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Elementary concepts of medicine: III. Illness: somatic anomaly with . . .

2003; Wiley; Volume: 9; Issue: 3 Linguagem: Inglês

10.1046/j.1365-2753.2003.00416.x

1365-2753

Olli S. Miettinen, Kenneth M. Flegel,

Child and Adolescent Health

In the preceding essay in this series, we found ourselves having to dismiss prevailing medical definitions of health; and we ended up taking the view that, medically, health is the absence of ill-health, illness (somatic) – with illness a condition of health in the sense of absence thereof. Our next concern naturally is the medical concept to which that 'illness' antonym of 'health' refers. According to one of our medical dictionaries (Dorland 1994), illness is 'a condition marked by pronounced deviation from the normal healthy state'. This dictionary presents 'sickness' as a synonym for 'illness'. Two features of this definition call for editing. For one, the 'normal' qualifier for healthy state: no explication of its meaning is given in the context, nor under that word itself. So, the authors presumably intended to write 'normal, healthy state', thereby equating healthy with normal. And for another, 'pronounced' deviation from the healthy state: we just do not believe that the authors envisioned a three-point scale from the healthy state through less-than-pronounced deviation from it to illness, with the middle category representing neither health nor illness but a 'grey zone' between these. So, we take the authors to have meant that illness usually is a pronounced deviation from, but as a matter of definition any deviation from – and thus mere absence of – health, which is our position as well. But regardless, this definition is unhelpful to us, as our concern is with direct definition of illness. Our other medical dictionary (Stedman 1995), the one that gives a tripartite, 83-word definition of health, does give a direct definition of illness also – this one again tripartite but comprising 'only' 50 words. This definition appears to represent an attempt to define the opposite of health without leaving a grey zone between health and illness. The second element in the triad is particularly interesting: A morbid entity characterized usually by at least two of these criteria: recognized etiologic agent(s), identifiable group of signs and symptoms, or consistent anatomical alterations. As synonyms for 'illness', this second dictionary presents not only 'sickness' (as does the first one) but also 'disease' and 'morbus'. The word 'disease' in the first dictionary is associated with this definition of its referent concept: Any deviation from or interruption of the normal structure or function of any part, organ or system (or combination thereof) of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. (Definition A) This definition of disease in this dictionary (Dorland 1994), distinct from that of illness/sickness, is in rather close accord with that of illness/sickness/disease/morbus in the other dictionary (Stedman 1995), with the combination of the first and second elements in the latter, tripartite definition. Notwithstanding the remarkable inconsistency of terminology, we take definition A above to be one of illness; and as with the dictionary definitions of health, the defining essence of illness does not emerge from this definition without considerable editing of it. We glean from it that the proximate genus of illness is said to be anomaly of the body's structure or function, and that the specific difference is manifestation in characteristic symptoms and signs – presumably signs that are manifest to the affected person. In these terms, then, that definition of illness (disease) amounts to: Any anomaly of the body's structure or function with characteristic manifestations to the affected person. (Definition B) This definition, representing mere reformulation of definition A (for disease), invites critical attention to that 'characteristic manifestations' note in the specific difference. For one, as we noted in the preceding essay, medicine has latent illness as a well-established concept, so that illness may not be manifest at all to the person who has it. Granted, somatic anomalies that inherently are, and remain, devoid of such manifestations are not illnesses, complete situs inversus, for example. That which makes latent illness an illness is, we hold, its potential for future manifestation(s) to the affected person. Then, as for present and potential future manifestations, that qualifier 'characteristic': syphilis surely is an illness as much as any other, but characteristic of this 'great imitator' is absence of characteristic manifestations to the affected person. These considerations imply that definition B needs to be replaced by: Any anomaly of the body's structure or function with present or potential future manifestation(s) to the affected person. (Definition C) Next, 'structure or function' calls for attention. For a start, the term 'function' in this context really refers to ability to function, that is, functionality. Now, the body's functionality is, arguably at least, inherent in its structure, when the latter is comprehensively conceived (including enzymes, minerals, water, etc.); but regardless, what else is there in a body but structure and functionality? Bypassing all of this, we say simply that illness is: Any somatic anomaly with present or potential future manifestation(s) to the affected person. (Definition D) Before accepting or rejecting this definition of illness, its meaning needs to be fully understood. This definition distinguishes the illness itself, a somatic anomaly, from its manifestation(s) (and from its consequence(s), of course). Thus, while commonly subsumed under coronary heart disease, angina pectoris by this definition actually is not an illness but merely a manifestation of the somatic anomaly coronary stenosis; but the term 'angina pectoris', in its ordinary loose usage, actually refers to patent, symptomatic coronary stenosis – by definition D an illness in its patent form. Even latent coronary stenosis is an illness, given its propensity to progress to patency (in angina). Patent or latent, the illness at issue in this example is coronary stenosis, not the present or potential future angina manifestation of it. Definition D ascribes the manifestation(s) to the somatic anomaly itself, and thus not to its somatic cause(s) or other precursor(s) nor to its somatic consequence(s). Thus, by this definition, anomalies of the genome, even when causal to illnesses, are not themselves illnesses so long as they in themselves cannot have manifestations to the person at issue. And more generally, if somatic anomaly A is a precursor of another one, B, and if only B is manifest or potentially manifest in the future (to the affected person), then only B is an illness. In particular, A is not an illness even if, as a precursor, it actually caused illness B. Thus, insofar as we take 'hypertension' (the term is misnomer for an arteriolar anomaly) to be an inherently latent condition as such, it does not become an illness on the basis of the manifestations of the illnesses it causes (stroke, i.a.), as these indeed are manifestations of those resulting illnesses and not of hypertension itself. Implicit in the illness-defining concept of anomaly and its manifestations is that the latter are, and thereby the former is, undesirable. Definition D (just as definition A) does, however, beg one critical question: what is the concept of somatic anomaly as the proximate genus of illness? The athlete finishing a marathon surely is in an anomalous somatic state, with ample manifestations of this; but (s)he does not thereby have an illness: this anomaly arises as the body's normal response to an episode of abnormal behaviour, just as does the hypothermic person's somatic response to an abnormal environmental exposure. (An automobile of which fuel has been exhausted, or which cannot be started because of very cold environment, is in an anomalous state; but it is not thereby in disrepair.) The somatic anomaly involved in illness is devoid of full explanation in the person's behavioural or environmental stress. If these are involved at all, they have resulted in somatic damage, a somatic anomaly in this sense. The illness-defining anomaly is something whose resolution calls for more than mere discontinuation of the behaviour or exposure in its causation, insofar as these were involved at all (cf. need for automotive repair). With these clarifications, we take definition D to constitute a tenable specification of that most central one among all concepts of medicine – illness.