Into the heart of the mat­ter

The Weekend Australian - Review - - Books - Jane McCredie

In the late 19th cen­tury, the US strug­gled un­der the bur­den of an ap­palling new disease. Symp­toms in­cluded headaches, pal­pi­ta­tions, high blood pres­sure, in­di­ges­tion, neu­ral­gia and de­pres­sion. Through the decades around the turn of the 20th cen­tury, neuras­the­nia — some­times re­ferred to as “Amer­i­cani­tis” — was one of the most com­mon di­ag­noses given to pa­tients. Its prin­ci­ple cause was con­sid­ered to be the ev­er­ac­cel­er­at­ing pace of modern life. One neu­rol­o­gist de­scribed it as “a disor­der of cap­i­tal­ist moder­nity”, while other ob­servers blamed it on new­fan­gled elec­tric light­ing.

Neuras­the­nia is not a term you’ll hear to­day, though it fi­nally dis­ap­peared from clin­i­cal guide­lines only in the 1980s. What hap­pened? Did sci­en­tists find a mirac­u­lous cure for the de­bil­i­tat­ing con­di­tion or was it never a real disease in the first place?

This is one of the in­trigu­ing ques­tions Aus­tralian science writer Mike McRae raises in Un­well: What Makes a Disease a Disease? Trac­ing shift­ing clas­si­fi­ca­tions of ill­ness from clas­si­cal times to the present, McRae demon­strates how so­cially con­di­tioned the ideas of “un­well” or “ab­nor­mal” can be, and how sub­ject to change.

“There are nu­mer­ous sick­nesses long aban­doned like patho­log­i­cal ghost towns,” he writes, “leav­ing unan­swered the ques­tion of whether they were ill­nesses that met a cure or med­i­cal mi­rages.”

Defin­ing a par­tic­u­lar kind of be­hav­iour or iden­tity as ill­ness can be a means of ex­er­cis­ing so­cial con­trol, as McRae makes clear. The cat­a­logue of dis­eases once con­sid­ered to re­quire treat­ment in­cludes left-hand­ed­ness, nos­tal­gia and ho­mo­sex­u­al­ity, of­fi­cially clas­si­fied as a men­tal ill­ness un­til the 70s.

A cen­tury ear­lier than that, Amer­i­can physi­cian Sa­muel Adol­phus Cartwright, in Dis­eases and Pe­cu­liar­i­ties of the Ne­gro Race, iden­ti­fied two new dis­eases: drapeto­ma­nia, an ill­ness caus­ing slaves to seek free­dom; and dysaes­the­sia aethiopica, an in­do­lence in the said slaves claimed to be caused by in­sen­si­tiv­ity of the skin. Treat­ment for the lat­ter in­volved vig­or­ous wash­ing, fol­lowed by slap­ping oil into the skin with a broad leather strap and putting “the pa­tient to some kind of hard work in the sun­shine”.

Then there’s hys­te­ria, the con­di­tion al­legedly caused by the uterus tak­ing off from its ap­pointed po­si­tion to go for a wan­der around the body. The fa­ther of medicine, Hip­pocrates, be­lieved an er­rant uterus could en­ter the chest cav­ity and suf­fo­cate its un­for­tu­nate 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”.

The symp­toms of hys­te­ria in­cluded un­ruly be­hav­iour and overt sex­u­al­ity, deemed ab­nor­mal qual­i­ties in any­body born with a uterus, as McRae makes clear: Hys­te­ria was a disease only when women did not act as so­ci­ety ex­pected them to. 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.

The whole idea of disease makes sense only in op­po­si­tion to a “premise of rel­a­tive nor­mal­ity”, McRae ex­plains in this in­tel­li­gent, nu­anced book. The de­ci­sion about what should be con­sid­ered nor­mal or healthy in any given so- ci­ety de­ter­mines “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”.

Clas­si­fi­ca­tions of ill­ness are not en­tirely sub­jec­tive, of course. Our grow­ing un­der­stand­ing of disease has been one of the foun­da­tions of im­prove­ments in health and life­span, as McRae ac­knowl­edges: The bi­nary model we use to sep­a­rate disease from good health has, for the most part, been in­cred­i­bly use­ful for re­duc­ing suf­fer­ing in the world. If we stand far enough back, it be­comes ob­vi­ous that bi­ol­ogy plays a lead role in caus­ing us pain and mis­ery. By un­der­stand­ing the com­plex sys­tem of chem­i­cal gears and hor­monal pul­leys that make up the hu­man body, we have a good shot at al­le­vi­at­ing dis­com­fort and im­prov­ing well­be­ing …

Amer­i­can car­di­ol­o­gist San­deep Jauhar also takes a his­tor­i­cal per­spec­tive to the topic of ill­ness in his sur­vey of the hu­man heart and our often ill-fated at­tempts to treat it.

Heart: A His­tory tells an en­gag­ing sci­en­tific and clin­i­cal story about the or­gan that was, un­til the early 20th cen­tury, largely be­yond the reach of medicine. Sur­geons had by then tack­led all other ma­jor or­gans, in­clud­ing the brain, Jauhar writes, “but the heart stood apart, en­cased in his­tor­i­cal and cul­tural pro­hi­bi­tions much thicker than its mem­bra­nous peri­cardium”.

A supremely prac­ti­cal ob­sta­cle was that any at­tempt to cut into a liv­ing heart trig­gered mas­sive, gen­er­ally fa­tal, bleed­ing. The devel­op­ment of the heart-lung ma­chine in the mid-20th cen­tury al­lowed blood to be tem­po­rar­ily di­verted from the heart, clear­ing the way for sur­gi­cal pro­ce­dures that are now com­mon­place. Sci­en­tists and clin­i­cians pi­o­neer­ing new car­diac treat­ments through the 20th cen­tury often took a gung-ho ap­proach, as Jauhar de­tails. The pi­o­neer of car­diac catheter­i­sa­tion, Wer­ner Forss­mann, de­vel­oped the pro­ce­dure by prac­tis­ing on him­self, push­ing a tube all the way from an in­ci­sion in his el­bow crease up un­der his armpit and into the right atrium of his heart. The 26-year-old sur­gi­cal in­tern was ridiculed as a quack and sacked from his po­si­tion at a Ber­lin hos­pi­tal for his pains.

English sci­en­tist George Mines paid an even greater price for elu­ci­dat­ing the elec­tro­phys­i­ol­ogy of the heart: he died af­ter be­ing found un­con­scious on the floor of his lab­o­ra­tory at age 28, ap­par­ently a vic­tim of his own ex­per­i­ments.

The great age of car­diac in­no­va­tion may have come to an end, Jauhar sug­gests. New sur­gi­cal pro­ce­dures and pre­ven­tive health mea­sures have led to a 60 per cent re­duc­tion in car­diac mor­tal­ity dur­ing the past half cen­tury and that may be as good as it gets: “Car­di­ol­ogy in its cur­rent form might have reached the limit of what it can do to pro­long life.”

If your disease is not one of those cul­tur­ally cre­ated syn­dromes iden­ti­fied by McRae, or if the won­ders of modern medicine de­scribed by Jauhar fail to save you, you may have the mis­for­tune to en­counter the third of these au­thors.

Bri­tish foren­sic pathol­o­gist Richard Shep­herd works with bod­ies that, whether through disease, mis­ad­ven­ture or homi­cide, have ceased to func­tion on a per­ma­nent ba­sis. Across a 40-year ca­reer he has per­formed more than 20,000 au­top­sies but still re­mem­bers the first time he cut into a hu­man body as a med­i­cal stu­dent: What a re­mark­able mech­a­nism the hu­man seemed to me that day … I (ex­pe­ri­enced) that sense of won­der at the body: its in­tri­cate sys­tems, its colours and, yes, its beauty. For blood is not just red — it is bright red. The gall blad­der is not just green, it is the green of jun­gle fo­liage. The brain is white and grey — and that is not the grey of a Novem­ber sky, it is the sil­ver­grey of dart­ing fish. The liver is not a dull school-uni­form brown, it is the sharp red­brown of a freshly ploughed field.

There is much drama in Un­nat­u­ral Causes, as the au­thor trav­els to New York post-9/11 to help iden­tify body parts or deals with ma­jor ac­ci­dents and mas­sacres at home in Bri­tain. There is con­tem­pla­tion, too, as Shep­herd casts his mea­sured gaze on chang­ing at­ti­tudes to in­fan­ti­cide or the con­fu­sion and con­tro­versy that have swirled around deaths from sud­den in­fant death syn­drome.

For all his in­ves­tiga­tive pas­sion, the cu­mu­la­tive ef­fect of a life­time im­mersed in un­ex­plained or vi­o­lent deaths takes its toll on the pathol­o­gist. In the 1980s, when he be­gan his ca­reer, “pathol­o­gists were ex­pected to join se­nior po­lice of­fi­cers as hard-drink­ing, tough-talk­ing, al­pha males”, he writes. Shep­herd has played the game, cul­ti­vat­ing for many years a pro­tec­tive de­tach­ment from his work and those around him.

Even­tu­ally, though, he de­vel­ops post-trau­matic stress disor­der caused by “a life­time of bear­ing first-hand wit­ness to vi­o­lent, un­ex­pected death’’. An abyss opens in front of him: It was wait­ing for me. The bod­ies, piled high, the stench of decay and heat, young peo­ple who had been danc­ing when the bomb went off, when the boat went down, young peo­ple with­out hands, chil­dren ex­humed in their coffins, ba­bies’ tiny bod­ies bear­ing help­less tes­ta­ment to man’s in­hu­man­ity, charred bod­ies, drowned bod­ies, bod­ies sev­ered on the rail­way track. A deep, deep pit of hu­man suf­fer­ing. writes about science and medicine.

For­tu­nately for Bea­tles fans, in the 1960s hys­te­ria was no longer con­sid­ered an ill­ness

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