Book review: The Imaginary Patient: How Diagnosis Gets Us Wrong

Arpan K. Banerjee
Solihull, United Kingdom


The imaginary patient is depicted by a translucent depiction of a standing person, with their form shown through blue dots.
Cover of The Imaginary Patient: How Diagnosis Gets Us Wrong.

Making the right diagnosis is central to the medical encounter. A doctor always started off by taking a history, examining the patient, and sometimes performing additional tests. But when a creditable diagnosis could not be made, the medical profession often invented conditions that later were shown not to exist. Such diagnoses are debunked by the neurologist Jules Montague in a fascinating book.

The first of such diagnostic labels is status lymphaticus, formerly applied to patients, particularly children, who died after receiving chloroform anesthesia. These children at the turn of the twentieth century had undergone radiation therapy for their thymus, which had been judged to be enlarged through measurement with X-rays. This measurement was later proven to be inaccurate, but many of these irradiated children later had a higher incidence of thyroid cancer. When chloroform was shown to have its own dangers and was abandoned, this imaginary condition disappeared.

The next spurious diagnosis was neurasthenia, a state of nervous exhaustion first described in 1869 by the American Dr. Beard. He called it the plague of the modern age, a response to the stresses of modern life. The German sociologist Max Webber, the psychologist William James, and the author Marcel Proust were all diagnosed as having this disorder, which was treated by physical and mental rest for three months. The diagnosis was popular in America and also reached Europe as the influential Austrian German psychiatrist Krafft-Ebbing emphasized its debilitating effects on the nervous system. In late nineteenth-century London, one tenth of the discharges from the National Hospital for Nervous Diseases in London was attributed to neurasthenia. Such patients were considered feeble minded, and the increase in their numbers was lamented by the eugenics movement. The diagnosis disappeared after the 1950s. Interestingly, today, doctors are diagnosing chronic fatigue syndrome in patients whose clinical features would have once been attributed to neurasthenia.

The history of discrimination meted out to LGBTQ people is also harrowingly described in this book. Over the years, many prominent medical, political, and religious figures were criminalized for a sexual orientation condition that we now do not consider a disease. We are reminded of the brilliant mathematician Alan Turing (considered by many to be the father of computing), who was subjected to chemical castration for his sexual orientation and is believed to have subsequently taken his own life. We are also reminded in the chapter on the overdiagnosis of cannabis psychosis how labels can be used to justify discrimination against ethnic minorities on both sides of the Atlantic.

Sometimes diagnostic labels provide comfort for certain patient groups. For example, children diagnosed with PANDAS (pediatric autoimmune neuropsychiatry disorders associated with streptococcal infections) exhibit involuntary movements. The diagnosis remains controversial, and some have questioned if it is a real condition. Nevertheless, some patients have been treated with immunotherapy, while others argue that it is a psychiatric condition. Another controversial condition, Morgellons disease, is considered a delusional parasitosis in which patients are convinced that parasites are emanating from their skin, causing symptoms of constant itching and a feeling of crawling underneath the skin’s surface. It is interesting that British physician Thomas Browne described this syndrome in the seventeenth century.

Other diagnostic conundrums discussed in The Imaginary Patient include the problems of modern genetic screening, such as living with the risk of breast cancer for patients with a BRCA1 mutation. Many will undergo a bilateral mastectomy to minimize the risk of cancer. Genetic analysis is likely to raise more questions in the future as variants of unknown significance (VUS) and indeterminate genetic mutations are being detected.

The book is well researched and has extensive references and a comprehensive index. It is well written and will make the reader reflect on many of the complex and sometimes controversial issues that arise in the process of making a diagnosis.


The Imaginary Patient: How Diagnosis Gets Us Wrong
Jules Montague (2022)
Granta Books ISBN 9781783785841





ARPAN K. BANERJEE qualified in medicine at St Thomas’s Hospital Medical School, London. He was a consultant radiologist in Birmingham 1995–2019. He was President of the radiology section of the RSM 2005–2007 and on the scientific committee of the Royal College of Radiologists 2012–2016. He was Chairman of the British Society for the History of Radiology 2012–2017. He is Chairman of ISHRAD. He is author/co-author of papers on a variety of clinical, radiological, and medical historical topics and seven books, including Classic Papers in Modern Diagnostic Radiology (2005) and The History of Radiology (OUP 2013).


Summer 2022  |  Sections  |  Books & Reviews