Disease as idea

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Lovers and livers: disease concepts in history Jacalyn Duffin, Toronto: University of Toronto Press; 2005 299 pp $27.50 ISBN 0-8020-3805-0

Lovers and Livers is a compilation of lectures delivered in 2002 by Jacalyn Duffin, a hematologist and prolific medical historian based at Queen's University in Kingston, Ont. Through these lectures, she encourages us to look at diseases as “ideas influenced by the tastes and preoccupations of society.” Duffin argues that it is “only when we already entertain cultural doubt about a trait or a behaviour” that we construe it as pathological and look to material causes to corroborate this view. To explore the “priority of culture over biology,” Duffin proposes that vestiges of an old condition, lovesickness, may still affect the way we talk about illnesses such as erotomania, HIV and hepatitis C.

Understanding how illness, disease and culture are related to one another is the central problem in the emerging literature of “disease construction.” The descriptive language of medicine is in constant flux, as it is recalibrated from generation to generation. Philosophical traditions cohabit this historical space in a beneficial exchange of ideas. For example, Descartes' Passions of the Soul can be read as a synthesis of Renaissance medical concepts with Cartesian theory. Over time, Cartesian notions of clear and distinct ideas and mind–body dualism have undergone a number of substantial revisions. Wittgenstein talks about “family resemblances” among words instead of clear and distinct ideas, and Eleanor Rosch writes of conceptual prototypes. Mind–body dualism has been reformulated to encompass our contemporary view of consciousness. Similar transformations occurred in our concepts of truth, beauty and love. However, although philosophical and medical ideas have changed, disease construction must somehow anchor itself in an historical constant: the inevitability of human suffering.

Figure. Photo by: Fred Sebastian

Mirko Grmek, famed historian of medicine and Duffin's mentor, viewed illness concepts as groups of ideas in equilibrium at a given time, much like an assemblage of diverse organisms in a common habitat. As one way of thinking about illness falls into disuse (e.g., the concept of hysteria), another tends to take its place (e.g., multiple personality disorder). This notion has been thoroughly explored by Ian Hacking, using the pliable concepts of dissociation and multiple personality as modern reinventions of the soul. Syndromes such as these can be viewed as “containers” for many who don't fit the expected behavioural mould. Yet these containers are not pure abstractions. For each illness concept, there are real people experiencing what Susan Sontag referred to as our “dual citizenship” in the realms of both sickness and health.1

The medical link between hepatitis and sex has been discussed in the scientific literature.2 In her book, Duffin pairs the historical malady of lovesickness with a contemporary disease, infectious hepatitis.

She traces lovesickness back to ancient Egyptian and Greek love poems, in which the condition could prove fatal — as in the legend of Sappho plunging to her death over unrequited love. In medieval times, Persian doctors were likely the first to medicalize lovesickness, prescribing sex cures. Anecdotes from Renaissance medical writers and painters support the idea of love's ongoing power to cause illnesses with symptoms of melancholy, anorexia and even mania or suicide. After the Inquisition, sex cures may have fallen out of favour, and writers including Voltaire, Swift and Goethe linked lovesickness with venereal disease. Lovesickness was eventually divided into categories such as masturbation, homosexuality and pedophilia. Sexual perversity occupied Romantic fictional writers, while “[p]opular images of lovesick women … [became] yet another tool of misogynist social control.” Technological developments in surgery allowed procedures to cure a host of female complaints by ovariectomy, while doctors expanded their disease vocabulary to include homosexuality. In the 20th century, sex was demystified and its endorphin-enhancing health benefits promoted. Addiction psychology reframed lovesickness as “co-dependence.” And, in the 1980s, sexually charged illness gained international prominence with HIV and the various manifestations of hepatitis C, a disease that has been shaped by our ambivalence about the “goodness of love.”

Although the liver has played a central role in medicine since antiquity, technological advances in the 19th and early 20th centuries allowed a detailed understanding of what had previously been considered jaundice. A link between blood transfusions, infectious hepatitis and HIV eventually led to highly publicized events such as the Krever inquiry. In the process, those infected with hepatitis C, identified through a blood test but otherwise experiencing no apparent illness, were medicalized, tainted with the “bad” type of infection usually reserved for drug addicts and homosexuals. Yet only half of asymptomatic cases of hepatitis C progress to a serious physiological illness. Asymptomatic hepatitis C represents an illness “caused by an invading organism and also by factors external to the patient: by the scientific discoveries; by the Krever inquiry; by journalists, politicians, lawyers, and jurists; and by the compensation packages.”

How readers regard this book will depend on their background and expectations. Philosophically, the topics mirror the Cartesian body–soul divide. For some, this may be a stretch. Is Agape (v. Eros) in ancient Greece the same as “courtly love” in the time of chivalry? Is it meaningful to juxtapose 17th-century paintings of lovesickness against 20th-century sexually transmitted diseases? At what point do sweeping generalizations usher in what Tolstoy called the “slyness of reason”? For doctors, as for their patients, human suffering is a common thread that transcends shifting medical terms and a labyrinth of philosophical theory. Sexually charged illnesses stand at a particularly vulnerable intersection between culture and biology, often colouring our relationships with patients who are sick but whose symptoms resist an easy reduction to physical causes. And Duffin's latest book can serve to stimulate discussion about the “lurid metaphors with which they have been landscaped.”1