds. Shrines with powers of healing dotted the Christian landscape. More than 5 million pilgrims a year still visit Lourdes, and, to this day, the Vatican's official procedure for sanctification depends on medical proof of the would-be saint's having performed at least two miraculous cures.
  ... In short, prior to the nineteenth century, neither physicians nor patients had a precise idea about what was and what was not a disease. Disease was simply a discomfort and a danger, often leading to death, to be avoided and relieved as best one could. ... As the taboo against treating the body slowly lifted, there arose a diverse corps of professional healers: barber surgeons performing operations; herbalists prescribing medicines derived from plants; and doctors of medicine relying mainly on purging the body of presumed toxic substances believed to be the causes of disease.

  ... The waning influence of religion and the waxing prestige of science were slow and gradual processes. In the sixteenth century, the Church began to authorize the dissection of executed felons. Although physicians participated in this enterprise, the true fathers of anatomy were the great Renaissance artists, especially Michelangelo and Leonardo da Vinci.
  ... Once the secrets of nature are revealed, they cannot be ignored. Physicians and lay persons alike began to view the body as a machine whose workings must be understood, rather than merely manipulated in the tradition of herbal empiricists. The stage was now set for the development of the scientific diagnosis of patients, both dead and alive. The diagnosis of live patients is a surprisingly recent development. The first diagnostic method, thoracic percussion, was discovered in 1756 by Leopold Auenbrugger (1722-1809), the son of an innkeeper in Graz, Austria. As a youngster, Auenbrugger learned to tap caskets of wine to determine the quantity of liquid in the container and applied the technique to the human chest. This simple but ingenious method led the famed French physician, René-Théophile-Hyacinthe Laennec (1781-1826) to hit on the idea of thoracic auscultation and, in 1816, to the invention of the stethoscope. Although standard thermometric values were developed in the seventeenth century, the systematic measurement of body temperature was introduced into medicine only in 1851. The development of an ever-growing array of diagnostic instruments and techniques followed quickly. Today, the practicing physician can diagnose many diseases in the living patient as objectively and almost as effectively as the pathologist can diagnose them at autopsy. The long-standing gap between antemortem (clinical) diagnosis and postmortem (autopsy) diagnosis has narrowed but has not disappeared. Despite modern diagnostic techniques, the postmortem examination of the cadaver remains an indispensable tool for scientific medicine and forensic pathology.
  ... Although the development of the modern, scientific concept of disease was a gradual process, the publication, in 1858, of Cellular Pathology as Based upon Physiological and Pathological History, by Rudolf Virchow (1821-1902), is generally accepted as signaling the birth of modern medicine as a profession based on empirical science. The study of pathology as the phenomenology of disease, combined with the study of bacteriology as the etiology of infectious disease, placed medicine as the study of bodily disease on the rock-solid foundation of modern science.

Thomas Szasz, Pharmacracy: Medicine and Politics in America (2001: xxiii-6)

the elasticity of psychiatric diagnosis

Whatever the merits of the SSRIs, they have been among the most heavily promoted drugs of the past decade. The manufacturers of anti-depressants have taken full advantage of the relaxation of U.S. FDA restrictions on prescription drug advertising in 1997. In 2000 Paxil was the fourth most heavily promoted prescription drug in America, with $91.8 million in direct-to-consumer spending. Eli Lilly spent $37.7 million that same year advertising fluoxetine—$23.3 million as Prozac and $14.4 million as Sarafem. To put these figures in context: GlaxoSmithKline spent more money advertising Paxil than Nike spent advertising its top shoes. Direct-to-consumer advertising clearly works. From 1999 to 2000, antidepressants saw a 20.9 percent increase in sales to a figure of $10.4 billion, maintaining their position as the best-selling category of drugs in the United States. In 2000 Prozac was America's fourth most prescribed drug: Zoloft was number seven, and Paxil was number eight.
  Of course, the SSRIs could not have achieved such spectacular success if they did not work for some patients. Yet an equally important reason behind the success of psychoactive drugs in general, and the SSRIs in particular, is the elasticity of psychiatric diagnosis. Categories of "mental disorders" are in constant flux, and they often expand dramatically once a new treatment is marketed. For example, social anxiety disorder—the fear of being embarrassed or humiliated in public—was considered a rare disorder until physicians began treating it with Nardil (phenelzine) in the mid-1980s and then, later, with SSRIs such as Paxil. Today social phobia is often described as the third most common mental disorder in the United States. Similar stories can be told for obsessive-compulsive disorder and panic disorder... As David Healy has pointed out, the key to selling psychoactive drugs is to sell mental disorders.
  But to sell a mental disorder, you must first capture it and make it your own. A drug manufacturer is not allowed to promote a product for a specific disorder until that product has FDA approval. As a result, SSRI manufacturers jockey aggressively among themselves to claim new pieces of the mental disorder market. While the FDA has approved all six SSRIs on the market for depression, Paxil was until recently the only drug approved for social anxiety disorder. (In 2003 it was joined by Zoloft and Effexor.) All of the SSRIs except Celexa and Effexor have been approved for obsessive-compulsive disorder, but only Effexor and Paxil have been approved for generalized anxiety disorder. Zoloft and Paxil have claimed panic disorder and posttraumatic stress disorder, but only Prozac has been approved for bulimia. Eli Lilly's patent on Prozac expired in 2001, but Lilly has begun marketing the same drug under a different name, Sarafem, as a treatment for "premenstrual dysphoric disorder".
  Conventional wisdom attributes the spectacular success of the SSRIs to their relative absence of side effects. For instance, monoamine oxidase inhibitors, an alternative type of antidepressant, can be dangerous without strict dietary restrictions, and people taking the longer established tricyclic antidepressants often complain of drowsiness, dizziness, dry mouth, or constipation. Prozac and the other SSRIs initially appeared much less burdensome. Another significant reason for the success of the SSRIs lies in their ease of use. "One pill a day forever," says Jonathan Cole. "Fluoxetine at one pill a day is the ideal primary care physician's drug." Today, in fact, it is no longer even one pill a day. Prozac Weekly is a once-a-week version of Prozac that Lilly has marketed using coupons in newspapers and magazines. The one-pill strategy has clearly worked, whether the one pill is taken daily or weekly. It has been estimated that as much as 70 percent of the SSRIs is prescribed not by psychiatrists but by primary care physicians.
  ... In bioethics the conventional response to the phenomenon that Kramer called cosmetic psychopharmacology" has been to classify it as enhancement technology. The distinction between enhancement and treatment had gained currency during the ethical debate over gene therapy in the late 1980s and early 1990s. Many people were eager to press a research agenda into the therapeutic uses of genetic technology for conditions such as adenosine deficiency or cystic fibrosis but worried about the use of such technologies for eugenic purposes. Since then, bioethicists have used the term "enhancement technology" as a shorthand for all sorts of technologies whose uses go beyond the strictly medical, from synthetic growth hormone for short boys to Botox injections for aging women. The unstated assumption behind the term has been that there is a morally important distinction between enhancement and treatment. Treating illness, it has been argued, is an essential part of medical practice. Doctors have an obligation to treat sick people. Enhancements, in contrast, are seen as extras—ethically acceptable, perhaps, but not something that a doctor has any particular obligation to provide or that a liberal society has an obligation to fund.
  Yet the distinction between treatment and enhancement turns out to be much more elusive than it first appears, especially in psychiatry. Where is the line between psychopathology and social deviance, perversion, or eccentricity? When does shyness turn into social phobia, or melancholy into depression? The problem is complicated still further by the fact that so little is known about the causes or pathophysiology of mental disorders, or even about how chemical treatments for these mental disorders work. Philosophers have traditionally argued that illness is a departure from species-typical human functioning, but that definition offers us little guidance when the subject turns to the human mind and human behavior. What kind of behavior is typical of Homo sapiens?
  It might be better to ask, What should we make of the social place that the SSRIs have come to occupy? Every culture has its own socially prescribed psychoactive substances, from peyote, kava, and betel nuts to alcohol, caffeine, and nicotine. But with the SSRIs, the gate to the drug is guarded by doctors, and the passport for access is the diagnosis of mental disorder. Unlike alcohol, which is dispensed in bars and liquor stores, or caffeine, which is dispensed at Starbucks and Unitarian churches, SSRIs are dispensed at doctor's offices and pharmacies. It is the social place occupied by SSRIs that has produced the ambivalence that many of us feel about their popularity. Unlike bartenders and espresso baristas, doctors have not generally thought of their job as making well people feel better than well. But that might change.

Carl Elliott, Prozac as a Way of Life (2004: 4-7)

his hour was in sight

A secret hoard of indifference—like a thick cake a fond old nurse might have slipped into his first school outfit—came to his aid and helped to reconcile him to sacrifice; since at the best he was too ill for aught but that arduous game. As he said to himself, there was really nothing he had wanted very much to do, so that he had at least not renounced the field of valour. At present, however, the fragrance of forbidden fruit seemed occasionally to float past him and remind him that the finest of pleasures is the rush of action. Living as he now lived was like reading a good book in a poor translation—a meagre entertainment for a young man who felt that he might have been an excellent linguist. He had good winters and poor winters, and while the former lasted he was sometimes the sport of a vision of virtual recovery. But this vision was dispelled some three years before the occurrence of the incidents with which this history opens: he had on that occasion remained later than usual in England and had been overtaken by bad weather before reaching Algiers. He arrived more dead than alive and lay there for several weeks between life and death. His convalescence was a miracle, but the first use he made of it was to assure himself that such miracles happened but once. He said to himself that his hour was in sight and that it behoved him to keep his eyes upon it, yet that it was also open to him to spend the interval as agreeably as might be consistent with such a preoccupation. With the prospect of losing them the simple use of his faculties became an exquisite pleasure; it seemed to him the joys of contemplation had never been sounded. He was far from the time when he had found it hard that he should be obliged to give up the idea of distinguishing himself; an idea none the less importunate for being vague and none the less delightful for having had to struggle in the same breast with bursts of inspiring self-criticism. His friends at present judged him more cheerful, and attributed it to a theory, over which they shook their heads knowingly, that he would recover his health. His serenity was but the array of wild flowers niched in his ruin.

Henry James, The Portrait of a Lady (1976: 40-41)

measuring it with its own extravagence

In the midst of the serene world of mental illness, modern man no longer communicates with the madman: on the one hand is the man of reason, who delegates madness to the doctor, thereby authorising no relation other than through the abstract universality of illness; and on the other is the man of madness, who only communicates with the other through the intermediary of a reason that is no less abstract, which is order, physical and moral constraint, the anonymous pressure of the group, the demand for conformity. There is no common language: or rather, it no longer exists; the constitution of madness as mental illness, at the end of the eighteenth century, bears witness to a rupture in a dialogue, gives the separation as already enacted, and expels from the memory all those imperfect words, of no fixed syntax, spoken falteringly, in which the exchange between madness and reason was carried out. The language of psychiatry, which is a monologue by reason about madness, could only have come into existence in such a silence.
  ... The Greeks had a relation to a thing they called hubris. The relation was not solely one of condemnation: the existence of Thrasymachus [“Listen—I say that justice is nothing other than the advantage of the stronger”] or that of Callicles, is proof enough of that, even if their discourse comes down to us already enveloped in the reassuring dialectics of Socrates. But the Greek Logos had no opposite.
 European man, since the depths of the Middle Ages, has had a relation to a thing that is confusedly termed Madness, Dementia, or Unreason. It is perhaps to that obscure presence that Western Reason owes something of its depth, as with the threat of hubris [to] the sophrosyne of Socratic speechmakers. In any case, the Reason—Unreason relation constitutes for Western culture one of the dimensions of its originality: it accompanied it long before Hieronymous Bosch, and will follow it long after Nietzsche and Artaud.
 But what then is this confrontation below the language of reason? Where might this interrogation lead, following not reason ... but seeking to retrace in time this constant verticality [ie. of madness], which, the length of Western culture, confronts it with what it is not, measuring it with its own extravagance? Towards what region might it take us, which was neither the history of knowledge nor history plain and simple, which was commanded neither by the teleology of truth nor the rational concatenation of causes, which only have value or meaning beyond the division? A region, no doubt, where it would be a question more of the limits than of the identity of a culture.

Michel Foucault, History of Madness (2006: xxviii-xxix)