Writings on Medicine

2. Diseases

t w o Diseases At the beginning of his Essays on Painting, Diderot writes: ‘‘Nature does nothing incorrectly. Every form, beautiful or ugly, has its reason; and of all the beings that exist, there is not one that is not as it must be.’’1 One can imagine an Essays on Medicine that would begin with: ‘‘Nature does nothing arbitrarily. Disease, like health, has its reason, and among all the living beings, there is not one whose state is not as it must be.’’2 This kind of prologue could not concern all populations at all times. Over centuries and in many places, illness was either a possession by some ‘‘malignant’’ being against which only a miracle worker could triumph or a punishment inflicted by a supernatural power on the deviant or the impure. There is no need to travel to the Far East for examples of this. Already in the Old Testament, (Leviticus 13 and 14) leprosy is considered and rejected as an impurity, and lepers are being chased out of communities. In Greece, the first forms of cure and therapeutics are of a religious order. Asklepios, son of Apollo, is the healing god; his priests are his executants. It is in Asklepios’s temples 34 Diseases 35 that patients are received, examined, and treated according to rites from which the serpent and the cock still survive today as symbolic participants. One can speak with reason of ‘‘Greek medicine’’ only from the Hippocratic period onward—that is to say, from the moment when diseases came to be treated as bodily disorders about which it is possible to construct a communicable discourse concerning their symptoms, their supposed causes, their probable course, and the behavior that must be observed if one is to correct the disorder that all these indicate. It has always been noted that this medicine, for which Hippocrates’ Aphorisms3 are a sort of gospel, is contemporary with the first investigations meriting the name of science and with the rise of philosophical thought. Plato’s dialogue Phaedrus contains a tribute to Hippocrates, whose method is declared to conform to ‘‘right reason.’’4 Nevertheless, one would not accept that such medical practice, however secular and reasoned, could be termed ‘‘scientific’’ in the modern sense of the term. Contemporary medicine is founded, with an efficacy we cannot but appreciate, on the progressive dissociation of disease and the sick person, seeking to characterize the sick person by the disease, rather than identify a disease on the basis of the bundle of symptoms spontaneously presented by the patient. Disease points us to medicine rather than to evil. When a doctor speaks of Basedow’s disease (that is, of goiter exophthalmia), he designates a state of endocrine dysfunction whose presentation of symptoms , etiological diagnosis, prognosis, and therapeutic decision making are all supported by a succession of clinical and experimental studies and laboratory tests, in the course of which patients are treated not like subjects of their disease, but like objects. Plague, cancer, shingles, leukemia, asthma, and diabetes are also species of organic disorder that are felt by the living as a harm, an evil [un mal]. Disease is the risk of the living as such—risk as much for the animal or the vegetal as it is for the human. Yet in this last case, and by contrast with the risk that is born from a resolution to act, the risk that is born with birth is quite often inevitable. Suffering, the restriction of chosen or required habitual activity, organic deterioration, and mental decline are all constitutive of a state of harm, but are not by themselves specific attributes of what the physician of today identifies as disease, even at the moment when he endeavors to put an end to this harm or to attenuate it. Nevertheless, the 36 Diseases patient-disease relation cannot be one of complete discordance. In contemporary societies, where medicine endeavors to become a science of diseases, the institutions of public health and the popularization of medical knowledge have the effect that, for the patient, living his disease means talking and hearing talk in clichés or stereotypes; living his disease also means implicitly valorizing the results of a knowledge whose progress is due in part to putting the patient between brackets, however much he may be the avowed subject of medical concern. The current understanding of somatic diseases is the doubtlessly provisional...