A pathological misunderstanding
Work in progress – by Stephen Lewis
Giovanni Battista Morgagni (1682–1771) is often described as the father of modern pathology. However, the image presented through continued reference to him and the bearing this has upon our modern understanding of the concept of disease may be in need of some clarification.
Published in 1761, Morgagni’s De Sedibus et Causis Morborum per Anatomem Indagatis equates post- mortem anatomical findings with observations made of the same individuals during life. As a result, it established the idea that there could be something tangible and localised associated with disease. In so doing, Morgagni provided a material basis for the nosology, promulgated by Thomas Sydenham (1624–1689) and subsequently others, that diseases were specific entities that could be systematically classified in much the same way that species came to be classified by the Swedish botanist Linnaeus (1707–1778). (Indeed, Linnaeus presented his own classification of disease in his 1763 Genera Morborum.)
The century following Morgagni’s death saw a significant shift in medical thinking and in the relationship between patient and physician. The previous person-oriented medical cosmology gave way to an object- oriented one: a move from bed chamber to hospital, and ultimately laboratory, as the source of medical knowledge and choice of treatment was effected. The focus of medical attention progressively shifted away from the suffering individual to the source of that suffering. The logic was simple: remove the source of the suffering and the patient will be made well again.
The work of Marie François Xavier Bichat (1771–1802) in Traité sur les Membranes (1800) helped shift attention deeper, to the level of the body’s tissues, while Rudolf Virchow (1821–1902) took this deeper still, to the cellular level, in Die Cellularpathologie (1859). At the same time, a shift in the notion of disease seems to have begun to take place. Where there was once a diseased person, the idea that there could be diseased organs, diseased tissues and even diseased cells emerged. Indeed, the words ‘pathology’ and ‘disease’ have now come to be so closely associated that they are in some contexts interchangeable.
However, an impasse has been reached in this reductionist trend that ran from Morgagni through Bichat to Virchow. During the 20th century, the search for causes of disease reached the level of the non-living, chemical components of the body. But on crossing the boundary between living and non-living substance, one reaches a point where one cannot reasonably speak of ‘diseased genes’, and to speak of ‘diseased body chemistry’ would be nonsensical. The word ‘disease’, it seems, is reserved for only those components of the body that might be said to be ‘alive’ in some sense.
Originally, the word ‘disease’ literally meant an experience of ‘dis-ease’ – that is, ‘un-ease’ – and described what is now more often implied by the word ‘illness’. In English, the earliest use of the word ‘disease’ dates from the early 14th century and simply meant ‘discomfort’, having been derived from the old French ‘desaise’, which meant much the same. By the late 14th century, however, it had already come to be used in the sense of being unwell or ailing, but its literal sense of general discomfort seems to have continued until the early 17th century. Thus, a word that began by referring to how an individual felt in their entirety has now come to be applied also to component body parts.
This reification of ‘dis-ease’ has, at times, been perpetuated by a misunderstanding that has appeared in some influential texts on the history of medicine. The title De Sedibus et Causis Morborum per Anatomem Indagatis properly translates as ‘On the Seats and Causes of Diseases, Investigated by Anatomy’. But it has sometimes been mistranslated as ‘On the Sites
and Causes…’ – with ‘sites’ erroneously substituted for ‘seats’. Had Morgagni really meant ‘sites’ he would surely have chosen to use the more appropriate Latin word ‘situs’. Instead, he seems to have deliberately chosen ‘seat’. Coupling ‘seat’ with ‘cause’ implies that he regarded the post-mortem lesions observed to be sources of disease – which we may reasonably understand here to mean an experience of ‘un-ease’ – rather than as disease entities per se.
While Virchow described himself as a thoroughgoing ontologist in that he held that diseases were discrete entities, the same should not be assumed of Morgagni. Morgagni showed that an individual’s experience of un-ease had a seat from which it might be said to emanate – not a site where it should be assumed to exist. In this sense, the pathology to which Morgagni is progenitor is literally the study of suffering (from the Greek ‘pathos’, meaning ‘feeling’ or ‘suffering’) rather than merely the study of altered anatomical structures. It should be understood as the study of the suffering individual in the fullest sense.
Dr Stephen Lewis is a senior lecturer in the Faculty of Applied and Health Sciences at the University of Chester.