Last week I reread Owsei Temkin’s classic essay from 1963, “The scientific approach to disease: specific entity and individual illness,” for a course I am co-teaching on individuality and medicine. (I have not found the Temkin essay online. If you would like a copy of it, put a request in the comments section.) In it, Temkin distinguishes between the “ontological” and the “physiological” concepts of disease. An ontological approach treats diseases as specific entities—“things” that exist out in nature and befall humans and other creatures. The best example of an ontological approach to disease is the germ theory: the notion, developed by Pasteur, Koch, and others in the late 19th century, that many common diseases are caused by microbes. An ontological approach treats diseases as static; curing disease entails getting rid of the thing that causes it. An ontological approach gave us some of the greatest triumphs of twentieth century medicine: penicillin, the polio vaccine, the triple-drug AIDS therapy.
In contrast, a physiological disease concept treats illness as a process. Temkin also calls this a “biographical” or “historical” concept of disease. A physiological approach is individualized; it treats disease as a unique constellation of disease agent, heredity, experience, and local conditions. In its extreme form, it treats every case as different, because no two individuals have the exact same circumstances. Temkin shows how this approach characterized ancient Greek and Roman medicine, and illustrates how the two, ontological and physiological, have been in dynamic interplay down through the centuries.
Thinking about how to explain this distinction to my students, it occurred to me that ontological diseases are nouns, while physiological diseases are verbs. Objects versus processes; things versus actions. This is a little bit crude, but as a mnemonic it works well to remind one of the fundamental distinction Temkin makes. It’s important to remember that these are not properties of the diseases, but of one’s approach to disease.
Catching up on The Daily Show last night I saw an interview with USC professor David Agus, author of the new book, The End of Illness. Near the beginning of the interview, Agus uses exactly this concept. He says,
We look at diseases as one little factor…You have cancer. You have heart disease. Well to me, those diseases are verbs. You are cancering. You are heart diseasing. And I want to take you from a disease state, the other direction.
After a long and successful run in the twentieth century, the ontological approach to disease has recently ceded the limelight to the physiological disease concept. Genomic medicine is all about individualized or personalized medicine. It promises to end “one size fits all” medicine and treat patients as individuals once again. Individualized medicine is also about prevention—about identifying and stopping disease before it starts. Indeed, Agus segues immediately from diseases-as-verbs to prevention: “And I want to prevent illness.” The physiological approach to disease, individualized medicine, is intimately bound to this notion of disease prevention.
Prevention seems an unassailably benevolent goal; however, in this age of intensive medical management and a potent biochemical, pharmaceutical therapeutic style, prevention also means the erosion of the patient as a medical actor. We all become patients. Your health needs to be managed from birth to death, probably with an armamentarium of drugs designed to forestall a battery of diseases for which you have risk factors.
Agus seems to say that everyone should take a physiological approach, that all cancer and all heart disease, and perhaps even all diseases are verbs. But Temkin concludes his essay by insisting that neither the physiological nor the ontological approach is “correct.” Rather, one must treat a given disease ontologically or physiologically (or perhaps in some combination), depending on whether one is a patient, a doctor, a researcher, a public health worker, or what have you.
It is a marvelous example of how a historical approach to biomedicine—even from an essay half a century old—can deepen our understanding of current events in science, health, and disease.
Temkin, Owsei. “The Scientific Approach to Disease: Specific Entity and Individual Illness.” In Scientific Change: Historical Studies in the Intellectual, Social and Technical Conditions for Scientific Discovery and Technical Invention from Antiquity to the Present, edited by AC Crombie. 629-47. NY: Basic Books, 1963. Reprinted in The Double Face of Janus, Johns Hopkins, 1977.
See also Rosenberg, C. E. “What Is Disease? In Memory of Owsei Temkin.” Bull Hist Med 77, no. 3 (Fall 2003): 491-505
Interview with David B. Agus by Jon Stewart, http://www.thedailyshow.com/watch/thu-february-2-2012/david-agus
17 thoughts on “Diseases as verbs”
Please send a copy of the Temkin paper!
Hi! Nice article. Would you be able to send me a copy of the Temkin paper? Thanks!
Hi, thanks. I’ll be happy to. I am overseas at the moment but when I return I will be happy to. If you don’t have it in a week or so, ping me.
Please send me a copy of the Temkin paper. Many thanks.
Hi, I am working on a related subject and ahven’t been able to locate the paper – would you be able to send me a copy of Temkin’s paper? Thanks, Lisa
This is long after you have posted this excellent article.
Nevertheless, could you mail me a copy of Temkin’s essay? I would be very grateful if you did.
Would you mind sending me a copy of the Temkin paper? Thank you so much 🙂
Hi, I am doing my masters dissertation on the nature of disease. I have got 9 days till the deadline and I would like to add something to it on Temkin’s work. I cannot find his essay. If you could send me a copy I would really appreciate that. Thanks.
Hi, it’s an old post, but I am also writing about a related subject and already added a quote from Temkin – I would really like to read the entire essay if it’s possible for you to send it. Thanks.
Did I send you the Temkin? Sorry about the slow reply–I’ve been swamped with other stuff. If I didn’t and you’re still interested, shoot me a note at nccomfort at gmail.
Hi there, I too am looking to see if you could send me the Temkin essay since I haven’t been able to find it.
This was posted a long time ago and you might already be familiar with this, but medical anthropology also makes a similar distinction (the work of Arthur Kleinman in the 80s) as have psychiatrists (leon eisenberg and george engle wrote important articles). In the history of medicine, you have the work of Charles Rosenberg who used Temkin to establish a new approach of thinking about disease, one of ‘framing’ rather than ‘constructing’, also in the 1990s (check out his intro to ‘framing disease’). Just in case you need other references when thinking about this! 🙂
Thanks for your comment. Yes, I know and admire Kleinman and of course Rosenberg immensely. We teach his “Framing” piece (among many others) regularly in our graduate seminars.
I just sent you the Temkin essay.
Hi, very interesting read
I’m currently putting together a thesis on disease nosology and the space required allowed for diseases as distinct ontological entities. the Temkin paper sounds informative, would it be possible to have a copy?
Hi there, I’d love a copy of the Temkin article please! Many thanks!
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