Retief, Francois

Wessels, André

South African Medical Journal (SAMJ)

SAMJ FORUM526July 2008, Vol. 98, No. 7  SAMJAs the uncontested dictator of the Soviet Union for nearly 25 years, Joseph Stalin made no attempt to gain popular support among his nation, but enforced his interpretation of communist-socialist rule by means of unremitting oppression and terror. He caused severe suffering to vast numbers of his compatriots, and the deaths of many millions of Russians. At the time of his demise, the gulags held some 7.5 million condemned exiles. A survey of his health shows that he suffered from infectious diseases such as typhus, smallpox, tuberculosis and possibly poliomyelitis, and had severe dental problems, irritable colon syndrome, acute appendicitis with complications, and hypertension with ischaemic cardiac and cerebral disease. He died of an intracerebral haemorrhage at the age of 74 years. He was a complex picture of psychological abnormalities. However, he was probably not clinically insane but manifested a psychopathic personality with prominent elements of narcissism, sadism and paranoia.Stalin was the greatest dictator of the 20th century. The people of the Soviet Union widely revered him as its wise protector against imperialism and capitalism. Yet he was responsible (directly and indirectly) for the death of at least 50 million Russians.1,2 In furthering the cause of ‘the workers’, he deemed it necessary to persecute the Russian Orthodox Church (killing 8 000 priests and monks in the process), the intelligentsia, writers, artists and scientists – and to eliminate the bulk of his friends and colleagues from the time of the Communist Revolution. When his estranged son, Yakov, unsuccessfully attempted to commit suicide, Stalin’s comment was: ‘Ha, he cannot even shoot straight!’3The question can indeed be asked whether Stalin was sane; in this study, his mental health, illnesses and death are reviewed. Such a study is hampered by the fact that Stalin forbade the documentation of his illnesses.4 Against the background of his life history (outlined in the section below), his organic diseases and psychiatric disorders are discussed in subsequent sections, primarily to ascertain whether Stalin was insane or not.Life historyIosif (Joseph) Vissarionovich Djhugashvili was born in Gori, Georgia, on 21 December 1878. Owing to a variety of childhood illnesses, Joseph only went to school when he was 10 years old. In 1894 he was admitted to the Theological Seminary at Tiflis, where he studied before becoming involved in socialistic revolutionary activities, which led to his expulsion.3,5,6 He then left home and ceased contact with his mother. She died of tuberculosis in 1937; he did not attend the funeral.7,8 He became a dedicated revolutionary and fugitive from the Tsarist police and Okhrana (secret police), and spent more than 8 of the next 17 years in periodic imprisonment and exile in Siberia. It later emerged that, for much of this time, he was also an agent for the Okhrana. In 1903, he married Ekaterina Svanidze; she died of tuberculosis 4 years later, having borne him a son. In 1912, Stalin was elected to the executive of the Bolshevik Party, and he changed his name to Stalin (man of steel).3,6,8During the October 1917 Communist Revolution, Stalin was a relatively minor Bolshevik functionary in St Petersburg. Appointed General Secretary in 1922, he used his position so effectively that he was a forerunner in the leadership race after Lenin’s death in 1924, and he became the accepted leader and chairman of the Politburo by 1928. Earlier (in 1919), he had married a fellow revolutionary, 16-year-old Nadezhda Alhiluyeva. It was a predominantly unhappy marriage, but produced a son and daughter. In 1932, Nadezhda committed suicide.1,3,9Stalin’s first Five-Year Plan (1928 - 1933) entailed a massive programme of industrialisation and move to collective farming, which initially resulted in a prolonged decline in agricultural output, and widespread suffering and starvation among farmers and labourers alike. It is estimated that about 10 million people died during this phase. Stalin then launched his second Five-Year Plan (1933 - 1938) and initiated the Great Purge, during which he systematically eliminated most of his previous political comrades and the Bolshevik leadership corps. All criticism and opposition were ruthlessly suppressed, and the country was ruled through a system of fear, oppression, indoctrination and propaganda.3,6The German invasion of Russia on 22 June 1941 during the Second World War (1939 - 1945) caught Stalin unprepared. His daughter, Svetlana, later said that her father ‘disintegrated HISTORY OF MEDICINE Was Stalin mad?Francois Retief, André WesselsFrancois Retief is a Rhodes Scholar, founder dean of the medical school at the University of the Free State, founder rector of MED-UNSA, and former secretary-general of the Department of Health; he retired as rector of the University of the Free State and is now a research fellow in the Department of English and Classical Culture at the university. Co-author André Wessels is a professor in the Department of History at the same university.Corresponding author: A Wessels (wesselsa.hum@ufs.ac.za)Forum Was Stalin mad.indd   526 6/19/08   10:13:16 AMSAMJ FORUM527emotionally’, and could not be reached for weeks.10 Initial losses were enormous; at least 26 million Russians died in the entire campaign. However, the tide gradually turned, and pivotal successes at Stalingrad (1942) and Kursk (1943) heralded victory. The end of the war saw Stalin at the peak of his political career, revered by his countrymen and esteemed internationally.3,6In 1945, Stalin was 67 years old. As progressive illness started limiting his physical and mental capabilities, he became withdrawn, morose, increasingly suspicious of those around him, and even more ruthless.3 He also alienated the West by enforcing Communist rule over Eastern Europe; the Cold War resulted.3,5 He developed the notion that Kremlin doctors were hatching a plot against the Soviet elite, and in January 1953 ordered the arrest, torture and conviction of 43 of these doctors.6 However, destiny intervened when Stalin died of a stroke on 5 March 1953.11 Initially embalmed and laid to rest in the Lenin mausoleum, Stalin was finally buried next to the Kremlin wall after the extent of his atrocities became evident in 1961.2,3,12Organic diseasesBefore the age of 7, Stalin had suffered from measles, scarlet fever, a severe attack of smallpox which left his face disfigured, and probable poliomyelitis. On three occasions he was involved in traffic accidents. Early in life, his left arm and shoulder became seriously disfigured, resulting in weakness and shortening of the arm by about 5.5 cm, and leading to stiffness of the elbow and shoulder. This troubled him throughout his life, caused intermittent pain and was a practical disability in his daily activities. The cause of the lesion was probably spreading sepsis from a wound sustained during his first traffic accident, but poliomyelitis could also have been responsible for extensive atrophy of the arm muscles. Some sources blame the disfigurement on an assault injury inflicted by his father; others ascribe it to an injury dating from his bank robberies as a young revolutionary. Svetlana even claimed that it was the result of a birth injury. The suggestion that he might have had syphilis cannot be substantiated.3-6During his exile in Siberia in 1909, he contracted typhus.4 In 1917, pulmonary tuberculosis was diagnosed which probably caused the pleural adhesions detected at a later stage.6,13 In March 1921, he was operated on for appendicitis with complications that caused his surgeon to fear for his life.3 At about this time, he developed chronic dental problems that plagued him for the rest of his life, necessitating many painful operative procedures.6 From 1926 he became aware of episodes of vague abdominal pain accompanied by flatulence and diarrhoea, which were probably caused by irritable colon syndrome.6 Recurrent joint and muscle pains, often associated with coldness of his deformed left arm, gradually became troublesome.6,14 In 1927, the results of a medical examination were essentially normal,15 but by the early 1930s hypertension had set in, and he was advised to adopt a healthier lifestyle.16 However, Stalin persisted in overeating, drinking moderately to heavily (usually wine), smoking cigarettes and a pipe, and taking virtually no exercise. Gallbladder disease was suspected and, by 1933, chest pain suggestive of angina pectoris manifested. Stalin refused all medical treatment, however, taking only folk remedies and iodine drops for the hypertension.4 In 1936 he had recurrent tonsillitis. He became increasingly hostile towards his doctors and, in 1938, Pletnov was accused of Trotskyism and convicted to 15 years in custody, but disappeared from jail in 1941.17During World War II, Stalin was relatively healthy except for severe influenza in October 1941.3 However, his cardiac problems became worse during 1945, and the Potsdam Conference was delayed because of a suspected minor myocardial infarction.4 During the Victory Parade in 1945, Stalin was clearly tired and unwell.18 From about this time, he developed episodes of dizziness, even brief loss of consciousness, suggestive of cerebral ischaemia.4 His memory deteriorated but his political aggression increased, clearly now associated with paranoia. Minor problems such as painful corns, a skin condition (possibly psoriasis) and upper respiratory infections aggravated matters.15 A septic leg lesion was cured by an operation in 1948,19 and in December of that year he probably had a minor stroke, resulting in a speech defect. Although he still refused medical treatment, he stopped smoking in 1952, possibly because of signs of emphysema.14 Apparently due to minor dysphasia, he was unable to speak at his 70th birthday celebration in December 1949.16 His physical and mental deterioration was associated with a reactivation of aggression and, when Vinogradov warned him in January 1953 of the seriousness of his illness and dared to defend his colleagues, the ‘Kremlin doctors’ purge’ was launched.6,14Alone in his dacha outside Moscow on 1 March 1953, Stalin suffered a severe stroke, and was found by his guards lying on the floor, semi-conscious, having wet himself. Members of the Politburo were informed, who visited the scene in the early hours of 2 March and summoned a doctor, who arrived at 09h00. A complete right-sided hemiplegia with a varying level of consciousness and aphasia was diagnosed, as well as an arrhythmia of uncertain nature; his blood pressure was 210/110 mmHg, and periodic Cheyne-Stokes breathing was noted. Treatment consisted of drugs such as digitalis, caffeine, camphor preparations and penicillin. Leeches were applied to his head and neck, an enema was given, and intermittent oxygen was administered for apparent respiratory distress. A nurse fed him by teaspoon. Members of the Politburo kept up a 24-hour vigil, and his children were notified. Svetlana stayed with him until his death. Initially, Stalin’s condition remained relatively unchanged; an EGG showed signs of a recent myocardial infarction.20 It is, of course, known that cerebral haemorrhage may, in its own right, cause arrhythmia July 2008, Vol. 98, No. 7  SAMJForum Was Stalin mad.indd   527 6/19/08   10:13:17 AMSAMJ FORUM528and EGG changes typical of infarction. Stalin vomited blood on two occasions. Late on 5 March, he developed cyanosis and severe dyspnoea suggestive of acute left ventricular failure, and died at 21h50. Radio Moscow announced his death at 04h03 on 6 March. A post mortem confirmed the clinical diagnosis: a large left intra-cerebral haemorrhage, cerebral arteriosclerosis and small scattered areas of previous cerebral infarctions, and left ventricular hypertrophy with minute haemorrhages in the myocardium (no fresh infarction), as well as in the intestinal mucosa.3,4,11Psychiatric disordersStalin had a complex personality, which has been extensively discussed by numerous authors.4,9,15,21 Perhaps the two outstanding and complementary characteristics were his absolute aversion to any authority, and his ruthless insistence on total control at all times. There is speculation that his childhood experiences at the hands of a cruel and authoritarian father conditioned these characteristics. Even at school, he insisted on being the leader in games; he manipulated situations so that he could win, even when it entailed dirty play, and he bullied those weaker than himself.5,6,19 A lack of loyalty – even amorality – was evident in the insensitive treatment of his mother and his second wife and children, and especially in the way he betrayed his revolutionary friends to authorities at the Tiflis Seminary, and in his collaboration with the Okhrana while ostensibly being a loyal Bolshevik. In the Great Purge of the 1930s, he mercilessly, and for little apparent reason, had killed large numbers of his friends and compatriots.A strong case can indeed be made for postulating that Stalin exhibited the classic symptoms of narcissism (morbid love of or self-absorbedness with oneself), with strong additional elements of sadism (deriving pleasure from the suffering of others) and paranoid tendencies (nursing unwarranted suspicions about the motives of others, and desiring revenge). The latter trait quite probably also concealed an element of inferiority and personal cowardice.4,21But was Stalin insane? Most authors agree that, although he exhibited ample evidence of a disturbed psyche, he maintained a sharp grasp on reality, uncannily able to manipulate people in power, and in this way remaining the mastermind behind the evolution of Soviet Russia for a quarter of a century. He could not have done this had he been schizophrenic.15 True paranoia as a psychosis (separate from schizophrenia) is a very rare disease, characterised by delusions of persecution (often grandiosity) in an otherwise normally orientated person.22 The paranoid person thus appears absolutely normal, except for the narrow delusion of persecution. Stalin’s psyche, as set out above, exhibited an array of negative characteristics, of which paranoid tendencies were part. There is no evidence of true hallucinations (which strongly suggest psychosis.)22 It is therefore postulated that Stalin did not suffer from a psychosis (true insanity, with loss of contact with reality), but that he had a marked psychopathic personality.References  1.    Laquer W. Stalin: The Glasnost Revelations. New York: Charles Scribner’s Sons, 1999: 1-10.  2.    Antonov-Ovseyenko A. The Time of Stalin: Portrait of Tyranny. New York: Harper Colophon Books, 1980: vii-xv, 302.  3.    Hyde HM. Stalin: The Story of a Dictator. New York: Da Capo Press, 1971: 20-153, 212-290, 435-490, 559-604.  4.    Neumayr A. Dictators: Napoleon, Hitler, Stalin. Bloomington: Medi-Ed Press, 1995: 423-428.  5.    Brackman R. The Secret File of Joseph Stalin. London: Frank Cass, 2001: 1-13, 195-196.  6.    Rayfield D. Stalin and his Hangmen. London: Penguin Books, 2004: 4-47, 145-256, 387-389, 423-435.  7.    Grey I. Stalin. London: Weidenfeld & Nicolson, 1979: 9-13.  8.    Fischer L. The Life and Death of Stalin. London: Jonathan Cape, 1953: 67-81.  9.    Randall FB. Stalin’s Russia. New York: Free Press, 1965: 1-29, 286-293.10.   Ebon M. Svetlana. New York: Signet Books, 1967: 92.11.    Miasnikov AL. The end. Soviet Review 1991; 32(1): 84-92.12.    Tucker RC, De Jonge A. Stalin, Joseph. In: Parry M, ed. Chambers Biographical Dictionary. 100th ed. Edinburgh: Chambers, 1997: 1742.13.    Taylor B. Josef Stalin: A medical case history. Maryland State Medical Journal 1975; 24(11): 35-46.14.    Medvedev ZA, Medvedev RA. The Unknown Stalin. London: Tauris, 2003: 1-29.15.    Service R. Stalin: A Biography. London: McMillan, 2004: 236-345, 571.16.    Medvedev RA. On Stalin and Stalinism. Oxford: Oxford University Press, 1979: 154-155.17.    Romano-Petrovna N. Stalin’s Doctor, Stalin’s Nurse. Princeton, NJ: Kingston Press, 1984: v-viii.18.    Montefiore SS. Stalin: Court of the Red Tsar. New York: Alfred Knopf, 2004: 499-514.19.    Kun M. Stalin: An Unknown Portrait. Budapest: CEV Press, 2003: 12-13, 242.20.    Hackinski V, Norris JW. The Acute Stroke. Philadelphia: FA Davis & Co., 1985: 180-184.21.   Rancour-Laferriere D. The Mind of Stalin. Ann Arbor: Andis Publications, 1988: 1-110.22.    Sim M. Guide to Psychiatry. Edinburgh: Churchill Livingstone, 1974: 428-448, 593-598. July 2008, Vol. 98, No. 7  SAMJForum Was Stalin mad.indd   528 6/19/08   10:13:18 AM

Was Stalin mad?

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Was Stalin mad?

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