Health and Disease: I. History of the Concepts

views updated

I. HISTORY OF THE CONCEPTS

Health and disease are among the fundamental experiences of human life. The concepts that people in various cultures have used in an attempt to understand and respond to those experiences have to do with the way humans relate to nature and culture. The concepts of health and disease have farreaching consequences for diagnosis and therapy, the attitude and behavior of physicians, how patients deal with disease, social attitudes and structures, the shape of moral choices, and the cultural significance of sickness and wellness behaviors.

Health and disease are not merely medical terms; they are also vital themes in art, philosophy, theology, sociology, and psychology. In fact, these very disciplines remind medicine again and again of its distinctly anthropological character, in the sense that medicine deals with the nature and destiny of humans. Neither medicine nor the concepts of health and disease with which it deals can be properly understood by using the starkly contrasting categories of natural sciences and human sciences as a framework. Just as medicine cannot be reduced to either of the two, so it is also necessary to connect nature and culture in order to understand health and disease.

A universally valid definition of health has been as hard to formulate as a universally valid definition of disease. Health and disease are physical, social, psychological, and spiritual phenomena that can be represented in concepts that are both descriptive and normative (the latter meaning based on norms), although these two sorts of concepts have not always been clearly distinguished in the historical development of these ideas. Humans not only determine what will be regarded as health and disease; at the same time they also interpret these experiences and decide how to respond to them.

Concepts of disease and health are especially important because they influence the manner and goal of medical treatment. Thus a mechanical or technologically structured understanding of disease (which views the human as a defective machine) requires a mechanical or technologically structured therapy (regarded as repair) and therapeutic relationship (a relationship of technician to defective machine). More personal or holistic concepts urge corresponding types of therapy and healer–patient relationships.

Contemporary medicine increasingly faces the task not only of overcoming sickness but also of preserving health. Prevention and rehabilitation play increasingly important roles alongside curative therapies. Treatment is understood to include attentive caring and support. Chronic suffering and death place different demands on the doctor–patient relationship than do acute illnesses. In light of such developments, concepts of health and disease require new definitions. A historical retrospective may assist in arriving at those definitions.

This entry does not attempt to offer a thorough cross-cultural analysis of concepts of health and disease; rather, it presents essential dimensions and changes in these concepts in the general course of history, their relationships with sociocultural backgrounds, and their practical and ethical consequences (Diepgen, Gruber, and Schadewaldt; Riese; Rothschuh; Schipperges, Seidler, and Unschuld; Temkin). A consideration of these historical developments can stimulate new reflections and initiatives, but history differs from any theoretical system. History has its own rules and logic. A progressionist explanation of the gradual development of notions of health and disease is inadequate. There are continuities and discontinuities, progress and regress, even within a single event or movement. This complex nature of history in general characterizes the history of medicine and specifically the history of the concepts of health and disease.

Health and disease suggest a variety of meanings from psychological, social, and spiritual perspectives. The word illness in the English language refers to the subjective or personal side of disease, whereas disease refers to the medical conception of pathological abnormality. It is possible for a person to feel ill without having a disease, and conversely, to have a disease without feeling ill. The term sickness transcends both of these concepts by focusing on social consequences. The concept of the sick role corresponds to the social nature of disease. The way in which societies vary in their interpretations of physical and mental disorders and in their treatment of and symbolic reactions to them reflects the cultural dimension of disease.

Nonetheless, some basic categories will be useful in the following discussion. One category is the explanation of disease, illness, and sickness. From a physical perspective, the different approaches of the past attribute disease to either liquid or solid components of the body or to the relationship between the body and the soul. Other distinctions refer to whether diseases should be regarded as existing entities (the ontological notion of disease) or as phenomena affecting individual persons in a variety of ways (the symptomatic notion of disease); and whether and to what extent the constitution and disposition of the individual (endogenous factors) and/or external (exogenous) factors play a significant role in determining health and disease.

A second category concerns response to disease, illness, and sickness. These responses have frequently been shaped by the explanation of disease, illness, and sickness. These two categories evolved into the science and clinical practice of medicine.

Primitive Peoples

There is no life without disease and pain; their ubiquitous nature is demonstrated by history. The skeletons of the first humans (500,000 b.c.e.) display bone disturbances and fractures. It is difficult to offer accurate descriptions of the health and disease of historically primitive peoples, because claims must depend on limited and problematic archaeological, paleopathological, and written sources (Clements).

At the dawn of human history, medicine had a magicomystical, demonic-religious character. Exogenous factors such as spirits, spells, and gods were considered responsible for disease. Personified living entities, spirits, took over a healthy body and made off with the soul of the person or allowed foreign elements to invade the body. Spirits, dead or living, could exercise fateful effects, acting out of revenge for breaches of taboos. Disease, directly related to sin and wrongdoing, represented not only an individual but also a social destiny. What befell one person befell the whole family, group, or tribe.

The diagnostic and healing powers of the healer or priest-doctor were supernatural. The healer had to be able to recognize which forces were at work in any given case. He did this by reading the stars or by drawing meaning from minerals, plants, and animals. Amulets and magic spells, oracles, atonement and confession, exorcism, bloodletting, and ceremonies of purification functioned as both preventive measures and cures. The whole community took part in the healing process; even pets were brought into it. Primitive peoples exhibited great cleanliness for the sake of prevention and strictly observed their cultural taboos.

There are remnants of these primitive notions of disease in today's lay language. For example, in English slang menstruation is sometimes called "the curse"; the German word for lumbago, Hexenschuss, means witch's wound. To what extent one can observe these assumptions about sickness and health, and the social structures that correspond to them, among the primitive peoples of today is hard to say. Modern civilization and medicine have left their impact in every part of the world. Primitive peoples, too, change over time.

Ancient Cultures

Precursors to medical systems and theories of disease were found in the ancient cultures of Mesopotamia and Egypt between the fourth millennium b.c.e. and the first, which established connections between concepts of nature and religion, on the one hand, and views of sickness and health on the other. Parallels between Chinese, Tibetan, Indian, and Greek perceptions of sickness and health indicate that these cultures may have derived these ideas from the same sources. Ancient American cultures also shared similar perceptions.

For these cultures health and disease were physical as well as religious phenomena. Sickness was still associated with sin, even as empirical interpretation of health and disease began to spread. Egyptian papyri (2000–1500 b.c.e.), for example, describe the courses of various diseases and categorize them according to regions of the body. The papyri list causes, symptoms, and prognoses, as well as empirical interventions. Putrefaction within the body in the form of spoiled material (materia peccans) caused sickness; these substances had to be removed if the patient were to be cured. The Greek historian Herodotus (fifth century b.c.e.) describes monthly purifications in Egypt.

Dietetic, medicinal, and surgical interventions were used, and much attention was given to public health. The medicine of ancient cultures combined religious ritual with empirical treatment. The Babylonian code of Hammurabi (d. 1750 b.c.e.) contained the first list of surgical fees and penalties in the case of failure; each varied according to the social status of the patient.

The explanatory dimensions of medicine, such as symptomology, nosology (the classification of diseases), diagnosis, and etiology (the study of the causes of diseases), as well as clinical dimensions such as prognosis, therapy, and prevention, began to establish themselves in these centuries. The traditional healer became the professional doctor; specialization developed. In this era, empirical observation, causal explanation, magic, and faith coexisted in medical theory and practice.

Greece and Rome

More extensive and reliable historical sources exist for ancient Greece and Rome. The ancient Greeks (500 b.c.e.) explained health and disease cosmologically and anthropologically, that is, in close relation to nature in general and to human nature in particular. Medicine sought not only to cure disease but also to maintain health. The pre-Socratic philosophers, who were the physicians of this time, developed a universal model of health, whose outlines can be found in the medical texts of Hippocrates (c. 460–c. 377 b.c.e.) and other physicians of the Corpus Hippocraticum (400 b.c.e.–200 c.e.). These pre-Socratic physicians must be distinguished from magicoreligious healers, who still existed at that time (Kudlien).

The great physician Galen (129–c. 199 c.e.) elaborated a model of health and disease as a structure of elements, qualities, humors, organs, temperaments, times of day, and times of year (Schöner). Health was understood in this perspective to be a condition of harmony or balance (isonomia) among these basic components that make up both nature in general and the individual body. Disease, on the other hand, was regarded as discordance, or the inappropriate dominance (monarchia) of one of the basic components. Disease in the perspective of humoral (pathology determined by bodily fluids) was interpreted as the disproportion (dyscrasia) of bodily fluids or humors: phlegm, blood, and yellow and black bile. Solidistic pathology traced disease to disturbances among the solid components of the body (shape, consistency, distance, etc.). The pneumapathological (spirit) approach attributed disease to a failed relationship between body and soul. Health (eucrasia) was characterized by equilibrium in the body.

Dietetics was considered of primary importance to the therapeutic process, followed by medication and lastly by surgery, a hierarchy exactly opposite to the prevailing Western approach of today. In the ancient perspective, dietetics involved much more than a health-conscious regulation of food and drink. Rather, it entailed a broad concept of how one should live a healthy life. Dietetics was concerned with six aspects of life that, although natural, did not regulate themselves, as did such physiological functions as respiration and digestion. Because they required human manipulation, these six aspects of life were called "non-natural" (sex res non naturales). These areas included how humans deal with:

air and light;
food and drink;
sleep;
motion and rest;
secretions; and
passions of the mind (Rather).

According to Galen, and in contrast to contemporary views, health and sickness were not the only states of existence. Rather, there was a third condition, an intermediate state of neutrality that existed between health and sickness: Medicine was therefore conceived as the science of health, sickness, and neutrality. In this notion of medicine, the overcoming of sickness was secondary to the preservation of good health or to aiding patients in living with impediments and handicaps. Galen said that because health precedes illness both in time and in esteem, one should try first to preserve health and only second to cure the illness as far as possible.

Philosophy and medicine mutually influenced one another in antiquity, although Hippocrates is said to have separated medicine from philosophy. Health and disease are not only empirical descriptions. They always have philosophical implications and practical effects. The Greek philosopher Plato (c. 428–c. 348 b.c.e.) defined medicine as the theory of health, and in the perspective of his ethical concept of health, he legitimized the active euthanasia of the physically handicapped and the mentally ill. Plato and his student Aristotle (384–322 b.c.e.) developed a typology of three physicians with corresponding types of relationships with the patient. The slave doctor commands, and the patient has to obey. The doctor for freemen explains the treatment to the patient and the patient's family. Doctors understood to be medically educated laymen signified individuals who take responsibility for their own health, sickness, and death.

While abortion and active euthanasia were forbidden as therapeutic acts for the Hippocratic physician, the Stoics justified these practices in situations in which the patient had lost or was in danger of losing moral autonomy and rational awareness. Harmony of the mind was placed above health and disease, above wealth and poverty. For the Stoic philosopher Seneca (c. 4 b.c.e.–65 c.e.), disease meant physical pain (dolor corporis), the suspension of joy (intermissio voluptatum), and the fear of death (metus mortis)—implying that disease combines physical, psychological, social, and mental dimensions. While being persecuted by the Roman emperor Nero, Seneca ended his own life through active euthanasia with the help of his friend and doctor Statius Annaeus.

The Middle Ages

The Christian Middle Ages (500–1300) interpreted health and sickness in a theological perspective. Cosmological (or natural) and anthropological (or human) approaches were subordinated to, without being supplanted by, the super-natural notion of transcendence. Christian beliefs and natural causes for health and disease were not mutually exclusive. Sicknesses could be described simultaneously as physical entities and as acts of God's intervention. The Christian, Arabic, and Jewish traditions all viewed health or quality of life as the outcome of a good relationship with God.

Medicine consisted of theory and practice, each of which was further divided. Medical practice consisted of dietetics, medicaments (therapeutic substances), and surgery. Galen's humoral pathology prevailed throughout the Middle Ages, and dietetics in antiquity's broad sense of the term continued to function as the most important form of treatment. The emphasis on spirituality did not run counter to medical aid and health education. As the vessel of the soul, the body warranted careful attention.

During the Middle Ages, a variety of specific health rules (Regimina sanitatis) were developed for people of various ages, occupations, and classes, as well as for both sexes. One famous example, the Regimen Sanitatis Salernitanum from the thirteenth century, has survived in various medical customs and was published in all major European languages.

According to the medieval Christian viewpoint, the figure of Christ as healer (Christus medicus) stood behind every doctor, and behind every patient was the figure of the suffering Christ. Health, disease, and healing gained their meaning from this perspective. These concepts were related intimately to the idea of salvation history (eschatology), seen as a progression of the world starting with its establishment in paradise (constitutio), through its earthly existence (destitutio), and finally to resurrection (restitutio).

These concepts also had their practical consequences, manifested in biographies and other documents of arts and literature. Each transition from health to sickness and from sickness to health represented this eschatological process on an individual level. Even though sickness, suffering, and death had salvific significance or were essential traits of human life, they were fought with dietetics and medical therapy. But they were also to be accepted, because earthly life is different from paradise. In this regard, Saint Augustine (354–430) remarked that people have to say "yes" to some forms of pain but are not forced to love them.

The Greco-Roman link between health, beauty, and morality was abandoned during the Middle Ages. Every sick, suffering, or handicapped individual had the right to receive medical treatment. Hospitals, first founded during the Middle Ages, were open to all suffering and helpless people, based on Jesus' words: "I was sick, and you cared for me" (Matthew 25: 26). At the same time, however, the Bible was used to justify excluding lepers from society.

The classical and Christian concept of the seven cardinal virtues (prudence, temperance, fortitude, justice, faith, hope, and love) applied to healthy people as well as to the sick, doctors, and the community. Suicide and euthanasia were regarded as sins because they were deliberate attempts to shorten life. Therefore the ancient Hippocratic oath was continuously accepted in this epoch. The art of dying (ars moriendi) was considered a central part of the art of living (ars vivendi). Sickness could be traced to inherited sin, personal guilt, demonic possession, or a test from God. Job of the Old Testament represented a classic example of the latter.

In contrast to present-day attitudes, health was also viewed as negative in the moral and religious sense ("corrupting health": sanitas perniciosa) and sickness as positive ("a healing sickness": infirmitas salubris). Coping with illness was believed to manifest a person's fortitude; furthermore, a life without physical or psychical damage or pain was thought to produce a false image of earthly life and the human condition. A contemporary biographer, writing about the constant illness of the saintly German abbess Hildegard of Bingen (1098–1179), who was also a prominent naturalist and physician, said that her whole life could be compared to a "precious dying."

The Modern Era

With the coming of the modern era at the time of the Renaissance, which began in the fourteenth century, an emphasis on this world, nature, and the individual replaced the medieval focus on the hereafter. The secularization of paradise—or the hope of realizing beauty, youth, and health in an earthly life—has influenced human thought and action and the course of medicine up to the present. Empirical observation, causal explanation, and rational therapy became the ideals of education, research, and practice in medicine. Nevertheless, magic, astrology, and alchemy continued to play a role in medicine for quite some time.

At the transition from the Middle Ages to the modern era, the German physician and philosopher Paracelsus (1493–1541) designed an all-encompassing system of medicine. Along with philosophy, astronomy, and alchemy, ethics acquired a fundamental role. Paracelsus replaced the ancient humoral pathology with three rudiments from alchemy: salt, mercury, and sulfur. Dominance of one of these biochemical components over the others led to different types of diseases. Disturbances in the spiritual principle also led to disease. According to Paracelsus, the general factors that contributed to disease belonged to nature as well as culture: (1) cosmic influences (ens astorum); (2) material influences (ens veneni); and (3) individual constitution (ens naturale), spirit (ens spirituale), and God (ens Dei). Paracelsus's concept of disease is ontological or essentialistic: Disease is a "thing," which he compared with a parasite, a separate organism. This notion contrasts with the Hippocratic concept, which explained sickness as an individual, symptomatic phenomenon.

The utopian writings of the English statesman Thomas More (1478–1535), the English philosopher Francis Bacon (1561–1626), and the Italian philosopher Tommaso Campanella (1568–1639) include basic categories for determining health and disease as well as guiding principles for eugenic public health policies. Their concepts justified suicide and euthanasia—but only under the condition that it be done freely (at the decision of the individual). During the Renaissance the different types of euthanasia, still relevant in the discussions of the subject today, were already established. Not everyone supported active euthanasia as a social reaction to sickness. The German theologian Johann Valentin Andreae (1586–1654), unlike More and Bacon, expressly rejected euthanasia in his 1619 work Christianopolis. He stated that "reason commands that human society should be more gently disposed toward those who have been less kindly treated by nature" (p. 274).

The philosophy of the French mathematician René Descartes (1596–1650), with its mechanical model of health and disease, became highly important for the concepts of disease and therapy. According to Descartes, the body is a perfect clockwork mechanism set in motion by God to function mechanically. The soul, also divinely created, acts independently from the body. This dualistic system of body (res extensa) and soul (res cogitans) was widely accepted in medicine and produced a mechanistic view of physiology, still accepted in the present, that also existed in lay interpretations of health and disease. Scientific explanation concerned the discovery of the fixed rules of mechanistic structures and their processes. Clinical medicine concerned the detection of damaged structure, malfunction, and departure from these rules, and the restoration of proper anatomic structures and physiology.

During the Enlightenment (eighteenth century), the real beginnings of a public health movement began to take shape. The German philosopher Gottfried Wilhelm Leibniz (1646–1716) made numerous recommendations for public health. The American statesman and philosopher Benjamin Franklin (1706–1790) formulated a characteristic phrase of the time: "Health is wealth." The German physician Johann Peter Frank (1745–1821) and the French philosopher Jean-Jacques Rousseau (1712–1778) represented the opposition between state policies and individual agendas. According to Rousseau, civilization and the state had ruined human health in its natural state. Frank, in contrast, believed that social reforms lead to progress. Several books were published primarily on prevention and rehabilitation. The German physician Christoph Wilhelm Hufeland (1762–1836), author of the widely distributed Makrobiotik (1797), manifested again the relationship between concepts of health, disease and therapy—especially as normative categories—with the social attitudes and reactions. He believed that physicians should not be allowed to engage in active euthanasia, pointing out that physicians who start to decide which sick persons are worthy of living become "the most dangerous people in the state."

The concepts of health and disease vacillate between anatomy and physiology. The definitions of disease and health of the Scottish physician John Brown (1735–1788) received great recognition in the medicine, philosophy, and literature of his time. His 1780 work Elementa Medicinae defined health and disease in terms of the relationship of opposing forces within a person: of organic excitability and external and internal stimuli, resulting in an excited or irritated condition of the organism. According to Brown, disease is the result of overstimulation (sthenie) or insufficient stimulation (asthenie). Health, on the other hand, is characterized by equilibrium between the capacity to be stimulated and internal and external stimuli. Treatment, therefore, functioned either to strengthen or subdue stimuli. Bloodletting and diet calmed a condition of overstimulation, whereas ether, camphor, and opium had the opposite effect. Equally important for the further progress of medicine was the anatomical foundation of pathology by the Italian physician Giovanni Battista Morgagni (1682–1771) with his fundamental work De sedibus et causis morborum (On the seats and causes of disease), published in 1761.

Romanticism and idealism, around 1800, introduced interpretations of health, disease, and death that are of general importance and transcend substantially the limits of medicine (Leibbrand). These three states were regarded as dialectically connected with one another and interpreted as the main stages of the genesis of Spirit out of nature, a Hegelian theme (von Engelhardt). According to the German poet Friedrich von Hardenberg (1772–1801), who wrote under the pseudonym Novalis, there is always disease in health and health in disease; illness or sickness is given a central value: "Medicine should be an elementary science of every cultivated person" (Novalis, p. 474). Illness can be an experience or medium of personal growth. The personhood of the patient becomes a central claim: "Human being = person; that is the point of unity," (Heinroth, p. 158) categorically announced the german physician Johann Heinroth (1773–1843). The German philosopher Joseph Schelling (1775–1854) held that health is the harmonious relationship of the basic organic functions of sensibility, irritability, and reproduction. The German philosopher Georg Hegel (1770–1831) argued that life would be impossible without disease, that each organism contains the "germ of death" from birth, and that all therapy presupposes that disease is not a total loss of health but rather a conflict within physical or psychical forces. Only through disease and death of the individual does the universal and eternal world of the spirit come into being. "Above this death of Nature, from this dead husk, proceeds a more beautiful Nature, proceeds Spirit" (Hegel, p. 443).

MEDICINE AND THE NATURAL SCIENCES. Medicine in the remainder of the nineteenth century followed the model of the natural sciences and not that of natural philosophy and philosophical anthropology of the romantic-idealistic era. This increasingly self-conscious scientific medicine concentrated on curing disease and neglected the maintenance of good health. It also neglected the contributions of the arts, literature, and theology. The patient became more and more an object. The patient's subjectivity or personality was disregarded, and the history of the patient was reduced to the history of the disease. Anatomy and physiology were connected; the cell replaced tissue as the center of attention. Experimentation, statistics, and causal thinking became the basis for medical research. A Cartesian concern for mechanistic structure and function according to discernible rules became paramount.

The German pathologist Rudolf Virchow's (1821–1902) definition of disease was widely accepted: "Disease begins at that moment when the regulatory system of the body is not sufficient to overcome a disturbance. It is not life under abnormal circumstances, nor the disturbance as such which produces a disease, rather the disease begins with the insufficiency of regulatory mechanism" (p. 193). According to Virchow, the body's regulatory ability varied from person to person. The healthy body is capable of bringing an abnormal situation back into equilibrium. Disease was an observable phenomenon in the living body, caused by internal and external factors. The cell became the basis of disease, and—using a political metaphor—it deserves recognition, along with blood and nerves, as the "third estate." The infection of cells, and thus the body, by external infectious agents became the dominant explanation of disease. The clinical response was to eradicate the infection.

In the nineteenth century, dietetics lost its broader or anthropological meaning and came to refer simply to the intake of food and drink. Thus a 2,000-year-old tradition, already limited in the eighteenth century, reached its end. Nevertheless, the tradition of dietetics survived longer in the area of hygiene than in pathology. Scientific medicine in its modern form considered heredity, psychical, and social factors relatively unimportant to the etiology of disease. Infection was the decisive explanatory factor; therapeutic results from the period substantiated this theory. Thus, the development of concepts of health and disease and of clinical responses to them was synergistic, a historical process that continues into the present.

At the beginning of the twentieth century, constitutional pathology and anthropological medicine began to counteract the one-sided approach of infectious disease modules of medicine. Medicine recovered the importance of the individual and social circumstances in health and disease—constitutional pathology on the physical level, anthropological medicine on the psychical or mental level. Human beings were conceived as participating in nature as well as in culture. The German physician Viktor von Weizsäcker (1886–1957) reintroduced in his anthropological medicine "the person as subject," in regard to the patient, the doctor, and science.

In medicine as well as in biology, the concept of finality (causa finalis) regained attention; diseases not only have a physical cause (causa efficiens) but also manifest a sense of meaning. The controversy between monocausal thinking (causalism) and multifactorial thinking (conditionalism) influenced medicine during those decades around 1900 and is still lively: Can disease be deduced from one cause, or is it necessary to take different causes of different areas of reality into consideration? The concept of cause not only has consequences for the theory of disease origin and disease process but also affects medical therapy, prevention, and rehabilitation, all of which in turn shape the individual and social situation of the sick person.

Philosophers and theologians, as well as writers and artists, hoping to give people assistance that the natural sciences and medicine were unable to provide, continued to produce valuable interpretations of health and disease that took the spiritual or cultural nature of human experience into account, calling into question the established normative equation of health as positive and disease as negative. The French writer Marcel Proust (1871–1922) stated that humankind owes its major cultural accomplishments to sick and suffering people: "They alone founded religions and created masterpieces" (p. 405). Increasingly, arts and literature have been acknowledged as being helpful in coping with disease, pain, and death.

The German philosopher Martin Heidegger (1889–1976) claimed that he wrote his analysis of death in Being and Time (1927) especially for doctors; in this work, Heidegger emphasized that only the human beings have the consciousness of death and of their own death. The German physician and philosopher Karl Jaspers (1883–1969) defined disease and health in the perspective of his philosophical position. Neurosis being "a failure in the marginal situations (Grenzsituationen) of life," he visualized the goal of its therapy "as a self-realisation or as a self-transformation of the individual through the marginal situation, in which he is revealed to himself and affirms himself in the world as it is"(p. 275). Jaspers contended that psychiatry shared two major methodologies: that of "explanation," which characterizes the natural sciences (disease), and that of "understanding," which is typical of the human sciences (illness). The ethical and practical consequence of his concept of disease in the objective, subjective, and cultural sense is outlined in his concept of the existential communication between the physician and the patient. Existential communication combines the subjective and cultural dimensions in an ethical perspective.

In the twentieth century, psychology and sociology expanded the scientific understanding of health and disease, emphasizing the difference between disease as objective and physical, and illness and sickness as subjective and social. According to this general perspective, contemporary people associate disease with the following interpretations: challenge, enemy, punishment, weakness, relief, strategy, loss or damage, and value (Lipowski). Medicine concentrates on weakness, loss, and damage, that is, the physical components of this model.

In the sociological perspective the role of the sick person is characterized by:

freedom from daily duties,
freedom from the responsibility for the sick condition,
the obligation to want to become well again, and
the obligation to seek medical help (Parsons; Schaefer).

Descriptive and normative aspects permeate this sociological definition of the role of the sick person. Disease is not only described in its social causes and consequences; demands and expectations are formulated. Subsequent studies have revealed further processes of different levels (age, sex, socioeconomic state, type of disease, etc.) of defining a person as sick. Also important are the differentiation between "bad" and "ill," or criminal behavior and sickness, and the negative or stigmatizing consequences of diagnostic acts.

The 1947 World Health Organization (WHO) definition of health—"a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity"—has to be interpreted in its social and political context and purposes. These included attempts to justify international involvement in the internal affairs of countries. It is another matter whether medicine can offer explanations and therapies to achieve complete, multifunctional wellbeing, the definition of which includes social and spiritual as well as medical aspects. The WHO definition was used as the starting point for intense bioethical debates on the moral and political responsibilities of the international community in regard to healthcare—especially for corresponding projects in developing countries. But this definition, taken generally, is limited in its sharp contrast between health and disease and its exaggerated estimation of health. With good reason, health can also be regarded as the ability to bear injury, handicaps, and the anticipation of death, and to successfully integrate these abilities into one's life. Integration is the capacity to cope with death; death is a part of life and not only its contrary or end.

Conclusion

The history of concepts of health and disease is the history of concepts that explain and direct response to disease, illness, sickness, and health. These concepts are deeply rooted in physical and psychical experiences and have medical and social consequences. The importance of scientific explanations, with their roots in Cartesian medicine and developments in the nineteenth century, is obvious. Of equal importance, perhaps, are attempts to counterbalance an excessive emphasis on scientific medicine with anthropologic, social, ethical, and political dimensions of the concepts of health and disease. After all, for much of its history medicine has not been confined solely to disease but also took responsibility for health. Therapy in the past meant more than just curing; it also meant prevention or preservation of health and assistance in chronic disease and in dying. Disease was interpreted as a disturbance of the organism, the sick person, and his or her social situation. Furthermore, medicine did not have sole domain over health and disease; a multitude of important interpretations originated from the arts, theology, and philosophy. In this holistic perspective, people of the present also expect medical and social aid.

Sickness and health, in their natural and cultural breadth, remind medicine of its fundamentally scientific and humanistic nature. Health and disease are concerned with life and death and are closely connected to the physical, social, psychic, and spiritual nature of humans.

Today, disease and health are conceived as more closely connected (Canguilhem; Engel). The transitions and parallels are seen more strongly, and the interplay of the body, soul, spirit, and environment is more carefully observed. Attention is shifting from infectious diseases to chronic illness and death, though the experience of acquired immunodeficiency syndrome (AIDS) and other diseases prove the continuity of those events. The emergence of molecular medicine, with its reliance on genetic concepts of health and disease, may lead to a reintegration of the scientific and humanistic dimensions of the concepts of health and disease. The global scientific and economic limitations of medicine have made the concepts of health and disease a central topic in theory as well as in practice, for science as well as for everyday life.

Developing countries have special problems to over-come that stem from their own cultural changes and from their reception of Western medicine. The Western world must be critical of its own normative position in regard to these developing countries as in regard to its own concept of life. Disease should not be understood merely as a limitation or a loss, but also as a challenge. Coping with illness can manifest courage and compassion; meeting this challenge strengthens self-confidence, causes social reform, and enriches the world of culture.

dietrich von engelhardt (1995)

revised by author

BIBLIOGRAPHY

Andreae, Johann Valentin. 1916. Christianopolis, ed. and tr. Felix Emil Held. New York: Oxford University Press.

Antonovsky, Aaron. 1987. Unraveling the Mystery of Health. San Francisco: Jossey-Bass.

Canguilhem, Georges. 1984. Le normal et le pathologique, 5th edition. Paris: Presses Universitaires de France.

Clements, Forest Edward. 1932. "Primitive Concepts of Disease." American Archeology and Ethnology 32(2): 185–243.

Diepgen, Paul; Gruber, George B.; and Schadewaldt, Hans. 1969. "Der Krankheitsbegriff, seine Geschichte und Problematik." In Handbuch der Allgemeinen Pathologie, vol. 1, ed. Franz Büchner. Berlin: Springer-Verlag.

Engel, George L. 1960. "A Unified Concept of Health and Disease." Perspectives in Biology and Medicine 3(4): 459–485.

Engelhardt, Dietrich von. 1984. "Der metaphysische Krankheitsbegriff des Deutschen Idealismus: Schellings und Hegels naturphilosophische Grundlegung." In Medizinische Anthropologie, ed. Eduard Seidler. Berlin: Springer-Verlag.

Hegel, Georg Wilhelm Friedrich. 1970. Hegel's Philosophy of Nature, tr. Arnold Vincent Miller. Oxford: Clarendon Press.

Heinroth, Johann Christian August. 1844. "An Heinrich Damerow, 1842." Allgemeine Zeitschrift f¨r Psychiatrie 1:158.

Jaspers, Karl. 1973. "Die Begriffe Gesundheit und Krankheit." In Allgemeine Psychopathologie, 9th edition. Berlin: Springer-Verlag.

Kudlien, Fridolf. 1968. "Early Greek Primitive Medicine." Clio Medica 3(4): 305–336.

Leibbrand, Werner. 1956. Die spekulative Medizin der Romantik. Hamburg: Classen.

Lipowski, Zbigniew Jerzy. 1970. "Physical Illness, the Individual, and the Coping Processes." Psychiatry in Medicine 1(2): 91–102.

Novalis [Friedrich von Hardenberg]. 1981. Schriften, vol. 3. Darmstadt, Germany: Wissenschaftliche Buchgesellschaft.

Parsons, Talcott. 1973. "Definition von Gesundheit und Krankheit im Lichte der Wertbegriffe und der sozialen Struktur Amerikas." In Der Kranke in der modernen Gesellschaft, 4th edition, ed. Alexander Mitscherlich, Tobias Brocher, Otto von Merin, and Klaus Horn. Cologne: Kiepenheuer and Witsch.

Proust, Marcel. 1975. Auf der Suche nach der verlorenen Zeit. Frankfurt: Suhrkamp.

Rather, Lelland J. 1968. "The 'Six Things Non-Natural': A Note on the Origins and Fate of a Doctrine and Phrase." Clio Medica 3(4): 337–347.

Riese, Walther. 1953. The Conception of Disease: Its History, Its Versions, and Its Nature. New York: Philosophical Library.

Rotberg, Robert I., ed. 2000. Health and Disease in Human History. Cambridge: MIT Press.

Rothschuh, Karl Eduard, ed. 1975. Was ist Krankheit? Erscheinung, Erklärung, Sinngebung. Darmstadt, Germany: Wissenschaftliche Buchgesellschaft.

Schaefer, Hans. 1976. "Der Krankheitsbegriff." In Handbuch der Sozialmedizin, ed. Maria Blohmke, Christian von Ferber, Karl Peter Kisker, and Hans Schaefer. Stuttgart, Germany: Erike.

Schipperges, Heinrich; Seidler, Eduard; and Unschuld, U. Paul, eds. 1978. Krankheit, Heilkunst, Heilung. Freiburg, Germany: Alber.

Schöner, Erich. 1964. Das Viererschema der antiken Humoralpathologie. Wiesbaden, Germany: Steiner.

Stempsey, William E., 1999. Disease and Diagnosis. Dordrecht: Kluwer.

Temkin, Owsei. 1973. "Health and Disease." In Dictionary of the History of Ideas, vol. 2, ed. Philip P. Wiener. New York: Scribners.

Virchow, Rudolf. 1869. "Über die heutige Stellung der Pathologie." Tageblatt der 43. Versammlung deutscher Naturforscher und Ärzte, 185–195.

Weizsäcker, Viktor von. 1951. Der kranke Mensch: Einführung in die medizinische Anthropologie. Stuttgart, Germany: Koehler.

Encyclopedia of Bioethics