The ens morbi

The history of medicine is replete with talk of clinical findings constituting an ens morbi (disease entity). Disease entities have been conceived of as metaphysical entities, clinical entities, pathological entities, etiological entities, and genetic entities. These ways of considering diseases generated a significant dispute in the nineteenth century between those who held that disease entities (and the classifications within which they are understood) identify realities in the world and those who held that disease classifications are at best distinctions imposed on reality to achieve certain goals (e.g., of diagnosis, therapy, and prognosis). The first were termed ontologists, while those who took a more conventionalist, instrumentalist, or nominalist position were termed physiologists. This distinction appears to have been articulated in 1828 by Franflois-Joseph-Victor Broussais (1772—1838), who denounced ontological accounts of disease (1821). Carl Wunderlich (1815-1877), Ernst von Romberg (1865-1933), Alasdair Maclntyre, Samuel Gorovitz, and others have, in various ways, taken positions in sympathy with Broussais.

Ontological theories have held that disease terms or classifications name things in the world. Though Broussais had directed his criticisms against clinical classifications, disease ontologists can be taken to include any who perceived diseases as entities, including metaphysical views advanced by individuals such as Paracelsus (1493-1541), who held that diseases are specific entities that arise outside the body.

Disease entities have also been understood as clinical realities, or as recurring constellations of findings. Thomas Sydenham (1624-1689), in classifying disease entities, construed them as enduring types and patterns of symptoms: "Nature in the production of disease is uniform and consistent; so much so, that for the same disease in different persons the symptoms are for the most part the same; and the selfsame phenomena that you would observe in the sickness of a Socrates you would observe in the sickness of a simpleton" (p. 15). It is within such a view of disease that one can speak of a person having a typical case of typhoid. Such language expresses the view that there is a central identity for a disease that is its essence, or type. One can therefore classify diseases by type, as well as speak of instances of a disease as approximating a typical case. Within this understanding, one can also talk of typical cases as rare: "One rarely sees a typical case of secondary syphilis." Patients embody clinical realities where typical means the full and complete expression of a disease, or an ideal type, but not necessarily its usual expression. It was against this genre of account that Broussais spoke.

Etiological accounts, like metaphysical views, focused on the cause of the disease as the disease entity, but regarded disease entities as empirical, and usually infectious, agents. Rudolf Virchow (1821-1902) characterized this view as "ontological in an outspoken manner" (p. 192). Virchow considered this understanding of disease entities to rest on a confusion between a disease and its cause. "The parasite," he wrote, "was therefore not the disease itself but only its cause" (p. 192). The confusion of the disease with its cause led to a "hopeless, never-ending confusion, in which the ideas of being (ens morbi) and causation (causa morbi) have been arbitrarily thrown together, [and] began when microorganisms were finally discovered" (p. 192). The mature Virchow embraced a view of disease entities grounded in pathological findings, and he held that a disease entity is "an altered body-part, or, expressed in first principles, an altered cell or aggregate of cells, whether tissue or organ" (p. 192). Further, "this conception is expressly ontological. That is its merit, not its deficiency. There is in actuality an ens morbi, just as there is an ens vitae (life force); in both instances a cell or cell-complex has the claim to be thus designated" (p. 207).

Genetic accounts can also interpret the disease entity as an empirical reality, to be found in genetic abnormalities (Anderson; Fowler, et al). The promise of somatic-cell gene therapy raises the question of a disease entity once again. That is, does the disease exist in the genetic structure, or is the structure the cause of the disease?

Current uses of the term disease in standard nomenclatures and nosologies (classifications) have a predominantly nonontological character. A conventionalist view allows one to choose, for example, whether one wishes to treat tuberculosis as an infectious, genetic, or environmental disease (recognizing that all three sorts of factors contribute to the development of tuberculosis), based on which variables are most easily manipulated. One may decide that it would be best to treat tuberculosis as an infectious disease because little is known about the inheritance of resistance against tuberculosis, or because any eugenic programs to eliminate tuberculosis would be very slow in taking effect. It may also be seen as an environmental disease that is brought about by socioeconomic conditions such as housing, food, and other such factors. It is meaningless to ask whether such a definition of disease is true or false, only whether it is useful (Wulff).

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