THE CONCEPT OF DISEASE

C. ALBERTO SEGUIN, M.D.* "The criterion of psychosomatic health is maintenance by the organism of homeostatic equilibrium with itself and within its environmental field."Dunbar-Arlow

Like everything alive, medicine undergoes constant evolution. That is a well-known truth, but its consequences are often overlooked, even in connection with the most important and fundamental concepts. Among them none, perhaps, is more interesting than the concept of disease. The concept of disease has changed, of course, with the dominant conceptions of medicine in different epochs, and at present, when in our opinion medicine is passing through a decisive moment, a revision in the light of modern orientation seems necessary. The problem has been faced in different ways, following the trend of thought of the cultural moment. Aschoff says that the history of medicine can be written by describing the attempts made to establish the essence of the disease. A simple definition, fitting any theory, would be: "Disease is the lack of health," but in using such a definition we have only deviated from the problem. We have now to define health. We do not believe this to be the best way. The concept of health is a secondary one; it was born a posteriori, as a contrast to the notion of disease, as a negation of it. In the initial stages of the evolution of humanity, it is disease of which man first becomes aware. Later on, as a counterpart, and in a theoretical way, the notion of health was established. Before being conscious of his health, the primitive must have known that he was ill. The terms of the definition could then be changed by saying: "Health is the absence of disease."
THE CONCEPT OF DISEASE IN HISTORY

of being abandoned literally, influences the medical world even today. It was Hippocrates who first fought against this concept in his studies on epilepsy, when he stated the opinion that this disease was due to natural causes and not to any demon; but Plato thinks of the disease as something autonomous, superimposed on the organism. During the Middle Ages that idea grew immensely, backed by the mystic concept of sin as the cause of everything evil. It is easy to discover it in the belief in demoniacs, in possessions, in the descriptions of the incubos and sucubos, in the whole dark history of witchcraft and exorcisms, clouding under its black shadows several centuries of the life of humanity. It is interesting to remember that Sydenham classified diseases with the same criterium with which plants are classified in botany; as if they were entities with life of their own. Later, all through the history of medicine, the concept of disease as an autonomous entity can be seen under different disguises, taking sometimes philosophical characteristics, as with Schonlein, who stated that life is a struggle between the individualistic and the planetarian forces. The first tries to keep its autonomy while the second tries to destroy it, incorporating the living creature in the undifferentiated totality. That "planetary force" is, as he said, the malignant potency that tries to destroy Man. The same idea is found in the arguments about the "sedes morborum," the location of disease. For centuries the theoreticians of medicine discussed the place in the body in which the disease is located, as if it were a being looking for a place to settle. Morgagni was the first one to speculate about this matter, starting a discussion that continued through the centuries. It is necessary only to refer to the long opposition between "solidism" and "humorism." Some scientists, the solidists, believed that disease is located in the solid parts of the body; those who opposed that theory sustained that it was located in the humors. Virchow reacted against these ideas, but indulged finally in them. He tried to destroy the belief in disease as something independent, but he pointed to the cell as the "location" of it, saying implicitly the very same thing he combated against.
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We have said the primitive was first conscious of the disease. Perhaps it was illness which, through suffering, made him acknowledge his own ego and then, following the trends of his psychology, he concretized the idea of disease, as he did with many other fundamental ideas. To the primitive, disease is a being, an exterior potency, a demon attacking the man, penetrating into him, fighting with him, dominating and killing him. This is not the moment to analyze the consequences of this idea on the diagnosis, therapy and, in general, the whole field of medicine, but we want to emphasize the fact that this primitive concept of disease, in spite

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The bacteria era followed and, with it, the Golden Age for the demoniac concept of disease. It was then possible to conciliate the irrational and primitive tendency to concretize and personalize disease with the rational, scientific thought. Here was, at last, the malignant potency. It was possible to see and to study it. The germ was the scientific form of the demon who attacks and kills. That idea, however, could not stand against the growing knowledge of disease. It was very soon discovered that the germ was not enough to explain the whole pathologic process. The factors of environment were understood better, and it was easy to see that the organism was not passive before the "attack" of the microbe. Predisposition, immunity, resistance, etc., had to be taken into consideration. Nevertheless, even today the primitive, demoniac concept of disease dominates medical thought. Many professional men would easily agree to the definition: "Typhoid fever is the disease produced by Eberth's bacillus," or "Tuberculosis is the disease produced by Koch's bacillus." There are writers who have expressed those ideas in the form of mathematical formulations, showing how the primitive concept of disease can be made "scientific." Strumpel, studying tabes, said the following equation can be applied: K-S K "W

spite of their rational surface, present deep reactions, rooted in the unconscious which impose themselves on the rational superstructure. It is interesting to observe that psychoanalysis, the outstanding method of exploring the unconscious, and familiar therefore with its characteristics, has fallen into the same pitfall. The Freudian theory has concretized, personalized the psychological processes, making out of our mental life a theater where defined entities such as the Ego, the Id, the SuperEgo, the censor, fight. In psychoanalysis we find also the primitive demon, the cause of disease, under the name of Thanatos, the death instinct, which fills today's literature.
THE MODERN CONCEPT OF DISEASE

Let us study now in detail the "modern" concept of disease. It is impossible to review all the definitions of disease, but they lend themselves to a classification by taking into consideration the importance they give to one of the following instances: (a) (b) (c) (d) Etiology. Anatomo-pathology. Phenomenology. Valoration.

K, the disease, is in direct relation to S, the causal lesion, and in inverse relation to W, the resistance of the organism, as if there were a struggle between an aggressor and the possibilities of defense against it. Everyday language, reflecting the feeling of the moment, has many expressions which show us how the primitive concept of disease influences our modern ideas. We say that the disease "dominated the individual," that "the patient fights against it," "resists it," or surrenders to it"; that the disease "attacks, progresses and kills"; that the physician "faces it," etc. It is very easy to find similar phrases in medical books. The same thing ^happens, and perhaps more clearly, with death. Death is typically personified as a skeleton, generally with a scythe in its hand. We have all seen the famous etching which decorates many waiting-rooms: a young nude woman shelters herself in the arms of a physician, who embraces her with one arm, while he holds off with the other a skeleton that seems to be trying to take' his possession away from him. In the face of events so deeply important for their existence, men, in 3

Definitions in which etiology plays an important part deal, of course, with the "cause" of disease and lead us to the discussion of this concept in medicine. Pophal has made an interesting study of the problem,1 taking into consideration principally the work of Hueppe, who, analyzing Mach's ideas, tries to eliminate from our discipline the notion of "cause," substituting for it the idea of function. This attempt helps us undoubtedly in the discussion of the concept of cause, a concept so difficult to face in every science and especially in medicine. Could we refer as a "cause" to the spark that lights the powder when, without the chemical characteristics of this compound, the spark would have produced nothing, and when, those characteristics given, any other adequate stimuli would produce the same result ? Are those characteristics the cause ? If we think of disease new complications arise. Hueppe says that the external influences which put a phenomenon into motion are secondary to the intrinsic dispositions of the living being. In the case of disease the microbe, for instance, produces disease only because there exists in the organism the potentiality to answer in a determined sense. That answer can be provoked by different stimuli.
1 R. Pophal: "El Concepto de Enferad," La Cultura Medica, Buenos Aires, 1930.

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For an interesting example we shall quote from Pophal 1 :

As everybody knows, pneumonia is said to be a typical infectious disease, whose most frequent agent is the Diplococcus lanceolatus. The problem of the outburst of the disease is not, however, so simple that the presence of man and Diplococcus is sufficient to cause the pulmonary inflammation. There are many people who have die Diplococcus lanceolatus in their bucal cavity without ever having pneumonia. How does it happen, then, that the Diplococcus lanceolatus so frequently found in the bucal cavity, and innocuous, turns up to be in a determined moment a pathogenous agent in the lungs? We know that the normal mucous of the respiratory tract, as well as the alveolar tissue of the intact lungs, has a great power of resistance. Catarrhal inflammation is the consequence of a cold. Cold would be, then, in the sense of the old classic medicine, the "cause" of the pneumonia. We have already two causes. We must say now that under the same circumstances everyone does not get a cold. Colds have, as a premise, a certain predisposition either acquired or based on congenital peculiarities of the organism. There is enough reason to believe in a hereditary disposition to colds. We have, then, a third cause. Finally, we must take into consideration the disposition to the Diplococcus' infectionor the possibility of becoming ill after the infection has occurredas an important cause, and not forget the fact that after the disease is declared its outcome depends on the most varied circumstances: heart peculiarities, previous alcoholism, etc. All these factors may be considered as causes. Common language prevents no one from considering as the cause of an unhappy result, not the bacillus, but the cold, or the familiar hereditary peculiarity (when, for instance, the father died also from pneumonia), or, if it is the case of a drunkard, the abuse of alcohol. We have, then a group of causes, but which is the principal one, the "cause" in the sense of Hueppe? Not the Diplococcus, of course, if we think that it is, as the bacillus coli, an innocuous symbion. Following the theories of natural energetic science, we should say that the cause is the histologic peculiarity of the lungs, where the characteristic process we call pneumonia happens. Such a process never starts spontaneously or because of the so-called internal causes. It has to be stimulated and put into motion in some way from outside. Not always is die Diplococcus lanceolatus the instigator; it may also be the Friedlander's pneumo-bacillus. Or that stimulus may come from a streptococcic infection. Anyway, the concurrence of a lung with morbid predisposition and the probable stimulus is not sufficient for pneumonia to be provoked since other very particular conditions need to be present, and those conditions are submitted to great oscillations.

cause? There is something else. Let us consider that the subject slipped on something he obviously did not see, because of some eye defect or because he was absorbed in his thoughts. Had that defect or that preoccupation not existed, the fall would not have happened. Were they the cause? Here we remember the discoveries about the "accident-habit," the predisposition to have accidents. If our subject possesses a personality of that type, we again have the concept of cause displaced. We may increase the displacement if we think of the factors determining such a personality structure. If the concept of causality is useful in the physical sciences (we have already referred to the fact that in those sciences it is also theoretically in bankruptcy), it is not in biology. The reason may be found if we consider the living being as not reacting in a simple way but as a totality, a Gestalt. In physics we can, with the already stated limitations, speak of cause and effect, but in biology the first of the two terms is changed to stimulus that, acting over the living Gestalt, produces a response. Such a response is conditioned, not only by the stimulus, but by all the other internal or external stimuli influencing the system, and by the characteristics proper to that system. We find ourselves, then, before a complex series of relations needing a wider criterium. Mach says:
It is possible in every phenomenon to find direct and, indirect relations of dependency. Therefore, all the clearly and exactly recognized relations can be conceived as simultaneous reciprocal relations. That which is functional refers to the reciprocal dependency of two phenomena and excludes the primacy of one unique member of the chain, selected as cause. T h e idea of cause is not useful in medicine and

We shall present another example: Let us suppose that an individual going down a flight of stairs slips and, in falling down, suffers a fracture of the forearm. Where is the cause of such a fracture? Is it in the fall with the weight of the body on the arm? In the position of the forearm in the moment of the accident? Suppose our subject suffered some, previous disease which produced an increased fragility of the bone, without which the fracture would not have been produced. Would that disease be the

cannot be accepted either as a criterium for the definition of the concept of disease, or as the "essence" of it. But if we reject it, we must look for a better substitute. The notion of function, the expression of interdependent relation, may be taken into consideration. We shall refer to that again later. Definitions in which anatomic alteration is assumed to be the essence of disease were born with Virchow. Following the discovery of cellular pathology, the essence of disease was believed to be found in the morphologic alterations of the cells, and this conception, in spite of its deficiencies, still persists in present-day medicine. It is very simple, however, to point out its pitfalls: I there are diseases without any anatomic alteration, and the argument, so often misused, that anatomic alterations do exist but are yet undiscoverable, is

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so infantile and lacking in any logical or scientific basis that it cannot be taken into consideration. On the other hand, it has been proved in many cases, perhaps, in a large majority, that disease begins with a functional alteration, producing subsequently an anatomic change. Finally, going deeper into the essence of the problem, modern biological knowledge leads us to believe that the essence of natural phenomena lies in the vital processes, not in the static properties of any structure. The phenomenologic definitions find the essence of disease in the symptoms, the exterior manifestations. In connection with disease, symptoms were the first to be noticed and phenomenologic definitions are the first ones in history. Hippocrates gave these ideas the authority of science and since his time they have been present in almost every definition, even the most modern of them. These definitions give to the symptom a fundamental importance, taking them as a basis for classifications and for the creation o pathologic entities. Even today, this phenomenologic criterium in different forms and in combination with others is found in most accepted nosologies. The study of diseases is generally made by classifying them according to organs or systems; that is, according to the symptoms appearing in those organs or systems. All definitions which take as a basis alteration in junction are nothing but phenomenologic, the alterations showing themselves through symptoms. It is not difficult to perceive the defects of this concept. It needs, to begin with, the definition of symptom, or the determination of the conditions under which a functional alteration must be considered abnormal, i.e., a discussion of the notion of normality. On the other hand, even if we were able to establish a clear-cut criterium of normalcy for every one of the functions, that would be insufficient to give us a serious pragmatic foundation. A classification of diseases based on symptoms is clearly incomplete and useless. As we know, different processes may produce the same symptoms, and the same pathologic stimulus may cause different symptomatologic pictures. The phenomenologic criterium is, then, superficial and unsatisfactory. Jaspers has pointed out that in a definition of disease there is always a concept of valoration. The reality of tha: observation cannot be discussed, and the attempts of Jaspers to free himself from that tendency do not appear to be successful. It is understandable that in this case, as always, "man is the measure of everything," imposing on the concept of disease a negative valoration. Disease is abnormality, deficiency, danger, which means in-

dulgence in the teleologic orientation from which medicine has been unable to free itself. A valoration, on the other hand, is a concept of relation and implies a norma. We are again confronted with the problem of normalcy. When is any alteration of the organism called normal, and when is "the transition towards disease made? We cannot at this point study the idea of normalcy in all its aspects. That has been done on another occasion,2 and we shall reproduce here only the conclusions: The most acceptable concept of normalcy is related to that of adjustment. An organism able to adjust to a determined environment in a more or less stable form may be considered normal. In any case, we do not see how a concept of valoration, relative and changeable, can be considered valuable in the practical search for the essence of the disease or the possibilities of founding a nosology.
THE CONCEPT OF DISEASE IN PSYCHIATRY

It is useful to turn now to psychiatry. Because of reasons easy to understand, the problems of theoretical medicine occur in psychiatry in even more difficult forms. This is illustrated by reviewing those problems which have been analyzed so far: 1. The etiologic concept of disease cannot succeed in psychiatry, and a nosology with an etiologic basis has been impossible. The notion of cause is still more difficult to apply here than anywhere else. 2. The anatomic concept helps us no more. There are very few psychiatric syndromes with clear anatomic alterations, and, when they do exist, they never shed light on the psychopathological picture, nor do they help us to an understanding of it. 3. This explains why the phenomenologic concept predominates in psychiatry. It is sufficient to support that statement by reference to the fundamental works of Jaspers, Kurt Schneider and Adolf Meyer. Meyer's classification, the backbone of American psychiatry of today, is essentially phenomenologic. We do not need to repeat the reason given above to affirm our conviction that, in this case as in general medicine, an exclusively phenomenologic criterium is not satisfactory, either to establish a concept of disease or to build a nosology. 4. Valoration in psychiatry is an implicit part of the concept of disease, even more than in medicine, but it does not help us in our search for a useful concept of disease.
2 Seguin, C. A.: La psicoterapia moderna y la Higicne Mental. Lima, 1941.

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TOWARDS A MODERN CONCEPT OF DISEASE

[Vol. 8

We may conclude from the analysis just made that no one of the concepts of disease reviewed is satisfactory. They are obsessed in a greater or lesser degree with the idea of disease as something exterior to the organism, something added and parasitic. We believe that freedom from that pre-logic idea is a necessary condition in order to find a more satisfactory way. Disease is, in the last analysis, a vital manifestation, and must be considered as such. In life, we must study the fundamental, dynamic, uninterrupted interrelation of the living creature with its environment. That interrelation can be expressed in one word: adjustment. The living being, aside from a possible "spontaneous" activity, reacts constantly to the stimuli of its environment, adjusting itself to them and maintaining its equilibrium, that is, its life. Stimuli vary in their power to disrupt that equilibrium. If their power is not great, and the organism is able to adjust more or less easily, the stimuli are called physiologic. When that disrupting power is greater, they become pathologic. During the perennial evolution of life many "pathologic" stimuli, by means of successive adaptations, mutations and selections, may become "physiologic." To both of them the organism reacts, thus restoring its equilibrium or trying to do so. When the stimuli have little disrupting power the reaction is physiologic and does not generally appear in the consciousness. When that power is greater, the reaction is called disease, and it appears in the consciousness in the form of symptoms. We now have the following definition: disease is the reaction of the organism as a whole to external or internal stimuli altering seriously its equilibrium. Let us analyze it: 1. Disease is a reaction of the organism. This statement takes us away from the primitive concept of personification already discussed, emphasizing the characteristic of reaction adjudicated to the disease. It fits also into R. Mayer's energetic concepts of causality. The real "cause" lies in the previous characteristic dispositions of the entity in which the process happens. Thus the emphasis is completely displaced. Let us consider the following example: in pneumonia to speak of something already discussedthe presence of the pneumococcus is not the decisive factor, but rather the reaction of the organism: mobilization of physiologic and anatomic processes provoked in certain circumstances by its presence. But, if disease is a reaction of the organism, does

disease exist when that reaction is not present? Are not the effects of a parasitic (paludic anemia) or physic (destruction of tissue by heat) aggression considered as disease? 2. We believe the answer to these questions rests in the complement of the phrase. The definition reads: "the reaction of the organism as a whole." It means that we must not consider isolated facts. Anemia is only one aspect of malaria, as are also the reaction of the hematopoietic organs, the typical fever and the psychological components of the process. If we understand it, we shall be able to realize how important is the totality of the picture. Let us analyze further this concept of totality. There are no diseases of organs or systems; it is the organism as a whole which reacts. This is vital if considered from the point of view of the relation between mind and body, psyche and soma. We cannot study that problem here, but leaving for another opportunity a critical analysis of it, we shall say that upon considering the organism as a whole, the dualism disappears, and that since disease is a reaction of that totality, there are no somatic or psychic diseases, no somato or psychogenesis. Every pathologic process has organic and psychologic components, being as it is the product of a psychosomatic unity. In the cases in which there is really no reaction of the organism (we doubt that any such case may exist), we may speak of lesion and not of disease. 3. The definition speaks of external and internal stimuli. It is unnecessary to analyze this part further; its scope is easily understandable. 4. The following phrase is perhaps the most difficult part of the definition. It says: "external or internal stimuli altering seriously its equilibrium." An embarrassing question appears: when shall we say the equilibrium is seriously altered? It is very important to answer this question because that answer furnishes us with the criterium of differentiation between the physiologic and the pathologic reactions. We shall not enter into a discussion of the countless opinions that exist. Every theoretician has his own. Let us go back to the concept of adjustment. The normal organism adjusts itself continuously to the variations of internal and external environment. Changes in equilibrium are compensated more or less rapidly. When these alterations of equilibrium are sufficiently serious, they provoke unsuccessful efforts at readjustment; they provoke disease. This incomplete or unsuccessful adjustment shows itself subjectively and objectively. We call symptoms the subjective, and signs the objective

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manifestations of disease. The former reach consciousness charged with a peculiar affective tonus: that of suffering or displeasure. The latter are localized in the different organs or systems and can be discovered by our "diagnostic means." The equilibrium is, then, seriously altered when the organism cannot recover it, the results of that unsuccessful or deficient adjustment appearing as symptoms and signs. The definition thus considers the living being as a dynamic event and not as a static scheme destroyed by disease, and so does justice to its complexity.
A FORMULA OF DISEASE

If we treat cold as another disease, the factor E becomes complicated: E = (Cold = F [E. e]) + diplococcus + environmental factors. Considering now in e the factors of predisposition and "previous pathology" (also diseases), we shall understand the infinite complication we can reach: e = (Acquired predisposition-f hereditary predisposition) + (cardio-vascular diseases = F [E. e]) + (alcoholism = F [E. e]). The acceptance of the foregoing concepts, aside from its theoretical advantages, has some interesting consequences: our diagnostic methods have to be redirected. We are no longer trying to "put a label" on a clinical picture, i.e., to discover "p'athognomonic signs" to allow us "to fit" the given case in the frame of a nosologic entity. We must understand a reaction as such in all its unique characteristics, considering each one of them as "factors." The disease is a function of all of them. This will draw us away from the harmful tendency to label when the really important thing is to understand a dynamic and individual event. There is another fact of importance. The consideration of the disease as a reaction of the individual permits us to classify it as an expression of that individual. We refer the reader to the analysis of the concepts of E. Husserl by R. Allers.3 We have arrived, by parallel roads, at the same concept. If disease is an expression, it can only be considered as a unique phenomenon, and handled as such. The importance of this viewpoint for the co*ncepts of etiology, diagnosis, nosology, and therapy can only be pointed out here.
3 Allers, Rudolf: Concepto y metodo de la interpretation, in: Schwarz, Oswald: Psicogenesis y piscoterapia de los sintomas corporales. Edt. Labor, Barcelona, 1932.

Following what has been said about the notion of function in medicine, we can allow ourselves to suggest the following equation, without pretending to reduce the vital stream to mathematical formulae, but only as a synthesis of our ideas:

X = F(E.e)
X stands for the disease, which is a function of the stimuli (E) and the equilibrium of the organism (e). It is easy to understand how the terms of this equation can become complicated, if we consider diverse stimuli, external and internal, and all the conditions of equilibrium of an individual in a given moment; heredity, predisposition, immunity, etc. Such a consideration saves our formula from being thought of as a naive simplification. That stands out clearly if we apply it to the case of pneumonia already considered: X = F (Cold + diplococcus + environmental factors) ( predisposition + previous pathology).

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