Lovers and Livers: Disease Concepts in History (review)

During my medical training in the late 1960s and early 1970s, I struggled to understand diseases as the central activity in becoming a physician. The corridors of the medical school revealed a positivist, ahistoric world. There, a confusing mix of methods served to identify and label 'disease.' Some diseases were identified by their pathologic features (with these you really knew where you stood). Others were identified because of their clinical features; for example, rheumatic fever utilized the 'modified Jones' criteria' (a less than satisfactory situation altogether). And finally, how does one deal with nebulous entities such as neurasthenia with a debated existence and neither pathology, nor clinical criteria to support its identification, much less a diagnostic test?

It is onto this arena that Jacalyn Duffin casts her historian's eye. 'Diseases,' she asserts, 'are ideas ... influenced by the tastes and preoccupations of society.' For Duffin, Hannah Chair in the History of Medicine at Queen's University, diseases are constructed in a complex interactive exchange between a medical world and the social one in which it operates, as 'medical epistemology is shaped just as much by society as it is by science, if not more.' However, Duffin is also a physician who has practised haematology, and she places salutary limits on this construction, returning us to the nature of pathologic events in biology: 'a disease is a biological "reality" interpreted or embellished by culture.'

This book evolved from the 2002 Joanne Goodman Lectures, a series of three public addresses focusing on disease concepts. It is written in an engaging and accessible style, perhaps reflecting its origins. But make no mistake, this is an insightful book which deals with a complex topic. Duffin's gift is her ability to display her material in a logical, intelligent argument that will interest and intrigue both layperson and health professional.

Duffin opens with an exploration of what we think about under the heading of disease: the illness it describes; the people who suffer from it; the diagnosis; the outcome; the treatment or prevention. She proceeds first to add an observer to this interaction of the illness and the patient and then to explore theories of disease either from the point of view of the patient – individual misfortune versus an inevitable presence in a population – or from the point of view of the cause – an external affliction versus physiologic change arising within given individuals because of who they specifically are. Duffin uses this theoretic discussion as a framework for two examples that lend the work its somewhat quirky title: lovesickness and the understanding of hepatitis C.

In the second chapter Duffin explores the history of what she defines as 'love and sex, burning desire, lust, and rest-of-your-life, self-obliterating desire.' She traces lovesickness from a metaphor in the poetry of antiquity to its slow emergence as a disease in the discourse of medicine. As a diagnosis it is attenuated over the centuries or else fastens on the tangible pathology of venereal disease. But just as we are expecting its extinction in the twentieth century, Duffin finds 'erotomania' hidden in a dusty corner of dsm-iv (Diagnostic and Statistical Manual of Mental Disorders, volume 4), describes positron emission tomographic similarities between people in love and people with Obsessive Compulsive Disorder, and argues that co-dependency in women (those who tolerate and care for addicted partners) is another name for lovesickness.

The final chapter tracks the emergence of hepatitis C from a group of liver diseases through the medical breakthroughs in virology that generated the alphabet soup of hepatitides (A, B, C, D, E, F, G ). It is a fine overview of the history and conflicts of medicine of the recent past. It traces our concerns about the safety of the blood supply, the politics of compensation, and the stereotyping of patients as 'guilty' or 'innocent' depending on their mode of disease acquisition. It illustrates brilliantly Duffin's thesis of disease concept.

Along the way Duffin makes brief...