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Disease and Organic Aberration

The pair of concepts “ill - healthy” is initially descriptive and classifying, not explanatory. The disease concept clears the path for ideas about the causes and explanations of the phenomena of illness which man has sought and found in the course of history. Only afterwards a different distinction becomes relevant to explaining illness, a distinction which man has made in the course of history in order to understand himself and others better. This is the distinction between mind and body.

In Chapter II, 2, we saw that before the eighteenth century the presence or absence of bodily aberrations could hardly form a criterion for disease because way too little was known about normal and aberrant structures and functions of the body and its parts. Historically speaking, the disease concept could only fairly recently be associated with the existence of physical aberrations.

Although Szasz’s assertion that until the nineteenth century all diseases were considered physical diseases (for instance, in The Myth of Mental Illness, revised edition, p. 36) is untenable, it is conceivable that the development of medicine in the second half of the eighteenth and in the nineteenth century led to reconsideration of the issue of the role of organic aberration in illness. By that time the organic causes of so many illnesses had been identified that the inductive question could be and was asked whether perhaps organic aberration is involved in all illnesses, and whether this could be a criterion in classifying ill and healthy.

Not only historically, but also logically the classification ill-healthy precedes the distinction mind-body, at least if being ill is viewed as described in 2.1. Only after the classification ill-healthy and the conceptualization of illness had occurred, after dualism was developed in man’s thinking about himself, could the question be posed whether the aberrations and abnormalities that are encountered in the realm of being ill are of a bodily or a mental nature. This question presupposes dualism in the view of man: body and mind must be unlinked using a scientific abstraction so that one can think and act as though he is concerned only with the body or only with the mind.

It is surely not coincidental that postmortem research was the first step towards developing a medicine oriented to physical science (Morgagni, Bichat, and others). After all, the body after death is the only situation in which the body can be perceived as purely a body. During life the body can be viewed as exclusively a body only by pretending that the mind does not exist and ignoring it. For this to be possible body and mind have to be separable from each other in principle in thought.

In speech dualism was not limited to seeking and finding physical and mental aberrations and abnormalities. Our speech has expressions which distinguish bodily illness from mental illness. These expressions imply that the body and mind can be ill without participation of the “other part” of the person. Literally, not only factually but also theoretically, that is untenable.

Boyle et al suggest that the view that illness can be purely physical conceals a reified metaphor. That metaphor originated with Descartes when he posited that the body can be described as though it were a machine. In the expression “physical illness” the “as though” has vanished, the metaphor is reified, and therefore has become a myth, according to Boyle. So when Szasz states that mental illness can only be illness metaphorically, exactly the same can be claimed for physical illness. Taken literally, neither mental illness nor physical illness exist. Both are myths. The only way these concepts can be maintained is by determining that physical illness involves illness which is mainly manifested by physical disorders and aberrations; and mental illness involves illness which is mainly manifested by disorders and aberrations of psychological and social functioning. Both concepts will be used this way below.

Using the existence of bodily aberrations as a conjunctive classifying criterion for being ill raises the question whether medicine is adequately advanced to be able to identify all existing and possible organic aberrations. It must be possible to demonstrate with sufficiently reasonable certainty that physical aberrations can be fully and dependably found during medical examination before assuming that when such have not been found, they do not factually exist. If this ideal is for now unreachable, categorizing in three groups can provide a recourse. Group 1 includes diseases with proven physical aberrations; group 2 includes conditions for which no physical aberration can be found but that make a strong impression of being illnesses for which the physical aberrations will some day be discovered; and group 3 includes conditions that make the impression that probably no physical aberration will ever be found although one can never be sure.

Thus the criterion for classification in group 2 or 3 becomes expectation based on subjective conviction. That is not only scientifically undesirable but also a chaotic state of affairs as illustrated by the ardent and rather fruitless controversy about whether or not physical aberration is probable in, for instance, schizophrenia.

Of course nobody can predict how many new physical aberrations will be discovered in the future. The vastness of research in this area indicates that expectations are high, for instance with regard to the spectacular developments in genetics. Other arguments can also be named. Firstly, sometimes in the initial phases of illness, for instance some malignancies, no physical aberration can be demonstrated yet, although in retrospect once the aberrations have become apparent it must be assumed that physical aberration was already present in the initial stages. Secondly, changing living conditions give rise to new diseases. Whether, and if so, which, physical aberrations are involved becomes apparent only after a period of time. Until such time they would have to be accommodated in the dubious group 2. Thirdly, all diseases that are known only as symptoms or syndromes, for instance pruritus senilis, trigeminus neuralgy, and dystonia musculorum deformans, would have to be categorized in group 2 or 3.

Therefore a modification has to be added to the criterion: not the existence of a physical aberration is a valid criterion but the existence of a demonstrable physical aberration. This implies that a part of what conforms to the criteria of being ill – for now, anyway – is not a disease according to this definition. Thus is rendered insoluble the problem of where in practice to draw the line between disease and non-disease.

The next question is whether every demonstrated physical aberration indicates the presence of disease. The following comments can be made:
  1. Bodily aberrations can vary from extraordinarily severe to trivial. Further – arbitrary – lines will have to be drawn to distinguish trivial from significant. A blurring of lines is inherent in the realm of classification in the biological sciences, as explained in 2.1, and can therefore not count as a decisive objection.
  2. The considerations about the connection between bodily aberrations and illness imply that aberrations found have a relevant relationship to the phenomena of the illness. In order to impart meaning to the concept of relevance, the possible kinds of relationships that can exist between physical aberration on the one hand, and the phenomena of illness on the other, must be investigated. The physical aberration can be: 1. the cause of the phenomena of disease as is the case, for instance, regarding cirrhosis of the liver; 2. an accompanying phenomenon as for instance the exanthem in measles or rubella; 3. a consequence of illness such as the contractures of leprosy or decubitus ulcers in the bedridden; 4. efforts of the body to repair itself or to ward off the miasmatic factor such as fever and leukocytosis in pneumonia; and 5. possibly have little or nothing to do with the phenomena of illness such as an in itself unimportant aberration, or someone may have multiple, unrelated illnesses. So physical aberration can have several different meanings in the pattern of illness. Add to this that many physical illnesses are not derived from physical aberrations. Examples are infectious diseases, intoxication, and avitaminosis, the cause of each initially being outside of the body. The concepts of etiology and pathogenesis should be remembered here. Etiology means the cause of disease. Pathogenesis means the totality of processes that occur between the onset of the cause and the appearance of the disease, so the way the factor causing the disease works. If, for instance, a pathogenic microorganism damages the liver, thereby causing jaundice, then the microorganism is the etiologic factor, and the damage to the liver the most important pathogenic factor that gives rise to the jaundice.
  3. Physical variations, when present, are not always signals or indicators of disease being or having been present. There are several statistical variations that have a positive or neutral value judgment so are not considered aberrant. Examples are abnormal tallness, abnormally high vital capacity, abnormally sharp vision, and abnormal strength. The fact that these variations exist underpin the judgmental quality of the words “disorder” and “aberration.” This means that the biggest advantage of describing disease as a physicochemical disorder, namely the objective, value-free nature of the description, is but a deceptive advantage. The value judgment is already implicit in the description.
Finally, note that several aberrant bodily functions, which are generally considered disease can be described as a physicochemical disorder but not as an aberration in the shape or structure of the body. Essential hypertension and genuine epilepsy are the best-known examples and in this sense functional diseases. (See Chapter I, 4.2.)

In conclusion, physical aberration can only be a criterion for classification when it complies with three limiting conditions: the aberration has to be demonstrable, relevant, and have the nature of a process. Exactly these limitations, however, mean that the bodily aberration cannot count as a necessary criterion for being ill. In other words, the conjunctive cluster for the classification of ill-healthy (see 2.1) cannot be replaced by the conjunctive criterion of physical aberration. In addition, the most important reason for maintaining the physical aberration as a criterion of classification, namely its objective, value-free nature, is invalid, because this criterion in itself implies a value judgment.
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