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“THERE are fads in illness, as in most things,” writes Dr Richard Shepherd in a recent memoir of his long career as a forensic pathologist in the UK. “Their popularity waxes and wanes according to our perceptions.”
Dr Shepherd is particularly referring to the shifting diagnoses around sudden infant death from the 1970s on, but the same could be said of many illnesses.
You don’t have to look far back in history to find a host of conditions that once held disease status but wouldn’t be found in clinical guidelines today.
In Unwell: what makes a disease a disease? Australian science writer Mike McRae charts the fascinating story of some of those vanished illnesses.
There’s neurasthenia, a debilitating condition that swept across late 19th century America, causing headaches, palpitations, high blood pressure, indigestion, neuralgia and depression.
Sometimes referred to as “Americanitis”, neurasthenia was one of the most common diagnoses given to patients at the time.
Its principal cause was considered to be the ever-accelerating pace of modern life: one neurologist described it as “a disorder of capitalist modernity”, while other observers blamed it on the new-fangled electric lights invading American homes.
Neurasthenia only finally disappeared from clinical guidelines in the 1980s.
“There are numerous sicknesses long abandoned like pathological ghost towns,” McRae writes, “leaving unanswered the question of whether they were illnesses that met a cure, or medical mirages.”
His catalogue of diseases once considered to require treatment includes left-handedness, nostalgia and homosexuality, officially classified as a mental illness until the 1970s.
Defining a particular kind of behaviour or identity as illness can be a means of exercising social control, as McRae makes clear.
In the 1850s, American physician Samuel Adolphus Cartwright described a condition, “particular to negroes”, which he named drapetomania. The disease caused African-American slaves to seek freedom against God’s will.
Another of Cartwright’s clinical discoveries was an illness called dysaesthesia aethiopica that led to laziness in slaves.
Caused by an insensitivity of the skin, the disease could be treated by having “the patient well washed with warm water and soap” then rubbed with oil. Next, Cartwright recommended, “slap the oil in with a broad leather strap … [and] put the patient to some kind of hard work in the sunshine”.
Definitions of disease have been used to prop up gender hierarchies too.
From ancient Greece to the 19th century, misbehaving female reproductive organs were deemed to cause psychological symptoms including unruly behaviour and overt sexuality.
In some unfortunate women, the uterus would take off from its appointed position to go for a wander around the body. Hippocrates believed an errant uterus could enter the chest cavity and suffocate its owner.
As late as the 19th century, medical men recommended various techniques to jolt the wandering organ back into place, including clinical stimulation of the genitals to induce “paroxysm”.
“Hysteria was a disease only when women did not act as society expected them to,” McRae writes. “Errant female behaviour became a condition, one that could be managed by medical authority, always male.
“And that authority’s ideas about what a woman’s body should do, not how it operated in reality, turned functions now considered quite normal into diseases.”
Unlike hysteria or drapetomania, modern definitions of disease generally have a strong underpinning in biological reality, but McRae reminds us that the whole idea of disease only makes sense in opposition to our definition of the healthy or normal.
Such definitions determine “who is broken and who is a pariah, who is forgiven and who is damned, which conditions deserve to be studied and which aren’t worth our attention”, he writes.
With new scientific discoveries, with shifts in social attitudes, our definitions of disease will continue to change.
It’s interesting to wonder what conditions in 21st century clinical guidelines might one day look ill-founded, even ridiculous.
Jane McCredie is a Sydney-based science and health writer. She can be found on Twitter @janemccredie
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.
Our first Anonymous poster might do well to keep up with the literature
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747169/ “The most frequent injury resulting from MVCs in the majority of Western countries is Whiplash Associated Disorders (WAD)” Note that the rapidly evolving standards of motor vehicle construction in terms of passenger safety will have a dramatic effect on reducing this type of injury.
http://rsi.org.au/index.php/overuse-injuries/ This might come from a source which is not impartial but of all the references I’ve checked, this stands out as giving a fair commentary. The series of name changes and the use of different names in different areas muddies the water, but as in the “Year 2000 Bug” preventative action has meant a reduction in presentations of Occupational Overuse Syndrome (OOS), the new identifier for that which was known as Repetition (or Repetitive) Strain Injury. See also https://www.safeworkaustralia.gov.au/system/files/documents/1702/statistics_on_work-related_musculoskeletal_disorders.pdf and look at the newer terminology.
As for Lyme Disease, this is a disgrace for the medical profession. The first papers in the 1980s used the accepted CDC definitions to describe in detail, clusters of cases that unequivocally met the clinical requirements of Lyme disease. Something changed after two researchers were awarded funds to look into the problem but were upstaged by a PhD student, who, on departmental funding only, unequivocally demonstrated the presence of Borrelia, indistinguishable from the American type strain, B. burgdorferi B31. Hers was a targetted study and earned her a PhD. From that point, there have been seismic shifts in the Australian interpretation of serology and the complete abandonment of clinical diagnostic symptoms by Australian Authorities. Lyme Borreliosis is known as Lyme Disease in every country but Australia. Lyme disease is, in every other country, recognised as a primary infection involving one or more Borrelia species (Commonly B. burgdorferi, B. garinii and B. afzellii together with a fruit salad or other pathogens including a handful of Rickettsias, Babesia (which species?), Bartonella (again which species?) and overseas a handful of other vector-borne organisms. Lyme borreliosis in the strictest sense, where the primary pathogen is B. burgdorferi ss, in around 30% of cases, presents with a unique skin rash, Erythema Chronicum Migrans. This is pathognomic, The CDC in USA accepts ECM (or EM) as the only clinical feature if present that confirms an infection of B. burgdorferii. ECM is reasonably common in Australian patients that have never left the country yet this is ignored in the Australian diagnostic regime. Another unique feature of Lyme Disease is the presence of migratory pain, this is present in no other disease, disorder or syndrome.
The CDC (USA Centre for Disease Control) and the IDSA (Infectious Disease Society of America) devised a surveillance program using a two-tier test of ELISA, followed if positive, by a Western blot. This has a poor efficiency, catching only 30% of culture-confirmed cases. Its efficacy can also be gauged by the official statistics of 30,000 new cases of Lyme a year in contrast to the unofficial figures in excess of 300,000 new cases per anum. The CDC were at pains to point out that the two-tier test was to be used for their surveillance program only and because of a very high proportion of false negatives, “Must not be used clinically” Australian Authorities have turned this little snippet on its head, mandating the ineffective two-tier test and claiming that, if it has problems, they are that it has too many false positives.
Insult to injury, the authorities have refused to recognise test results from labs, not Nata accredited even though the 3 labs primarily used overseas meet the highest international standards and are, under our International agreements, are eligible for reciprocal recognition. Likewise, one Australian lab which meets all the standards for overseas recognition, has, so far been unable to achieve NATA accreditation. The decision that Lyme Disease is not present in Australia is a political decision, perhaps an Eminence-based decision rather than an evidence-based decision.
The current disbursement of research funds is questionable, a million to a researcher at an anti-Lyme institution to look at conversion disorders and a psychiatric explanation for Lyme. More money is being spent on chasing vectors. It is akin to the drunk looking under the streetlight for the wallet he lost up the dark alley “because the light is better here”. In the meantime, there are possibly thousands of patients who would pass the CDC clinical diagnosis threshold and who are even being denied symptomatic treatment. Is it no wonder that suicide is a common endpoint of untreated borrelioses.
Dipsomania? Only sent to the waste basket of history when Dean Martin pointed out that without it you would never feel better for the rest of the day than you did first thing after waking up. ?
Gastroscopy
The perfect cure for stomach ulcers
Whiplash (already), RSI (already), chronic fatigue, fibromyalgia and Lyme disease spring to mind as possibilties.