THE HISTORY OF DISEASE : INTRODUCTION

En el 19th International Congress of Historical Sciences (Oslo, 6-13 agosto 2000), se reunió una mesa redonda sobre historia de la enfermedad. Los participantes decidieron redactar los textos presentados y buscar un adecuado lugar de publicación. Todos queremos agradecer a la revista Asclepio que haya aceptado acoger en sus páginas nuestros trabajos, que pretenden ser una puesta al día de las principales tendencias en historia de la enfermedad. Orientaciones muy diversas y puntos de vista encontrados, procuran proporcionar un panorama breve pero suficiente de un tema tan importante como complejo.


THE HISTORY OF DISEASE: INTRODUCTION
José Luis Peset (Organiser) Instituto de Historia, CSIC It will be my intention to underline how disease is a mechanism of adaptation -that is, of attack, equilibrium and defence-of living beings to their habitat.Human development and evolution, in its cultural, social and ecological setting, give rise to alterations in the human organism, both mind and body, against which medicine and society must struggle.Generally speaking, current approaches to the concept of disease derive from man's historical struggle with disease, the struggle of human groups with pathogenous agents.
I want also to underline with Marx Wartofsky the complexity of the modern human «ontology», even in ill men.Disease is neither the pathology of an organ, nor the pathology of an individual organism.The modern explanation of human disease, focuses on the complex adaptation of the human species to its cultural, social, and ecological context.«The positive characterization of human ontology would then subordinate the biological, psychic, and personal or individual features to a more fundamental category: the socio-historical and cultural».It is in this framework that the problem of the concept of disease got its true meaning.
The clasical concept of disease is based in the general concept of physis, or Nature, the divine principle of life.According to the Greek philosophers, Nature is the principle of order, beauty and justice.This natural harmony is structured on three levels, individual, social and cosmic.Health for the ancient physician consists of the balance of order, individual, social and cosmic, while disease is lack of this harmony.Disease is a disorder of Nature, a disorder of divine justice, and so the knowledge of disease is the knowledge of the divine, that is sophía, or philosophy.
The modern concept of disease derives from the new philosophy of Locke, and especially from Hume's empirical criticism to Aristotelian thought.Following Condillac and Cabanis there was a search of a universal element to be attained through analysis.Wondering about the path of calculation or language, clinical observation functioned according to the scientific standard of chemistry, working as fire in searching of elemental purity.Disease itself was localized not only in a logical or natural clasification, but in the space offered it by the human body.Hippocrates sought the localization in individuals; Morgagni found it in organs; Bichat saw that the bearers of disease are simpler elements, namely, the tissues of his Anatomie générale ; Virchow was soon able to refer to cells.Diseases would no longer be a Galenic essence or a Sydenhamian species, but rather a suffering of organs and of functions.
After the first outbreak of cholera many innovations were to appear.A large number of microscopic causal agents were discovered; laboratories and technical advances multiplied.The research rules of the new bacterial pathology were laid down by Henle, Pasteur, and Koch.A new and comprehensive nosological edifice was being established.The new bacteriology -and with it toxicology (Orfila, Erlich)-would provide a mechanism for causal explanation wich would complete the clinical and pathological discoveries.It was now possible to fit a syndrome, a cause, and a nosological explanation into an adequate framework.Thanks to the work by Robert Koch and the enumeration of his rules, a new causal way of thinking was established, directly influenced by induction and positivist determinism.The works of August Comte and J. S. Mill supported the validity of these causal inferences.
But it would not only be in the field of environmental pathogenic agents that a causal account of disease could be developed.Investigations continued to be elaborated at other levels, in the social and individual sphere.The nosogenic potentiality of the new industrial society is shown in surveys and statistics.The works of Tissot and J. P. Frank are closely followed by Thackray, Chadwick, and Villermé.All modern hygiene has its starting point here.The rise of great and industrial cities with low grade outskirts and the emigration of peasants to the city favoured the spread of maladies associated with poverty, squalor, lack of food and of inmunological defences.Some of the diseases are occupational, in the case of miners or textile workers, but other diseases are produced by the harsh life conditions, like typhus and pulmonary diseases, especially tuberculosis.The same can be claimed regarding the enormous spread of syphilis, as also with the abuse of drugs, like alcohol, cocaine and morphine.
On the other hand, not only was it seen that social conditions injured the lower and working classes due to their harsh life, but it was also recognized that mental health was compromised by the new socio-economic structure.As a result, both higher and lower classes suffered.The clinics of Charcot and Freud were filled with hysterical people of very diverse backgrounds: some from the laboring classes damaged by their work in Paris; others from the Vienna's bourgeoisie, rendered ill in their leisure by sophisticated psychic traumas.This double lesional possibility of society, socio-material and socio-psychic, adds a new nosogenic level to human life.Towards the middle of the 19th century, the neccesity of an authentic social medicine was outlined by Virchow and S. Neumann.At the beginning of the 20th century this project became a true scientific reality, thanks to the work of Gottstein and Grotjahn.
Finally, with the birth of modern medicine, the nosogenic potential of individual causes was not forgotten.In this way, the discovery of the laws of heredity and evolution (Darwin, Galton, Mendel) was a fundamental step.The genetic and genomic studies in human beings, enabled many diseases to be traced to congenital and evolutive factors.The results of the Human Genome Project are been published in Nature, they are already available online.* * * * * As François Jacob wrote in La logique du vivant the new science is studying neither the clasification, nor the visible structure of live beings, but their organisation, as a step from the past to the future.Reproduction constitutes at the same time the origin and the end, the cause and the target.The basis of organisation are found in the human genomics, in its description and interpretation of its expression, and in the evolution of life from virus to human being, and its adaptation to biological, social and cultural environment.Coming back to Marx Wartofsky, «cultural practices ... already interact with biological contexts in the very evolution of the species.(...) Further still, the very biological structures and functions are shaped by a life-world which include the distinctively human activities of the production of artefacts, the use of speech, and the evolution of social forms of life wich help to determine what is normal, healthy, well adapted to a given historical function, and what is not».And he concludes: «Thus, even at the fundamental biological level, species-evolution bears the traces of a distinctive human ontology».
Today, neither simple identifications between syndromes and their causes, nor deterministic explanations of signs and symptoms are acceptable.Explanations of disease attempt to relate signs and symptoms with multiple causal factors and with theoretic explanations on a physiological level.The different factors of causality fit into a new relational formulation, according with Tristram Engelhardt.And the models of explanation must take into account a holistic approach to human life, including psychological and somatic, cultural and social issues.The concept of disease includes explanatory and normative issues.The cultural construction of the concepts of doctor and disease, of illness and health are the basis of modern constructivism.The reaction to diseases of the groups and individuals are characteristic, focusing on anthropological and social studies.Disease and the reaction against disease are sociocultural constructions, containing beliefs, interests, and feelings.
Indeed, disease is something more than a biological alteration.As David Roberts asserts in his Introduction to Daniel Defoe's A Journal of the Plague Year, the artist -and the historian, of course-who writes about human illness is threatened by the struggle with words.«Defoe's conviction that the suffering of plague victims could be recorded is constantly threatened by the inadequacy of words to the task».Defoe's book was the literary answer to the last European black death, the plague of Marseille of 1720.Rumour imitates the plague, and money spreads the disease.The main actor of this modern tragedy was the plague, with its new cultural, social and cosmic order.Coming through the hell, the Journal suggests the atmosphere of tragedy, but prepares the romantic sentimentalism.New time, new language and new moral are introduced in human society by the strong force of the Yersinia pestis and its vectors, fleas and rats.«His problem is partly that plague attacks not only the constitution but the conscience; it brings the worst out of many people».Public facts submerge the narrator into his community, the society of the city of London in 1665.«He balances his knowledge of individual cases against common generalizations; he shows how people experienced the disease differently».Some conclusions are being reached today.«The therapeutic process is constructed as a narrative in time, incorporating change, order and meaning», affirms David Harley.«Sickness is a form of communication... through which nature, society and culture speak simultaneously», according to N. Scheper-Hughes and M. Lock.«Illness always seems to tell us more about a person or an era than health does, although it is not clear why», writes David B. Morris.Susan Sontag looks for the interpretations, the metaphors of disease as demonic possesion, degeneration and war.«The study or pursuit of metaphor is a means of questioning the assumptions, descriptions and definitions of a literalistic and constricting outlook on reality», comments Richard Gwyn.In this sense, today the history of disease may be understood as a searching for words, words, words....