University of Virginia Library

HEALTH AND DISEASE

I

Health and disease are familiar notions, commonly
used in a complementary sense, viz., health as absence
of disease and disease as a lack of health. But any
attempt at a precise definition of these two concepts
meets with considerable difficulties and throws doubt
on the validity of the popular usage.

A person suffering from an ordinary cold may de-
clare himself ill, whereas the same person laid up with
a broken leg may claim to be in perfect health. These
common examples indicate the complexity behind the
concepts of health and disease, a complexity apparent
throughout the history of mankind. Health and disease
have been experienced by almost every human being,
and the emotional as well as rational reactions have
differed and have manifested themselves differently.
The history of these two ideas must, therefore, take
into account definitions and explanations by philoso-
phers and physicians, as well as the reactions and usage
of others. Within this vast history, any order can be
achieved only by neglecting innumerable details, by
paradigmatic use of relatively few opinions and prac-
tices, and by admitting that a different point of view
may show a different panorama.

The myths of many ancient civilizations tell of a
golden age, free from ills, then followed by troubled
and disease-ridden times. Before Pandora's box was
opened, men lived on earth “without evils, hard toil,
and grievous disease.” But now that the lid is off,
“thousands of miseries roam among men, the land is
full of evils and full is the sea. Of themselves, diseases
come upon men, some by day and some by night, and
they bring evils to the mortals” (Hesiod, Works and
Days, 90-103). Sickness here is just one among the
many forms of suffering to which man has been sub-
jected at all times. When and where he began to sepa-
rate illness from other kinds of suffering we do not
know, and down to our own days the demarcation
has remained uncertain.

In the Atharva-Veda of ancient India there is a
prayer for a mad person, that the gods might “uncraze”
him, as the translator has it. “Crazed from sin against
the gods, crazed from a demon—I, knowing, made a
remedy, when he shall be uncrazed.” It seems impossi-
ble to tell whether the crazy person is believed “sick”
or whether he falls into a different category. The
Atharva-Veda is not a medical work; it contains prayers
against many ills and sings the praise of many things.
In this case it is not easy to maintain a sharp distinction
between disease and other kinds of suffering.

Evidence of very early specialization in ancient
Egypt suggests, on the other hand, that some groups

of people learned how to remedy certain painful or
incapacitating conditions and bequeathed such limited
knowledge without any theories or even clear notions
of disease.

The manner in which illness was approached in the
archaic civilizations of Egypt and Mesopotamia shows
considerable similarities. Disease is described as a
complex of symptoms; often the localization in a spe-
cial part of the body is stated. There are many different
complexes of symptoms, of what may “befall” the
person (the meaning of the Greek word sumptoma),
and there are consequently many diseases, which may
be given names or may be connected with actions of
demons and deities. The disease pictures can offer
indications for the outcome, for death or recovery; they
also offer a basis for action.

Most of the types of disease are described as symp-
toms or syndromes presenting themselves at a certain
moment. For instance, the surgical Edwin Smith
Papyrus, whose original composition probably goes
back to the Old Kingdom, tells what the physician will
find when he examines injured men. The descriptions
vary with the kind of injury and its location, and there
is something approaching a diagnosis, and a prognosis,
and there is, of course, therapy. Examination of the
patient has led to a recognition of the nature of the
case. The text then adds that the ailment is one “which
I will treat,” or “with which I will contend,” or “not
to be treated,” verdicts connected with a forecast of
the disease as curable, uncertain, or incurable. Analogy
with the development of prognosis in the times of
Hippocrates (ca. 400 B.C.) suggests the possibility of
a social motive for such forecasts. The physician may
have felt the need to protect himself against possible
later reproach, especially if he undertook the cure of
a patient who then died.

While an injury invited examination and an immedi-
ate decision, internal ailments also were described in
both Egypt and Mesopotamia as pictures presenting
themselves at the height of the illness. However, such
a static view was not the only one. In Mesopotamia,
where the reading of omens was developed into an
art, the symptoms of the disease were understood as
omens too, just as a potsherd found by the exorciser
on his way to the sick man could be of ominous portent.
The symptoms need not all appear at once; they could
be observed over a length of time or could change.
“If, at the beginning of the disease, the temples show
heat and if, afterwards, heat and transpiration disap-
pear, (it is) an affection due to dryness; after suffering
from it for two or three days, he will recover” (Labat,
1951). The reference to dryness points to the realm
of observation and to reasoning in terms of natural
phenomena. But in a subsequent case, the demon
“râbisu” is accused of having attached himself to the
sick man, feeding on his food and drinking his water.

Disease in Mesopotamian medical texts often was
connected with “the hand” of some deity, and “the
hand” of such a god was also recognized in nonmedical
contexts (Labat, 1951). Similarly, Leviticus 13 describes
a skin condition diagnosed as Zara'ath, which is usually
translated as leprosy. Not only is this identification
medically doubtful, but Zara'ath was more than a
human disease; it could be found in houses and gar-
ments as well. It was a term denoting ritual impurity,
sometimes inflicted as punishment by God, as in the
case of Miriam (Numbers 12:10) and of Gehazi, the
servant of Elisha (II Kings 5:27).

Disease receives meaning when placed in man's
moral universe when its occurrence within a scheme
of creation and right and wrong actions is accounted
for. In the archaic civilizations of Egypt, India, Israel,
and Mesopotamia, this universe was comprised of
everyday life, as well as of magic and religion. Disease
was punishment for trespass or sin, ranging from in-
voluntary infraction of some taboo to wilful crime
against gods or men. Disease could also be due to the
evil machinations of sorcery. Gods or demons could
cause disease without taking possession, or they could
represent the disease within the body. The magic and
religious interpretations of disease did not necessarily
exclude naturalistic explanations. Archaic civilizations
were not logical systems rejecting what did not fit into
the dominant scheme of things. Mesopotamian medical
works have been characterized as mere literary fixation
of old medical lore (Oppenheim, 1962). For ancient
Egypt it has been contended (Grapow, 1956) that no
single concept could be found to cover the different
approaches to disease. Yet there were beginnings to-
ward a speculative rather than magical view of disease.
The connection of heart beat with pulse beat was
recognized, and systems of blood vessels were invented,
thought to carry disease to various parts of the body.
Possibly a noxious agent (Wḫdw) was assumed, which
spread putrefaction and indeed forced the body or its
parts to undergo the very process against which em-
balming was to protect the corpse (Steuer, 1948).
Wḫdw could also be a demon, and this has suggested
the transfer from an originally demonistic to a more
physiological principle. If this interpretation (Steuer,
1948) is correct, we see here the beginning of the
metamorphosis of archaic into the rationalized and
systematic thought of the medical and philosophical
works of classical India, China, and Greece. But no
arbitrary end can be assigned to the archaic ways of
looking upon health and disease; many features even
survive in the superstitions and the unconscious moti-
vations of modern man.

II

In the Indian Caraka Samhitā the emergence of
diseases prompts the great sages, compassionate doers
of good, to acknowledge that “Health is the supreme
foundation of virtue, wealth and enjoyment, and salva-
tion,” and that “diseases are the destroyers of health,
of the good of life, and even of life itself.” They send
a messenger to Indra to ask him how to remedy dis-
eases, whereupon the god teaches the messenger the
science of life, which begins with general speculations
on the world, on causality, on man and his components,
viz., mind, spirit, and body. Body and mind are the
dwelling places of health, as well as of disease. Wind,
bile, and phlegm are the three “dosa” responsible for
disease in the body, while passion and delusion cause
disease of the mind. Somatic and spiritual remedies
help in the former, whereas the latter must be ap-
proached through “religion, philosophy, fortitude, re-
membrance and concentration” (Sutrasthana, Ch. I).
Both health and disease thus have their place in a
religious, philosophical, and medical sphere. Diseases
originate from a wide range of external or internal
causes of a somatic or psychological nature; but
demons are still one of the possibilities.

In India, medicine, ayurveda, is the veda of
longevity. Similarly, in China, health and disease are
incorporated into the philosophy of the Tao and the
two polar principles, the yin and the yang. Health and
disease are now states of the human microcosm, which
has its parallel in the macrocosm. In accordance with
the role played in Tao philosophy and practice by the
notion of prolonging life, health and longevity tend
to be identified. However, there is a gulf between the
natural association of good health and long life on the
one hand, and the association of health and potential
immortality on the other. Western religions and, until
the eighteenth century at least, prevailing Western
philosophy too, thought of death as man's unavoidable
fate (Gruman, 1966). The same is true of Buddhism.
“So this is life! Youth into old age, health into disease”
(Dhammapada). This was the insight that started Prince
Siddhartha on the long journey leading to his illumina-
tion as Buddha. His four noble truths have been com-
pared with the questions an Indian physician would
ask himself when confronted with a patient: Is he ill,
what is the nature and cause of his illness, is the dis-
ease curable, what treatment is indicated? (Zimmer,
1948). But Buddha's goal of treatment was not im-
mortality; it was Nirvana, eventual extinction.

For the Greeks, too, health was one of the greatest
goods. To be healthy, said Theognis (frag. 255), is the
“most desirable” thing. The high level of Greek med-
icine is, in itself, a sign that disease was abhorred.
Hygiene, the maintenance of health, played a very
great role, above all for the well-to-do, who were
expected to devote much of their time to it. For the
philosopher, health had its value as the necessary basis
for the practice of virtue. But since health does not
altogether depend on man's actions, the Stoic philoso-
phers did not declare health an absolute value. The
sage was superior to all disease, of body as well as of
soul (Cicero, Tusculan Disputations, III, xxxiv, 82), but
this did not prevent Stoic philosophers from taking
great interest in the minute classification and subdivi-
sions of disturbances (perturbationes; ibid., IV, x, 23ff.).
They thought of disturbances of the mind, discussing
them in analogy to bodily diseases. For since early
times, disease, to the Greeks, was a somatic disturbance
with manifestations that could be somatic or psychic.
The causes of disease could be many; gods, too, could
send diseases and could cure them, as they could cause
or alleviate any disaster. But Greek physicians and
philosophers agreed that disease was a natural process,
so that the secularization of the concept of disease was
limited only by the divinity of nature herself. A Greek
physician of about 400 B.C. could, therefore, say that
all diseases were divine and all were human (Hip-
pocrates, On the Sacred Disease, Ch. XXI), thereby
meaning that all diseases had their roots in the body
and in human actions and were influenced by external
agencies which, like cold, sun, and winds, were divine.
Epidemic diseases were attributed to pollutions
(miasmata) in the air inhaled by all the people of an
afflicted region. The miasmata might be caused by the
action of the sun, which replaced the sun god Apollo,
who, according to the myth, had inflicted a plague
upon Thebes which was polluted by the deeds of
Oedipus (Sophocles, Oedipus the King, 96-98).

Medical speculations on the origin of disease paid
little attention to divine or magic interference, but all
the more to mistakes in the way of life, above all in
diet (Hippocrates, On Ancient Medicine, Ch. III). Some
four hundred years later, the Latin author Celsus be-
lieved that in Homeric times health had been generally
good. Indolence and luxury had later spoiled man and
led to much disease. Therapy fell into the hands of
physicians who treated by means of diet, and who
became interested in natural philosophy (De medicina,
prooemium, 1-5 and 9).

On the practical side, dietetic treatment paralleled
practices of the athletic trainers. On the theoretical
side, it went together with a view of health as balance,
harmony, symmetry, and of disease as their disturbance.
Using political metaphors, Alcmaeon of Croton (fifth
century B.C.) taught that health was maintained by the
balance (isonomia) of such powers as moist, dry, cold,
hot, bitter, sweet, whereas disease was caused by single
rule (monarchia) (frag. 4). Other explanations were

offered in terms of elements, body fluids (humors), or
atoms. In the second century A.D. Galen, in the tradi-
tion of Hippocratic, Platonic, Aristotelian, and Stoic
ideas, elaborated a doctrine which was schematically
systematized in late antiquity and then remained
dominant till the seventeenth century. Four basic
qualities in binary combinations characterized four
elements which had their analogues in the four princi-
pal humors of the body. Hot and dry corresponded
to fire and yellow bile, hot and moist to air and blood,
cold and dry to earth and black bile, cold and moist
to water and phlegm. These analogues could be ex-
tended to the ages of man, the season, and winds, so
that man in health and disease was explicable in terms
of natural philosophy. The humors were products of
digested food and of metabolism, and man's functions
were regulated from the anatomical centers of liver,
heart, and brain, from which veins, arteries, and nerves
originated, and in which the natural soul, the vital soul,
and the rational soul, respectively, had their seats. The
soul had somatic, as well as psychological, functions:
the natural soul represented man's appetites and regu-
lated his nutrition; the vital soul represented the pas-
sions, especially anger, and regulated the body heat
through the pneuma of the arteries; the rational soul
accounted for thinking, feeling, and willing, receiving
messages and imparting its commands via the nerves.

Man was in good health if his body, its parts and
humors, had the temperament proper to them, and
when the structure and functions of the organs were
intact. Otherwise there was disease, as a consequence
of which all possible symptoms could befall the patient.
In view of the labile condition of the body, ideal health
was rarely attained. But only when there was pain,
and when a man was impeded in the functions of his
personal and civic life, was actual disease considered
to be present. There existed a borderland of relative
health between perfection and actual disease.

Such a concept of health and disease rests on a
teleologically conceived biology. All parts of the body
are built and function so as to allow man to lead a
good life and to preserve his kind. Health is a state
according to Nature; disease is contrary to Nature. It
is thus possible to speak of disease as a disturbance,
and of health as good, as deteriorating, or as improving.

In its medical aspect the Galenic doctrine grew out
of a particular set of ideas found in the works of
Hippocrates, whose name was given to some seventy
Greek medical writings of about 400 B.C. Many of these
writings, allegedly associated with the island of Cos,
the birthplace of Hippocrates, reveal a strongly indi-
vidualizing approach to disease. It is left to the physi-
cian to combine the many physical and mental symp-
toms into a diagnosis of the particular case.

But that did not exclude recognition of diseases as
entities. The Hippocratics spoke of consumption,
pneumonia, pleurisy, the sacred disease, i.e., epilepsy.
On the last there even exists a monograph which dis-
cusses causes, development, course, and major symp-
toms; it illustrates that a disease was thought of as a
process developing in time. On the other hand, rather
than arrange symptoms into disease pictures, Hippo-
cratic physicians often associated symptoms with the
constitution of their patients, usually expressed in
humoral terms. The four temperaments, phlegmatic,
sanguine, choleric, and melancholic, still spoken of
today, echo a psychosomatic classification of human
constitutions according to the Hippocratic-Galenic
tradition.

In some books of the Hippocratic collection, as-
cribed to the medical center of Cnidos, disease enti-
ties stand in the foreground. Four “diseases” are con-
nected with the kidneys; there is a dropsy coming from
the spleen; the disease “hepatitis” is attributed to the
black bile flowing into the liver. In short, diseases are
classified, ascribed to organs, and, together with their
symptoms, explained in humoral terms. After the ad-
vances made in anatomy from the early third century
B.C., anatomical considerations were given increased
space, for instance in Galen, Rufus of Ephesus, and
Aretaeus.

Not all ancient physicians thought it necessary to
give anatomical and physiological explanations for
disease. The “empiricist” sect, relying on experience
only, tried to assemble the syndromes of diseases but
refrained from dealing with any causes other than such
evident ones as cold, hunger, fatigue. The “methodist”
sect, though it had developed from the atomistic spec-
ulations of Asclepiades (first century B.C.), according
to which the pores of the body could become too wide
or too narrow, was satisfied with acknowledging the
existence of three conditions: constriction, relaxation,
and a mixture of both, conditions recognizable from
the symptoms without recourse to speculation
(Edelstein, 1967).

At the end of antiquity, these sects all but disap-
peared in the Greek-speaking East. The Galenic system
predominated and was inherited by Syrians, Arabs,
Persians, and Jews, to make its entrance into the West
from the eleventh century on. The biological basis of
the Galenic system was little changed. But it was
transferred into a world that looked upon health and
disease otherwise than did the pagans.

III

To the Greeks, the preservation of health through
temperance in eating, drinking, and other activities was
a model for healthy thinking (Snell, 1953), sōphrosynē,

soundness of mind. With it were connected well-being
and deliverance from ills, as the etymological roots of
the allied Greek words sōs, sōtēria, “suggest.” For
Aeschylus (Eumenides, 535-37) “much desired happi-
ness, beloved by all, [comes] from a healthy mind.”
To the Stoic philosopher, happiness lay in virtue; a
person was healthy if his contentment relied on the
things in his power (Seneca, Epistulae morales, lxxii,
7). The wisdom of the sage thus coincided with his
attainment of true health.

Here was a transition from the classical ideal of
health as symmetry and beauty (Plato, Timaeus
87E-88A) to the ideal of spiritual beauty and spiritual
health, acquired, if necessary, at the expense of the
body, “the flesh,” as the Gospel has it.

Suffering in general and disease in particular had
long been seen as consequences of sin. With the spread
of Christianity, they could appear as chastisement of
those whom the Lord loved. Disease could be a portal
through which man acquired eternal salvation. Jesus
told the sufferer from a palsy that his sins were for-
given. To show “that the Son of man hath power on
earth to forgive sins,” he bade the sick man: “Arise,
take up thy bed, and go unto thine house” (Matthew
9:2-7). Again, Jesus justified his eating “with publicans
and sinners” by saying that “They that be whole need
not a physician, but they that are sick” (ibid., 10-13).
Thus sickness was not only a consequence of sin, sin
itself was a disease which needed healing. This has
found expression in endless allegories from Origen to
authors of modern times. When Matthew (17:14ff.)
speaks of a lunatic boy whom Mark (9:14ff.) describes
as deaf and dumb, Bede interprets this as a reference
to persons waxing and waning in sundry vices as the
moon changes, deaf to the sermon of faith and dumb
because not expressing faith.

The ascetic life regarded disease not only with in-
difference but even with pride, as mortification of the
flesh. To care for the lepers and thereby to expose
oneself to infection was a sign of sanctity. It has to
be admitted that the positive evaluation of disease had
also another, secular, root. In the pseudo-Aristotelian
Problems (xxx,i) the question was raised why all men
outstanding in philosophy, politics, poetry, or the arts
appeared to be of a melancholic temperament, even
to the extent of being afflicted with the sicknesses
arising from the black bile. This was to lead to the
notion of melancholy as a disease of superior intellects,
a notion that achieved its best-known artistic expres-
sion in Dürer's engraving Melencolia I (Klibansky et
al., 1964) and its most learned treatment in Burton's
Anatomy of Melancholy (1621).

The concept of disease at a given period is not
altogether independent of the nature of the prevailing
ailments. The Middle Ages and the Renaissance
suffered much from infections that appeared in massive
epidemic waves or were endemic, i.e., native to the
population. Arabic and Latin authors of the time
elaborated the ancient concept of infections and con-
tagious disease. As a dye or a poison (virus) could stain
a large amount of water or kill a large animal; as
putrescent material, marked by an evil smell, corrupted
what had been sound, so an infection polluted the body
and could spread among a population. Virus, stain, evil
smell, putrescence, and miasma were the notions asso-
ciated with infection and contagion.

The concept of infection was broad and unclear:
infection could develop in the body with the disease,
it could be due to the influence of the stars (hence
“influenza”), and it could take on different forms (the
word “pestilence” designated any severe epidemic). If
the disease spread by personal contact, it was conta-
gious. Of all epidemics, the plague, which manifested
itself in bubonic and pulmonary forms, was the most
severe. It appeared during the reign of the emperor
Justinian (A.D. 527-65), then in the fourteenth century
(“the black death”), and in many subsequent outbreaks,
of which those of London (1665) and Marseilles (1720)
were among the last in Western Europe. The plague,
dreaded as contagious, provoked public health meas-
ures, quarantine and isolation, to counteract the dan-
ger. In Romeo and Juliet (Act V, Scene ii) the searchers
of the town, suspecting that Friar Laurence and his
brother monk “... both were in a house/ where the
infectious pestilence did reign/ seal'd up the doors...”
and did not let them leave.

The most serious endemic contagion was leprosy;
then from about 1495, syphilis assumed first place.
Whether syphilis was imported from the new world
by the crew of Columbus or had existed in Europe
before is a moot question. The disease became widely
known as the French disease (the French, in turn,
calling it mal de Naples). The name syphilis was given
to the disease in a Latin poem Syphilis sive morbus
gallicus (1530), by Girolamo Fracastoro, who also
elaborated a theory of contagious disease which in its
fundamentals survived till the mid-nineteenth century.
Imperceptibly small particles, seminaria, capable of
propagating themselves, transferred contagious diseases
by direct contact, through an object (fomes), or at a
short distance. It is not likely that he thought of the
seminaria as microorganisms; rather he anticipated
something of the notion of a leaven (Greek: zumē). A
contagious disease was specific: it retained its character
in the transmission from man to man. The ontological
view of diseases, i.e., thinking of them as real, distinct
entities, was nothing new. Even the comparison of a
disease with an animal was old—Plato (Timaeus 89B)

had used it, and Varro (116-27 B.C.) had actually
spoken of animals, too small to be seen by the eye,
“which by mouth and nose through the air enter the
body and cause severe diseases” (rerum rusticarum 1,
2). But in the sixteenth to seventeenth centuries the
ontological concept of disease was considerably
strengthened. The Paracelsists, including their master
Paracelsus (1493-1541) and their rebellious member
van Helmont (1577-1644), contributed by endowing
disease with a body, thinking of it as a parasite, at-
tributing its causes to external factors independent of
man. Van Helmont, in particular, opposed the old
theory of diseases as catarrhs, as fluxes from the brain
to which vapors had ascended. He spoke of the spina,
the thorn, i.e. irritations, the form in which diseases
acted in the body. Outside the circle of Paracelsists,
William Harvey (1578-1657) in his embryological
work (Exercise 27) thought of tumors as leading a life
of their own, and of diseases from poison or contagion
as having their own vitality (Pagel, 1968).

The most impressive presentation of the ontological
point of view came from Thomas Sydenham (1624-89).
He took up the Hippocratic notion of the “consti-
tution” of a year, associated with the diseases prevalent
during the period. According to Sydenham, epidemics
had different constitutions depending upon “an occult
and inexplicable alteration in the very bowels of the
earth, whence the air becomes contaminated by the
kind of effluvia which deliver and determine the human
bodies to this or that disease” (Opera, 1844). Diseases
should be observed and their species studied as plants
were studied by the botanists, and though he could
not explain the formation of the species, Sydenham,
nevertheless, hinted at their origin. When the humors
of the body could not be concocted, or when they
contracted “a morbific blemish from this or that at-
mospheric constitution” (ibid.), or when they turned
poisonous because of a contagion, then they were
“exalted into a substantial form of species” (Works,
1848). The disease itself was Nature's struggle to re-
store health by elimination of the morbific matter.
With great praise, Sydenham quoted the Hippocratic
saying, “Nature is the healer of disease.” Nature needed
simple help from the physician; sometimes not even
that.

Sydenham was one of the founders of nosology, the
science of classifying diseases, which came into its own
at the time of the great systematist Linné (1707-78).
Boissier de Sauvages (1706-67), Cullen (1710-90), Pinel
(1745-1826), and Schoenlein (1793-1864) created
nosological systems which, on the basis of clinical
symptoms, classified diseases into orders, families,
genera, and species. This was the practitioner's science:
if, by its symptoms, he could diagnose the disease and
find its place in the scheme, he could then also pre-
scribe the remedies recommended for it. If he wished,
he could go further and instruct himself about the
scientific explanation of the disease, but he need not
do so if he distrusted the various theories offered.

IV

With the decline of Aristotelian science, the chal-
lenge to the Galenic doctrines by the revolutionary
Paracelsus, the reform of anatomy by Vesalius, and the
discovery of the circulation of the blood by William
Harvey, pathology had undergone decisive changes.
The humors did not disappear at once, but the new
physics and chemistry replaced the Galenic doctrine
of health and disease as a balance or imbalance, re-
spectively, of the qualities. Descartes thought of the
animal body as a soulless machine; even in man only
the conscious mental processes involved the soul. To
overcome the difficulty regarding acts which were
seemingly purposeful yet independent of, or even con-
trary to, man's will, Descartes introduced the idea of
reflex action. The Cartesian philosophy favored a
physiology and pathology on strictly mechanical prin-
ciples with the help of a corpuscular theory which
permitted the inclusion of chemical explanations.

If the body is a machine, health will be represented
by a well-functioning machine, disease by a defective
one. A machine can have some self-regulatory
mechanisms built in, but it does not create new ones
when the situation so demands. It was, therefore, logi-
cal for Robert Boyle to refuse to see all diseases as
healing processes. His theological bias was against the
pagan view of nature as a benevolent being. Natural
processes were blind and could be destructive. A
dropsical person might be plagued by thirst, yet drink-
ing would aggravate the disease (Boyle, 1725). The
radical Cartesian dichotomy of body and soul also
entailed a basic difficulty concerning mental diseases.
It was logically absurd to think of the soul, a res cogi-
tans, as being prone to sickness in the manner of the
body; this could only be done metaphorically in the
manner in which crime, sin, heresy had long been
called diseases of the soul.

Revolutionary as the new mechanical orientation
was, it did not sweep everything before it. Even those
physicians who were inclined towards mechanistic
theories admitted their ineffectiveness at the bedside.
They recommended a Hippocratic attitude and patient
observation of the disease. Many physicians were un-
willing to follow the new mechanistic trend, and to
some of them theories altogether meant little.

Generally speaking, in the seventeenth century
mechanization was less successful in biology than in
the world of physics. Harvey himself, van Helmont,

Glisson, Wepfer, Stahl are outstanding among those
who, in one form or another, did not believe that life,
health, and disease could be understood without as-
suming the participation of the soul or of vital princi-
ples immanent in the body. They spoke of anima, of
the Archeus, of a “president,” or they endowed all
fibres with irritability. It all meant that the human
organism was actively engaged in preserving or restor-
ing health.

Before the middle of the eighteenth century, discus-
sions about the respective roles of mechanism and
vitalism were mainly carried on by doctors of medicine,
who devoted their attention and practice to internal
diseases. Apothecaries were interested in chemical
medicine, and it fell to them to prepare the chemical
drugs that had come into vogue with Paracelsus. In
England they gradually assumed the role of general
practitioners. Here the apothecary, who sold the med-
icine, dispensed medical advice together with his med-
icines. For this kind of practice nosological orientation
was particularly valuable. Another class of medical
man, the surgeon, also looked upon disease differently
from the doctor of medicine. In the Middle Ages the
surgeons had become separated from the physicians
and were organized in guilds, usually together with
the barbers. They looked after wounds, ulcers, absces-
ses, fractures, dislocations, diseases of the skin and
venereal diseases, tumors, possibly also cataracts,
herniae, and stones of the bladder. Moreover, they bled
patients if the doctor so prescribed. Their domain was
external disorders in contrast to internal illness. In most
cases, these disorders were localized, and in judging
them and treating them the surgeon had to know
something of the anatomy of the human body. Anat-
omy became the surgeon's preferred science, as chem-
istry was that of the apothecary.

With the exception of relatively few well-trained
men, the guild surgeon was not educated enough and
his social status was too low to allow him a decisive
influence on medical thought. Nevertheless, it is not
by chance that, though a doctor of medicine, Vesalius,
the reformer of human anatomy, was professor of sur-
gery at the University of Padua. With the appearance
of his Fabrica, in 1543, normal human anatomy became
firmly based on dissections of human cadavers. Patho-
logical anatomy, which studied morbid changes, de-
veloped more slowly, in spite of the fact that post-
mortem dissections to establish the cause of death had
been performed prior to anatomies intended to teach
the structure of man's body. Postmortem dissections
concerned cases where the disease showed unusual
features or where legal questions arose. With G. B.
Morgagni's De sedibus et causis morborum (“On the
Seats and Causes of Diseases,” 1761) pathological
anatomy became a science in its own right. Its practical
aim was to correlate the course of the disease and its
symptoms with the changes noticed after death.

As the title of his book indicates, Morgagni traced
the symptoms back to lesions in the organs, something
surgeons had usually done. But in surgical disorders,
the lesions were mostly visible or palpable, which in
internal diseases they were not. Pathological anatomy,
therefore, was of little use to the physician as long as
it was not possible to explore the condition of internal
organs during life. Two steps helped realize this goal.
Auenbrugger taught (1761) that changes in sound elic-
ited by percussion of the chest yielded information
about changes in the consistency of the organs of the
chest. Auenbrugger's work was popularized by Na-
poleon's physician, Corvisart, after the French Rev-
olution had led to a union of medicine and surgery.
The second step, made by Laennec, consisted in the
introduction of the stethoscope (1819). With its aid
Laennec was able to compare more effectively than
before the sounds heard over the heart and the lungs
under normal conditions with sounds heard when these
organs were ill. Percussion and auscultation helped the
physician to obtain an objective view of the patient's
illness; he was less dependent on subjective complaints.
The Paris school, leading in the new anatomical con-
cept of disease, found followers in London, Dublin,
Vienna, and elsewhere. The new insight into disease
through the combination of clinical and anatomical
pictures led to the elimination of old disease entities
and the solid establishment of others, like typhoid
fever, gastric ulcer, multiple sclerosis, and diphtheria.

The new objectivity found its place in the hospitals,
which housed a large number of patients, many of them
suffering from the same disease. Apart from wards,
hospitals also included dissection rooms and then
laboratories. Down to the later nineteenth century, the
hospital was predominantly a place for indigent pa-
tients, who were not under the personal care of a
particular physician but became “material” for obser-
vation and charitable treatment. Thereby the large
hospitals invited a statistical approach to sickness and
to therapy. In the eighteen-twenties Louis, in Paris,
investigated the influence of bleeding in the early
stages of pneumonia upon the course of the disease.
Some patients were bled early, as was the custom,
others were not. The results showed that early bleeding
did not improve the chances for recovery. A very
important insight into the unreliability of time-
hallowed therapeutics had been gained, and the nu-
merical method had been well illustrated.

The objective view of illness found in the large
hospitals had not originated there alone. The rise of
the modern state developed statistical methods which

covered the nation's health. In England, bills of mor-
tality stating the number of deaths from various causes
had come into use sometime in the sixteenth century.
Originally designed as intelligence about the spread
of epidemic disease, these bills, in the seventeenth
century, were used by John Graunt as a basis for vital
statistics. Mercantilism, with its advocacy of national
industries in the interest of a positive balance of trade,
calculated the economic advantages of health and the
loss incurred to the national economy through sickness
and untimely death. Bellers, in 1714, suggested that
Parliament make provisions for the improvement of
medicine so that the population

(p. 3).

The lack of sentimentality which permitted estimating
human life and suffering in terms of shillings and pence
presupposed the existence of a large anonymous popu-
lation in urban centers. It expressed the development
of a rationalized way of life.

With beginnings less clearly defined, the medical
application of scales, clocks, and thermometers also
promoted objective study of disease. These instruments
and a few simple chemical reactions were the forerun-
ners of the powerful array of the diagnostic laboratory.
Greek physicians had already used clocks to measure
the pulse rate and had proposed scales to determine
metabolic processes. Moreover, both these instruments,
and the thermometer for measuring the temperature
of the body, had been explored for medical use by
Santorio Santorio (1561-1636). But their widespread
acceptance was very slow. As late as 1860 Wunderlich
found it necessary to argue that the use of the clinical
thermometer was neither too expensive, neither too
time consuming for the practitioner, nor too bother-
some nor altogether superfluous (Ebstein, 1928). A
common principle underlying these instruments and
their much more complicated successors is the need
to establish numerical data. In the Galenic tradition,
normalcy had been viewed as an optimal natural state.
Vesalius described the human body in its theoretical
perfection. But the numerical limits of normal pulse
rate or body temperature must be based on measure-
ments in many individuals. The elaboration of tables
of numerical values gave health and disease a statistical
aspect, and the physiognomy of diseases could be ex-
pressed on graphs. The typical fever curves of many
infectious diseases, worked out by Wunderlich, enabled
the physician to make a tentative diagnosis from the
chart.

To be sure, all these aspects of modern “laboratory
medicine” (Ackerknecht, 1955) were far ahead of the
eighteenth century, when even scales, clocks, and
thermometers were used only by a few relatively
audacious minds. Yet it is not without significance that
De Haen (1704-76), whose hospital reports were a
major contribution to the practical medical literature
of the century, also urged the use of the thermometer
and tried to establish the normal temperatures for
various age groups (Ebstein, 1928). Essentially, the use
of numerical data in the diagnosis of disease presup-
poses that the latter is a physiological process. The
activities of the body can increase and diminish and
still remain within the range of the “normal.” There
is a transition from undoubted health to manifest dis-
ease.

This notion was elaborated in the system of John
Brown (1735-88). He assumed that the interaction
between the excitability with which the body was
endowed and the stimuli, external and internal, which
it encountered during life determined health and the
contrasting conditions of asthenia and sthenia. Health
was the territory between these two conditions. In a
few countries the direct impact of this system was
dramatic, in others it was slight. But its indirect influ-
ence on the development of physiological medicine in
the nineteenth century was very great. Both health and
disease represented life, and disease differed only in
representing life under changed circumstances.

V

To look upon disease as detrimental to the national
interest, as a natural process under changed but yet
natural conditions, as a process to be studied objec-
tively at the bedside, in the dissecting room, and in
the laboratory, was part of the “Enlightenment” of the
Western world after about 1700. But the Enlighten-
ment, notably in the teachings of Jean Jacques Rous-
seau, had its own sentimentality, which it also be-
queathed to the nineteenth century.

Rousseau and his followers looked upon health as
a gift of man's natural state, which luxury and civili-
zation had spoiled. Mothers should breast-feed their
babies, children should wear clothes that do not restrict
their bodies as fashionable dress does. It was bad to
expose the mind, especially the feminine mind, to the
incessant reading of novels. In the eyes of middle-class
society vices led to disease, and some diseases, notably
alcoholism and venereal disease, were shameful be-
cause rooted in an immoral life. The fight which Tissot
(1728-97) and generations of physicians after him led

against masturbation, warning against its alleged
baneful effects upon health, was a secular version of
a biblical taboo (onanism). On the other hand, Tissot
gave advice in matters of health to the people who
had no access to medical help, and Johann Peter
Frank's great work, System einer vollständigen med-
icinischen Polizey (1779ff.), was to serve the absolute,
yet enlightened authorities in ruling their subjects for
the latter's own good.

That health was seen as such a good was in itself
significant. The more the promises of another world
receded, the more desirable health appeared, not only
as a state to which all people at all times had aspired,
but as an ideal toward which society might actively
work. The practice of variolation was a step in this
direction. Paradoxically enough, in the United States
it found an early advocate in Cotton Mather, who had
played so notorious a role in the Salem witchcraft trials
of 1692. Variolation, since it transferred real smallpox,
though by means of dried matter from a light case,
still was a risky procedure. The risk was eliminated
by Edward Jenner's introduction of vaccination with
cowpox in 1798. In this case at least it was now proven
that man need not be helpless but could remove the
very threat of epidemics.

Vaccination was introduced during the English in-
dustrial revolution, which created health problems of
its own and, like wars, illustrated the dependence of
health not only on nature but on social conditions as
well. Enlightenment and, to some extent, the industrial
revolution brought about a revaluation of the signifi-
cance of disease. Epidemics and the appearance of new
diseases had often been viewed as signs of the wrath
of God punishing sinful mankind. The 1495 mandate
of Emperor Maximilian, which mentioned syphilis as
the punishment for man's blasphemous life, was as
typical of this concept as were the sermons preached
in New York in 1832, when Asiatic cholera made its
appearance (Rosenberg, 1962). But medical disasters
could be averted. Edwin Chadwick, a pupil of Jeremy
Bentham and secretary of the Poor Law Commission,
was responsible for the report on The Sanitary Condi-
tion of the Labouring Population of Great Britain
(1842). The report urged the prevention of illness to
save expense and pointed out the sanitary factors re-
sponsible for widespread sickness and early death.
Moreover, industrialization had led to new hazards in
the occupational life of the workers, and these should
be prevented.

The attention of the student of public health was
forcibly drawn to the social conditions of the times.
It was against this background that Virchow, in 1848,
claimed for the history of epidemics a place in the
cultural history of mankind: “Epidemics resemble large
warning tables in which the statesman of great style
can read that a disturbance has appeared in the devel-
opment of his people which even indifferent politics
must no longer be allowed to overlook.” This meant
that social factors superimposed themselves upon bio-
logical ones to the extent that certain diseases really
were social phenomena (Ackerknecht, 1953). Such
ideas, evoked in the revolutionary period of 1848, were
largely dormant in the following decades, only to
reappear in the twentieth century.

Few movements might be expected to show less
affinity than industrial revolution and romanticism. Yet
while pulmonary tuberculosis was predominant among
industrial workers, it also numbered among its victims
John Keats, Novalis, Chopin, Schiller, and two of the
great medical explorers of tuberculosis, Gaspard Bayle
and Laennec. If periods have diseases fitting their style
(Sigerist, 1928), pulmonary consumption was a roman-
tic disease just as syphilis had belonged to the late
Renaissance, gout and melancholia or love-sickness to
the baroque. But apart from the high incidence of
tuberculosis during the time (1760-1850) covering both
the industrial revolution and the romantic movement,
disease, somatic as well as mental, received almost
loving care by romantically inclined authors and opera
librettists. This is not only true of tuberculosis, but also
of chlorosis, the anemia of the young girl, and of mor-
bid mentality ranging from madness in the gothic
novels to somnambulism and the bizarre characters of
E. T. A. Hoffmann and Edgar Allan Poe. The neurotic
character as hero made its debut with Goethe's
Werther (Feise, 1926). The romantic movement thus
reaccentuated the concept of disease as a contributor
to cultural life.

Equally romantic, however, was the frequent glorifi-
cation of healthy primitive life. “Beneath the rustic
garb of the plowman and not beneath the gildings of
the courtier will strength and vigor of the body be
found,” exclaimed Rousseau (Discours..., p. 104),
and “Healthy as a Shepherd-boy,” sang Wordsworth.
Nature, the country, the wilderness were the antidotes
to the cities, the foci of human degeneracy. Disease
was caused by an infringement of the laws of nature,
and these laws, so the phrenologists claimed, included
mental life too, since the mind had its organs in areas
of the cerebral cortex. An infringement of Nature's
laws was an infringement of God's laws. Health was
not only desirable; in Anglo-Saxon countries its preser-
vation was propagated as something like a moral duty,
a glorification of God. This combination of enlightened
thought and romantic mood gave a religious overtone
to the sanitary movement in its broadest sense.

The medical profession was strongly represented
among the phrenologists and various kinds of sanitary

reformers. Skepticism of traditional curative methods
led many physicians to believe that the healing power
of nature was superior to any medication, especially
since the homeopaths with their unbelievably weak
solutions of drugs showed at least as good results as
did regular practitioners. Some expected progress from
prevention rather than from therapy. The so-called
therapeutic nihilists, e.g., Josef Dietl, thought that
medicine should exert all its efforts towards becoming
a science; until then, it would be best to abstain from
all healing and merely help nature by providing
hygienic conditions for the sick. There was, moreover,
no uniform understanding of disease and its causes. The
anatomico-clinical trend, which led to the recognition
of new disease entities, seemed to favor an ontological
concept of disease. But upon reflection, this appeared
doubtful. It could be argued that while an ulcer of
the stomach explained some of the concomitant symp-
toms, the presence of the ulcer itself remained unex-
plained. Anatomy did not provide an understanding
of the causes of disease, which could only be obtained
from physiology, an experimental science.

It was the stress on experiment that distinguished
the new physiological concept of health and disease
from the earlier one of John Brown and Broussais.
Claude Bernard's Introduction à l'étude de la médecine
expérimentale (1865; Introduction to the Study of Ex-
perimental Medicine, 1926) became the classical philo-
sophical exposition of the new concept. “The words,
life, death, health, disease, have no objective reality,”
wrote Claude Bernard. Life referred to a number of
functions which could proceed normally or abnormally.
The task of physiology was to find out how the body
worked, and this could only be done experimentally.
The supremacy of the physiological concept of disease
had been recognized by Claude Bernard's teacher
Magendie and by the German school of physiologists,
pathologists, and clinicians, who, in the 1840's, were
aligning German medicine with the progress made
abroad. It was also recognized by Virchow, though his
epoch-making contribution, DieCellularpathologie in
ihrer Begründung auf physiologische und pathologische
Gewebelehre (1858), was in some respects a culmina-
tion of older trends.

After Morgagni had looked to the organs as the seat
of diseases, after Bichat (1771-1802) had pointed to
the tissues, Virchow declared the cells responsible for
the body's health and disease. To Virchow, the body
was a social organism dependent on the functioning
of its elements, just as the state depended on the activi-
ties of its elements, the citizens. Virchow tried to
explain changes visible in the cells physiologically, by
recourse to the concepts of irritation (for active
processes) and degeneration (for passive ones). But
these physiological explanations were not the direct
outcome of experimental work, and cellular pathology
impressed the medical world as anatomical in charac-
ter. Nor was it free from vitalistic features displeasing
to a group of physiologists around Carl Ludwig, Du
Bois-Reymond, Brücke, Helmholtz. They, too, had
their own revolutionary program, which Du Bois-
Reymond proclaimed in 1848: eventually physiology
would be dissolved into biophysics and biochemistry,
with analytical mechanics as the ideal form of all
science. This was radical reductionism in its classical
form.

The physiological concept of disease, whether re-
ductionist or not, did not well agree with ontological
systems. There was no reason why nature should be
bound to rigid types. Since every individual differed
from another, and since life could be subjected to an
infinite variety of changed conditions, every sick person
really represented his own disease. Claude Bernard did
not overlook this. Ordinary causes, such as cold,
hunger, thirst, fatigue, and mental suffering, were
modified by idiosyncrasy, which was partly congenital
and partly accidental. The pathological predispositions
were nothing but special physiological conditions: a
starved and a satiated organism reacted differently.

In disease, nature played the role of the experi-
menter; the observable changes could be viewed as
experiments of nature and analyzed accordingly.
Nosology, it was argued, was no more than a practical
makeshift to be disregarded by the medical scientist.
The existence of a clear demarcation between health
and disease was altogether doubtful. Virchow, who had
followed Henle in defining disease as life under
changed circumstances, later came to realize the in-
adequacy of this definition. Circumstances might
change drastically; a man could find himself in jail and
yet remain healthy. Disease began at the moment when
the regulatory equipment of the body no longer suf-
ficed to remove the disturbances. “Not life under
abnormal conditions, not the disturbance as such, en-
genders a disease, rather disease begins with the insuf-
ficiency of the regulatory apparatuses” (Virchow [1869],
p. 93).

In this respect, Virchow and Claude Bernard were
not very far apart. The latter placed increasing em-
phasis upon the internal milieu, i.e., blood and tissue
fluids, which provided a steady environment for the
cells composing the body and made it independent of
the vagaries of the external environment. The con-
stancy of the internal milieu was largely maintained
through the regulatory functions of the nervous system.
Later (1928) Walter Cannon introduced the term
“homeostasis” to designate the condition of actively
sustained equilibrium prevailing in the organism. By

then, the significance of endocrine glands in the regu-
latory mechanisms of the body had been recognized.

VI

Both Claude Bernard and Virchow had expressed
their respective ideas before Robert Koch's discovery
of the tubercle bacillus in 1882 won the decisive vic-
tory for the germ theory of disease. Many reasons
militated against easy acceptance, one of these being
the clash with the anti-ontological tendencies of many
medical scientists. Louis Pasteur, Koch, and their fol-
lowers had demonstrated that specific microorganisms
were responsible for specific diseases. Diseases could
even be defined bacteriologically. Thus the argument
about the relationship of pulmonary consumption and
the disease in which tubercles appeared was now
solved: tuberculosis was a disease characterized by the
presence of the tubercle bacillus, just as diphtheria was
“caused” by the diphtheria bacillus; the formation of
a membrane which originally had given its name to
the disease was no more than an anatomical symptom.

Although bacteriology concerned infectious diseases
only, its influence on the general concept of disease
was great. Presumably, diseases could be bound to
definite causes; hence the knowledge of the cause was
needed to elevate a clinical entity or a syndrome to
the rank of a disease. Moreover, an infection had a
beginning and it ended after the annihilation of the
invading microbe. Between these two points in time
the person in question was sick; before and afterwards
he was healthy; consequently, health was absence of
disease. What really mattered was the invasion by the
microbe, hence the study of the microbes and of the
circumstances of their transmission appeared of pri-
mary importance. The consideration of social and
nonscientific environmental factors, which were so
important to the older sanitarians, receded into the
background (Galdston, 1940). Bacteriology and the
science of immunology, which developed in its wake,
had their home in the laboratory, where experiments
were performed on animals, sera obtained from them,
and vaccines produced out of attenuated or dead cul-
tures of bacteria and out of sera obtained from animals.
To the die-hard sanitarian this was the negation of the
holy campaign against filth; the new science did not
lead to real health, which was to be freedom from
suffering for man and beast alike (Stevenson, 1955).

Actually, of course, bacteriology was far from prov-
ing so simple in its concepts of health and disease as
at first appeared. The microorganism was not just a
demon which possessed man once it had entered. It
remained true that during epidemics some people be-
came ill, others did not. Cases became known of per-
sons harboring pathogenic microorganisms without
themselves falling ill. Obviously then, the microor-
ganism was not the sole cause; generally speaking,
bacteria were just one form of external cause of disease.
Traditionally, antecedent, predisposing causes of dis-
ease were distinguished from proximate causes, which,
under the name of aitiai prokatarktikai, the Greeks had
identified with external causes. Julius Cohnheim, an
early sponsor of Robert Koch, declared in his famous
lectures on general pathology (1877) “that the causes
of disease are not and cannot be anything else but
conditions of life or, expressed differently, they are
outside the organism itself” (p. 8). In the general field
of pathology, this paralleled what Pasteur and other
early bacteriologists claimed for infectious diseases. At
the same time, Cohnheim's argument was a logical
extension of the view of disease as life under changed
circumstances. The body's regulatory mechanisms
enabled it to function normally, i.e., as observed in the
majority of people. Disease was a deviation from the
normal process of life caused by a reciprocal action
between external conditions and the internal regulatory
abilities of the organism. It seemed logical to argue
that “the normal process of life” could be “disturbed”
only by an overpowering change in external conditions.

Cohnheim, like many others before and after him,
believed that the concept of health and disease could
be derived from a statistical definition of what was
“normal.” But statistical deviations only separate the
frequent from the rare. If disease was to be defined
as deviation from the regular, i.e., the healthy process
of life, then deviation must imply a more than statis-
tical evaluation.

Cohnheim and many physicians, then and now, un-
consciously adhered to the old biological idea of “nor-
mal” as successfully self-preserving and self-propagat-
ing, and of “abnormal” or morbid as an impediment
of, or danger to, these potentialities. Thus Virchow,
in 1885, could even go so far as to say that disease
was “life under dangerous conditions” (p. 221). From
the reductionist point of view such a definition was
hardly tenable, for what does “dangerous” mean in
physical and chemical terms? Indeed, Ricker (1951),
a German pathologist of the twentieth century, denied
that health and disease were truly scientific concepts.
They belonged to the realms of applied sciences,
“health and its preservation to that of theoretical hy-
giene, disease to that of medicine as the doctrine of
the healing of diseases.”

VII

Modern concepts of disease are the result of a linking
of scientific thought, practical achievements, and social
factors. Bacteriology developed at a time when West-
ern countries were entering a new phase of the indus-

trial revolution, marked by the association of tech-
nology and science. Antiseptic surgery offered an
immediate practical application of the germ theory.
From the mid-seventies an increasing number of dis-
eases were made accessible to surgical treatment; more
important perhaps, surgical treatment could increas-
ingly count on a successful outcome. Here was one
branch of medicine where medical help promised re-
sults rather than mere hope. Health began to take on
the nature of a purchasable good, but at the same time,
the purchase of health began to become more costly.
Major surgical operations now were more easily per-
formed in the hospital than at home, and the replace-
ment of antiseptic surgery by aseptic methods rein-
forced this trend. The pattern that surgery established
by utilizing scientific methods was followed by internal
medicine, which also relied more and more on the
laboratory and on hospital facilities. Application of the
principles of bacteriological sterilization led to obvious
results in decreasing infant mortality. Bacteriology and
immunology offered scientific tools for the sanitation
of disease-ridden districts and the prevention of many
infectious diseases. DDT proved a successful contact
poison against the insect vectors of pathogenic mi-
crobes. The sulfonamides (1935) and, by the end of
World War II, the antibiotics, presented “miracle
drugs” in the treatment of infectious diseases.

Helped by these scientific achievements, the disease
picture since the middle of the twentieth century
differs from that of around 1900. The infectious diseases
have yielded their place in the table of mortality to
degenerative diseases, to tumors, and to accidents, and
life expectancy (particularly at birth) in Western na-
tions has continued to rise. The more possible it has
become to avoid diseases, or to be cured of them and
to enjoy health, the more health appears as a desirable
good to which everybody has a “right.” Such a right
did not extend to other purchasable goods, but the
special status that Christianity once granted to the sick
prepared the way for this special claim. Social devel-
opments during the nineteenth century moved the
matter from the realm of religion and philanthropy
to that of politics. Compulsory sickness insurance was
introduced in Germany in 1883 as a strategic measure
in Bismarck's fight against the social democrats. In the
twentieth century, other countries followed. In the
United States, voluntary insurance and medicare and
medicaid programs all serve the idea of making medi-
cal care available to an increasing number of people.
Western achievements look no less desirable elsewhere,
including the so-called underdeveloped countries. Even
in the League of Nations the health activities continued
after the decay of the political body. Its UN successor,
the World Health Organization, has accepted a pro
gram geared to the definition of health as “a state of
complete physical, mental, and social well-being and
not merely the absence of disease or infirmity.”

The history of the ideas of health and disease begins
with the crystallization of these ideas out of human
suffering. Of the stages through which these ideas have
gone, some belong to the past, others have merely seen
a metamorphosis. Disease as a physiological process
and disease as an entity are recurrent themes which
have been likened to the struggle between nominalism
and realism. Disease has been seen as nothing but a
form of misery, and health as part of man's salvation.
But there are also those, like Thomas Mann (The Magic
Mountain), who see a positive value in disease as the
price at which a higher form of health must be bought.
The prevailing tendency at the present moment seems
to merge disease once more with much that formerly
was considered distinct from it and to take so broad
a view of health as to make it all but indistinguishable
from happiness.

The history of the ideas of health and disease cannot
decide these issues; it can only present them. In doing
so it can, however, point out that health and disease
have not shown themselves to be immutable objects
of natural history. Health and disease are medical
concepts in the broadest sense. This means that man's
life in its inseparable union of body and mind is seen
under the aspects of possible preservation and cure.
Thus they are distinguished from purely scientific con-
cepts on the one hand and from purely social ones on
the other.

BIBLIOGRAPHY

The literature on the history of the concept of disease
is very great, and the items listed below are but a very
small selection. The books of Berghoff, Riese, Sigerist,
Edelstein (for Greco-Roman antiquity) deserve particular
attention.

Erwin H. Ackerknecht, Rudolf Virchow: Doctor, States-
man, Anthropologist (Madison, 1953), p. 127; idem, A Short
History of Medicine (New York, 1955). Atharva-Veda
Samhitā, trans. William Dwight Whitney, rev. ed. Charles
Rockwell Lanman, Harvard Oriental Series, Vols. VII, VIII
(Cambridge, 1905), VII, 361. John Bellers, An Essay Towards
the Improvement of Physick. In Twelve Proposals. By which
the Lives of many Thousands of the Rich, as well as of the
Poor, may be Saved Yearly (London, 1714), p. 3. Emanuel
Berghoff, Entwicklungsgeschichte des Krankheitsbegriffes,
2nd ed. (Vienna, 1947). Claude Bernard, An Introduction
to the Study of Experimental Medicine, trans. Henry Copley
Greene (New York, 1927), p. 67. Robert Boyle, “A Free
Inquiry into the Vulgar Notion of Nature,” The Philosophical
Works, 3 vols. abridged, ed. Peter Shaw (London, 1725), II,
106-49, esp. 143. The Caraka Samhitā (Jamnagar, India,
1949), II, 4, 13. Julius Cohnheim, Vorlesungen über all

Gemeine Pathologie (Berlin, 1877), I, 8, 12. Erich Ebstein,
“Die Entwicklung der klinischen Thermometrie,” Ergeb-
nisse der inneren Medizin und Kinderheilkunde, 33 (1928),
407-505, esp. 462, 482. Ludwig Edelstein, Ancient Medicine:
Selected Essays, ed. Owsei Temkin and C. Lilian Temkin
(Baltimore, 1967). The Edwin Smith Surgical Papyrus, with
translation and commentary by James Henry Breasted, 2
vols. (Chicago, 1930). Ernst Feise, “Goethes Werther als
nervöser Charakter” (1926), reprinted in Xenion: Themes,
Forms, and Ideas in German Literature (Baltimore, 1950),
pp. 1-65. Iago Galdston, “Humanism and Public Health,”
Bulletin of the History of Medicine, 8 (1940), 1032-39.
Hermann Grapow, Kranker, Krankheiten und Arzt.
Grundriss der Medizin der alten Ägypter, III (Berlin, 1956).
Gerald J. Gruman, A History of Ideas About the Prolongation
of Life, Transactions of the American Philosophical Society,
56, 9, new series (Philadelphia, 1966). Raymond Klibansky,
Fritz Saxl, and Erwin Panofsky, Saturn and Melancholy
(London, 1964). The Dhammapada, translated from the Pali
by P. Lal (New York, 1967). René Labat, Traité akkadien
de diagnostics et pronostics médicaux (Paris and Leiden,
1951), pp. 157, xxiii. Claudius Mayer, “Metaphysical Trends
in Modern Pathology,” Bulletin of the History of Medicine,
26 (1952), 71-81. A. Leo Oppenheim, “Mesopotamian Med-
icine,” Bulletin of the History of Medicine, 36 (1962),
97-108. Walter Pagel and Marianne Winder, “Harvey and
the 'Modern' Concept of Disease,” Bulletin of the History
of Medicine, 42 (1968), 496-509; this article contains refer-
ences to Dr. Pagel's important works on Paracelsus and van
Helmont. Gustav Ricker, Wissenschaftstheoretische Aufsätze
für Ärzte, 2nd ed. (Stuttgart, 1951), p. 48. Walther Riese,
The Conception of Disease, its History, its Versions and its
Nature (New York, 1953). George Rosen, A History of Public
Health (New York, 1958). Charles E. Rosenberg, The Cholera
Years (Chicago, 1962). Jean Jacques Rousseau, Discours sur
les sciences et les arts, ed. George R. Havens (New York,
1946), p. 104. Henry E. Sigerist, Civilization and Disease
(Ithaca, N.Y., 1943); idem, A History of Medicine, 2 vols.
(New York, 1951-61); idem, “Kultur und Krankheit,” Kyklos,
1 (1928), 60-63; idem, On the Sociology of Medicine, ed.
Milton I. Roemer (New York, 1960). Bruno Snell, The Dis-
covery of the Mind, trans. T. G. Rosenmeyer (Cambridge,
Mass., 1953), p. 162. Robert O. Steuer, “Wḫdw, Aetiological
Principle of Pyaemia in Ancient Egyptian Medicine,” Sup-
plements to the Bulletin of the History of Medicine, No. 10
(Baltimore, 1948). Lloyd G. Stevenson, “Science Down the
Drain,” Bulletin of the History of Medicine, 29 (1955), 1-26.
Edward A. Suchman, Sociology and the Field of Public
Health (New York, 1963). M. W. Susser and W. Watson,
Sociology in Medicine (London, 1962). Thomas Sydenham,
Opera omnia, ed. G. A. Greenhill, Sydenham Society
(London, 1844), pp. 30, 16; idem, The Works, trans. R. G.
Latham, 2 vols. (London, 1848), I, 19. Owsei Temkin, “The
Scientific Approach to Disease: Specific Entity and Individ-
ual Sickness,” Scientific Change, ed. A. C. Crombie (New
York, 1963), pp. 629-47. Rudolf Virchow, in Medicinische
Reform, No. 8 (25 August 1848), reprinted in Gesammelte
Abhandlungen aus dem Gebiete der öffentlichen Medicin
und der Seuchenlehre (Berlin, 1879), I, 22. Rudolf Virchow,
“Über Akklimatisation,” (1885) and “Über die heutige
Stellung der Pathologie,” (1869), in Karl Sudhoff, Rudolf
Virchow und die deutschen Naturforscherversammlungen
(Leipzig, 1922), pp. 221, 93. Henry R. Zimmer, Hindu
Medicine (Baltimore, 1948), pp. 33f.

OWSEI TEMKIN

[See also Behaviorism; Death; Demonology; Enlightenment;
Genetic Continuity; Macrocosm and Microcosm; Primitiv-
ism; Romanticism, Stoicism.]