The historical diagnosis of dropsy – which is now obsolete – indicated simply an abnormal accumulation of fluid; the word derives from the Greek hydrops (water). Alternative or supplementary terms included hydrothorax (fluid in the chest cavity), ascites (which still indicates excess free fluid in the abdominal cavity), anasarca (still used to describe generalized edema throughout the body), hydrocephalus (used until the nineteenth century to indicate excess fluid within the skull), and ovarian dropsy (large ovarian cysts filled with fluid). Edema was often a synonym for dropsy, but it now has additional connotations, and pulmonary edema has been differentiated from hydrothorax. Since the mid-nineteenth century, dropsy has been recognized as a sign of underlying disease of the heart, liver, or kidneys, or of malnutrition. Untreated dropsy was, eventually, always fatal.

Etiology and Epidemiology

The major underlying causes of dropsy are congestive heart failure, liver failure, kidney failure, and malnutrition. Because they were not clearly differentiated before the nineteenth century, a historical diagnosis of dropsy cannot be taken to indicate any one of these alone in the absence of unequivocal supporting evidence, as from an autopsy. However, heart failure was probably the most frequent of the four.

The etiologies of dropsy can be explained most conveniently in terms of fluid balance. One principal force in the maintenance of normal fluid balance is the hydrostatic (or hydraulic) pressure within capillaries. The other major force is oncotic pressure, the normal tendency for sodium or large particles (e.g., proteins) in capillary blood to draw water out of tissues, tissues, much as salt draws water to the cut surface of a raw potato.

The “Q” in Q fever stands for “query,” the designation applied by E. H. Derrick to an acute illness with fever and severe headache of unknown cause occurring in abattoir workers and dairy farmers in Queensland, Australia, in 1935. Despite the discovery of the causative agent, a rickettsia-like organism, this unenlightening name has remained current, although an alternative is abattoir fever. Q fever, occurring in epidemics in military personnel stationed in the Balkans and Italy during World War II, was known as Balkan influenza or Balkan grippe.

Q fever is caused by infection with Coxiella burnetii, previously known as Rickettsia burnetii, and is the sole member of the genus Coxiella, family Rickettsiaceae. It was initially confused with viruses, but though C. burnetii is an obligate intracellular parasite, it has a true bacterial cell wall.

Q fever is a zoonosis of worldwide distribution, and many species of animals, birds, ticks, and other biting insects are natural hosts. In animals, naturally acquired infection appears to be asymptomatic so that Q fever is not of any economic significance to farmers. Transmission to humans occurs via inhalation of contaminated dust while infected animals, carcasses, or animal products are being handled; via laboratory accidents; and sometimes via tick bite and the consumption of unpasteurized milk. Asymptomatic infection is common. Illness may take two forms. Acute Q fever is usually a self-limiting febrile flulike illness or atypical pneumonia lasting up to 4 weeks. Untreated, the fatality rate is less than 1 percent. Chronic Q fever may develop months to years later, presenting as endocarditis and/or hepatitis. Endocarditis usually occurs in those with preexisting heart valve disease; untreated, it is usually fatal.

South Asia, also known as the Indian subcontinent, extends from the Himalayas south to form a huge triangle that juts into the Indian Ocean with the Arabian Sea on one side and the Bay of Bengal on the other. India, Bangladesh, Afghanistan, Sri Lanka, the Maldives, and the small Himalayan countries of Nepal and Bhutan are included in this area. South Asia can be divided roughly into three parts, beginning with the triangle-shaped Deccan Plateau, moving north to the fertile plain along the Ganges and Indus rivers, and finally extending to the northernmost section at the foot of the Himalayas.

Background: The Ancient Indian Texts

The Ayurvedic Texts

Ancient Indian Medicine had close ties with philosophy and religion. The basic texts of Hinduism are the four Vedas: Rg, Sam, Yajur, and Atharva. Ayurveda, meaning the “science of life,” is considered to be the fifth of these texts and as important as the other four. All of the first four Vedas have sections that deal with healing and the prevention and cure of sickness. Yet the approach is usually magical or by prayer to the deities of the Vedic pantheon.

The Ayurvedic texts, by contrast, are of later origin and tend to attribute disease to divine causes less frequently. The codification of Ayurveda probably occurred around the sixth century B.C., and the texts presumably took their defined forms, in which they are still available, by the sixth or seventh century A.D. They were compiled in the northwestern part of India and in areas that today include Pakistan and Afghanistan, although, with the spread of the Aryans and their culture, Ayurveda came to be practiced over much of the country.

Poliomyelitis is an acute disease caused by inflammation and destruction of motor neurons after infection by a poliovirus. Sensory functions are not affected. Although frequently asymptomatic, the infection may cause fever and a number of other general symptoms, described as abortive polio or minor illness. Occasionally, however, these prodromal symptoms are followed a few days later by infection of the central nervous system (CNS) and fever, with meningitis, or paresis (weakness) or paralysis of one or more muscles. Many patients recover use of the muscle or some muscles affected in the following months, although some have permanent paralysis or paresis. When the muscles of respiration are affected, death may follow.

Other enteroviruses of the ECHO (Enteric Cytopathic Human Orphan virus) and Coxsackie groups may also cause meningitis and paresis, or temporary paralysis. In the past, cases of abortive polio and those with paralysis who later recovered were often included in statistics as polio cases. Today, only cases with paralysis or paresis after 3 months are recorded as paralytic polio.

Poliomyelitis was known by several names until the 1870s, when it became known as acute anterior poliomyelitis. Among them was Heine–Medin disease (after two early researchers, Jacob von Heine and Karl Oscar Medin) and infantile paralysis because it affected mainly young children. As more adults and older children were affected, poliomyelitis – inflammation of the gray marrow – became the name of choice and is often shortened to polio.

Acute diarrheal illness can be defined as the sudden onset of the passage of a greater number of stools than usual that show a decrease in form. It is generally accompanied by other clinical symptoms such as fecal urgency, tenesmus, abdominal cramps, pain, nausea, and vomiting. In most cases the symptom complex is a result of intestinal infection by a viral, bacterial, or parasitic enteropathogen; occasionally it is secondary to ingestion of a microbial exotoxin.

Distribution and Incidence

Acute diarrhea is often hyperendemic in certain populations: infants and young children in developing tropical countries of Latin America, Africa, and southern Asia; persons traveling from industrialized to developing regions; military populations stationed in or deployed to tropical areas; and toddlers who are not toilet trained and are attending daycare centers. Diarrhea rates in children less than 5 years of age in developing countries range from between three and seven episodes per child each year. The rate of diarrhea for non-toilet-trained infants in day-care centers in urban areas of the United States is comparable to the rate of illness seen in Third World countries. Travelers’ diarrhea occurs in 20 to 40 percent of persons visiting high-risk areas from regions showing low disease endemicity. The rate of diarrhea occurrence in infants and young children under 5 years of age in the United States is approximately 0.8 to 1.0 episode per child each year. In all populations, acute diarrhea occurs less commonly in older children and adults than in infants.

Etiology and Epidemiology

The ultimate source of most of the enteric pathogens is infected humans, although for selected pathogenic organisms (i.e., Salmonella, Giardia), animals may serve as a reservoir.

Sudden unexplained death syndrome (SUDS) occurs when a relatively young healthy person, usually male and Asian, dies unexpectedly while sleeping. The victim has no known antecedent illnesses, and there are no factors that might precipitate cardiac arrest. At autopsy, no cause of death can be identified in the heart, lung, or brain. Postmortem toxicologic screening tests reveal no poisons. A sudden fatality during sleep in a previously healthy member of an ethnic group subject to SUDS, but whose death is not investigated with an autopsy, is defined as a presumptive case of SUDS.

Distribution and Incidence

SUDS has occurred in the 1980s among Southeast Asian refugees and immigrants in the United States, mainly among Laotians, Hmong, Kampucheans, and Filipinos. In Asia, SUDS has been described in the Japanese and Filipino medical literature and is also observed in refugee camps in Thailand. In 1983 the death rate ascribed to SUDS in the 25- to 44-year age group of Laotian and Hmong males in the United States, 87 per 100,000, was comparable to the sum of the four leading causes of natural death among other U.S. males in that age group. The incidence of SUDS has decreased since 1983, and there is evidence that the longer a refugee has been in the United States, the lower the risk.

Epidemiology

The first comprehensive report of SUDS in the United States was published by the Centers for Disease Control (CDC) on December 4, 1981; it described 38 victims, all Southeast Asian refugees. All but one of the cases were males: 25 Hmong, 8 Laotian, 4 Vietnamese, and 1 Kampuchean.

The term “absolute idealism” is generally used to characterize the metaphysical view that Hegel presents in his philosophy. Although this phrase does not occur often in Hegel's work, he does use it to describe his own philosophy: “The position taken up by the concept is that of absoulte idealism” [EnL 160 Z; 8, 307]. Since Hegel uses the term “the concept” to signify a set of philosophic categories that contain an accurate description of the real, we can take this statement to indicate that the term “absolute idealism” is an appropriate means of characterizing his philosophy.

But what exactly is absolute idealism? Hegel provides us with some insight into his understanding of this phrase in a passage that describes the ontological status of the concept.

Mental disease refers, at present, to disorders of perception, cognition, emotion, and behavior. The disorder may be mild or severe, acute or chronic, and may be attributed to a defect of mind or body or of some unknown combination of the two. A diagnosis of mental illness is the judgment that an individual is impaired in his or her capacity to think, feel, or relate to others. In mild cases, the impairment may intrude on a person’s ability to gain satisfaction from meeting the challenges of everyday life. In severe instances, an individual may be thought so dangerous or incompetent that sequestration within a psychiatric facility is necessary, with a resulting loss of rights normally granted to citizens.

The Problem of Mental Illness

The simple title of this section belies the extraordinary scope, complexity, and controversial state of contemporary psychiatric thought. Some have argued that if the myriad types of disorders bedeviling humankind were ranked by the net misery and incapacitation they caused, we would discover that psychiatry captures a larger share of human morbidity than does any other medical specialty. It seems ironic - if not tragic - that a clinical field of such magnitude is at the same time distinguished among its peers by a conspicuous lack of therapeutic and philosophical consensus. That the discipline lacks a set of internal standards by which to differentiate unequivocally the correct theory from the false, or the efficacious therapy from the useless, is an open secret.

African trypanosomiasis, or sleeping sickness, is a fatal disease caused by a protozoan hemoflagellate parasite, the trypanosome. It is transmitted through the bite of a tsetse fly, a member of the genus Glossina. Sleeping sickness is endemic, sometimes epidemic, across a wide band of sub-Saharan Africa, the so-called tsetse belt that covers some 11 million square kilometers. Although the disease was not scientifically understood until the first decade of the twentieth century, it had been recognized in West Africa from the fourteenth century.

The chemotherapy to combat trypanosomiasis has remained archaic, with no significant advances made and, indeed, very little research done between the 1930s and the 1980s. Most of the victims are poor, rural Africans, which has meant that there is little or no economic incentive for pharmaceutical firms to devote research resources to the disease (Goodwin 1987). However, in the mid-1980s field trials of a promising new drug, D1-alpha-difluoromethylornithine (DFMO), demonstrated the drug’s efficacy in late-stage disease when there is central nervous system involvement. In addition, there have been exciting recent developments in the field of tsetse eradication with the combined use of fly traps and odor attractants (Hall et al. 1984). And, the World Health Organization’s Special Program on Tropical Disease is trying to overcome the research problem resulting from the reluctance of pharmaceutical firms to get involved.

In current nosology, diseases are categorized as degenerative, malignant, genetic, endocrine, and so on. For purposes of the history of diseases we must add a category that we might term ephemeral. This requires a bit of literary license, because many conditions that fall in the class of ephemeral diseases had a longer existence than that word usually implies. Ephemeral diseases comprise a large number of entities that carried working diagnostic names for earlier physicians (see, e.g., typhomalarial fever), but that are no longer recognized, at least by their previous names (Straus 1970; Hudson 1977a; Jarcho 1980).

Clinical Manifestations

A historical example of a disease that died only to leave behind a host of sprightly ghosts is the “green sickness” or chlorosis. Although noted in two Hippocratic treatises, Prorrhetic and The Diseases of Girls, the condition received its now classic description by Johann Lange in 1554 (Hippocrates 1853, 1861). He called the condition morbus virgineus. His description contains many of the elements found in the Hippocratic texts, as does the account by Ambroise Pare in 1561. Also reflecting the Hippocratic corpus is the work of Jean Varandal who is credited with first using the word “chlorosis” in 1615 (Starobinski 1981). For Varandal, chlorosis was a class of syndromes.

Reflecting a different approach, Thomas Sydenham’s description in 1683 embodied many of the clinical features relied upon at least two centuries later:

Yellow fever is an acute group B virus disease of short duration transmitted to humans by different genera of mosquitoes, but especially by the Aedes aegypti (known previously as the Stegomyia fasciata). It remains endemic in the tropical regions of Africa and the Americas in a sylvan or jungle form, but historically its greatest impact on humans has been in an epidemic or urban form. The disease can appear with symptoms ranging from extremely mild to malignant; in classic cases it is characterized by fever, headache, jaundice, albuminuria (high-protein content in the urine), and hemorrhage into the stomach and intestinal tract. High mortality rates were frequently recorded during epidemics (20 to 70 percent), although today we know that yellow fever mortality is actually relatively low, suggesting of course that the majority of the cases were mild and went undiagnosed. The jaundice has prompted the appellation yellow fever, and other designations such as the mal de Siam, fièvre jaune, gelbfieber, and virus amaril, whereas the hemorrhaging of black blood led to the name “black vomit” or vomito negro.

Known early in the New World as the “Barbados distemper,” “bleeding fever,” the “maladie de Siam,” “el peste,” vomito negro, and later yellow jack (because of the yellow quarantine flag flown by ships), the disease has been called by some 150 names. It was first termed “yellow fever” apparently by Griffin Hughes in his Natural History of Barbados (1750).

Pellagra is a recurring nutritional disease associated with a severe deficiency of niacin, a vitamin of the B-complex group that includes both nicotinic acid and nicotinamide. Because the body can convert the essential amino acid tryptophan into niacin, inclusion of enough tryptophan in the diet is as effective as niacin in preventing the disease. Pellagra is usually associated with signs of deficiencies of other B complex vitamins and nearly always is linked with poverty and a diet composed substantially of maize. In recent years, pellagra in India and Egypt has been tied to consumption of another grain, jowar, a type of millet or sorghum.

Pellagra is characterized by dermatitis, diarrhea, and dementia, and thus is known as the disease of the “3 D’s.” If untreated, a fourth “D,” death, may ensue. Before the cause of the disease was known, mortality was as high as 70 percent. As knowledge about the disease increased, however, and many mild cases, previously undiagnosed, were recognized, the mortality rate was reduced substantially.

Dermatitis is the characteristic symptom of pellagra and the one on which diagnosis is based. Symmetrical lesions appear on the hands and arms, on the tops of the feet and around the ankles, on the back of the neck, and across the face in a butterflyshaped design. Weakness, a sense of malaise, and a reddened skin, sometimes confused with sunburn, are the first indications of the disease. Later the skin crusts and peels, revealing a smooth glossy skin underneath. In Spain, where the disease was first described in the eighteenth century, it was called mal de la rosa; in France, peasants named it mal de la misère.

Epilepsy is characterized by the repeated occurrence of seizures that result from recurrent, abnormal, excessive, synchronous discharges of populations of cerebral neurons (Epilepsy Foundation of America 1981). It has a worldwide distribution and probably has been in existence since the dawn of human history. The condition is chronic but rarely fatal, and most types of epilepsy do not disturb the affected individual’s desire or ability to lead a normal life. Modern antiepileptic medications most often control seizures, and the limitations imposed by the disorder may be negligible. Unfortunately, epileptics are all too frequently stigmatized and excluded from many activities of daily life. Outdated beliefs and misconceptions about epilepsy have only recently shown signs of lessening in the United States and other industrialized societies.

It is misleading to think of epilepsy as one disease. There are many causes of this symptom cluster, just as there are for the symptom cluster of nausea and vomiting. A better term would be “the epilepsies.” The epilepsies do, however, share certain physiological characteristics. Clusters of neurons in some parts of the brain begin to discharge impulses in a disorganized fashion. The parts of the body controlled by the affected neurons respond with disorganized activity such as convulsions or tremors, or by loss of normal function such as loss of consciousness, paralysis of a limb, or localized numbness. The condition is also chronic, marked by the recurrence of seizures. By monitoring the brain with electrodes, an electroencephalographer can often detect abnormal brain waves, either localized in one part of the brain or coming from all parts at once.

The idea that diet is an important factor in health is a very old one and, if anything, had greater prominence in the time of Hippocrates than it does now. However, the development of a workable system or science of nutrition had to await the development of modern chemistry with its significant advances at the end of the eighteenth century. Before that time, the purpose of nutrition in adults was assumed to be the replacement of abraded (or worn-out) tissues. Meat, the tissues of other animals, seemed an effective food for this purpose, because it provided essentially like-for-like, but vegetable foods seemed to be made of quite different “stuff.” Animal tissues allowed to decompose became putrid and alkaline, whereas most vegetables became acid and did not become putrid. When heated and dried, animal tissues became hornlike, whereas vegetables became powdery. However, Iacopo Bartolomeo Beccari of the University of Bologna pointed out in 1728 that, when sieved (i.e., debranned) wheat flour was wetted and pummeled into a dough and then kept under running water until the floury starch had been washed out, the residual gluten had all the properties of animal tissues. Similar fractions were found in other plant foods. It was thought that these were the essential nutrients, and it was the job of the digestive system to winnow away the unwanted starch, fiber, and so forth and leave the glutenlike material to be circulated in the blood, for patching and filling.

Protein

With the discovery of nitrogen as an element toward the end of the eighteenth century, and the development in France of methods for analyzing the amount of nitrogen in different materials, came the discovery that both animal tissues and the “animal-like” fractions in vegetables contained nitrogen, whereas starch, sugar, fats, and vegetable fibers contained only carbon, hydrogen, and oxygen.

The Chinese liver fluke is a small worm that parasitizes the bile ducts and livers of humans, dogs, cats, pigs, and several wild animals in China, Japan, Korea, and Indochina. It was discovered in 1875, and recently, it was estimated that 20 million individuals in China alone are infected. Eggs are laid in the bile ducts, pass in the feces, and if they reach the proper freshwater snail, undergo a series of stages in this intermediate host. Eventually, free-swimming larvae are formed, which penetrate and encyst the skin or muscles of fish, expecially those of the carp family. Human beings and other definitive hosts become infected by eating the cysts (metacercaria) in raw or poorly cooked fish. Raw fish are a delicacy in many Asian countries, and fish are sometimes raised in ponds fertilized with human feces. Encysted metacercaria larvae are resistant to smoking, pickling, salting, and drying. Imported fish have caused human cases in Hawaii, and the popularity of Asian cuisine poses a potential danger to gourmets far beyond Asia.

Light infections are often asymptomatic. Heavy infections may produce diarrhea, fever, jaundice, and abdominal pain. Bile duct blockage and liver abscesses occur in chronic cases, and Clonorchis sinensis has been tentatively linked to liver cancer. Diagnosis is made by microscopic examination of the feces to discover the characteristic eggs. Drug therapy is sometimes successful. Preventive measures include rural sanitation, regulation of fish-farming methods, and cooking fish thoroughly. It is unlikely, however, that long-established culinary practices can be changed.

In past centuries people feared epidemic diseases with their sudden onset, ghastly symptoms, agonizing death for many, and sometimes disfigurement or physical impairment for survivors. Today, especially in the developed world (with a few notable exceptions), the dread of epidemic contagion seems almost as anachronistic as the burning of witches. It has been replaced by the dread of cancer. As with the epidemics of yesterday, the basic causes of cancer remain shrouded in mystery, while its effects in terms of human suffering are all too well known.

Cancer is a process whereby a loss of control of normal cell division and multiplication produces a tumor that can invade adjacent tissues and metastasize, that is, implant cancerous cells at a site that is noncontiguous to their origin, where abnormal multiplication continues. When cancer originates in connective tissues (mainly bone or muscle), it is called sarcoma; when it originates in epithelial tissues (lining tissues and organs such as the breast, lungs, or stomach), it is called carcinoma. The latter is by far more common. Invasive tumors occur in all complex species and probably antedate the advent of vertebrates. The oldest paleopathological evidence is limited to lesions that affected bones, such as those found in dinosaurs. Tumors have been found in Egyptian mummies dating from 2000 to 3000 b.c., and physicians of that ancient land knew of and treated patients for cancers of several sites.

The muscular dystrophies are a group of genetically determined, almost exclusively pediatric diseases. Generally, the earlier the age at which symptoms begin, the poorer is the prognosis. Because of a considerable overlap of manifestations and rates of progression and, until recently, the lack of any biochemical test, their classification is still unsettled. As a group, the principal differential diagnosis of the muscular dystrophies is from the muscular atrophies. In the former, the primary defect is in the voluntary muscle fibers; in the latter, it is in the innervation of muscles.

Classification

The most common of the dystrophies and the first to be described was that delineated by Guillaume B. A. Duchenne, a French neurologist, in 1868. Duchenne muscular dystrophy (DMD) is a sex-linked recessive disorder. Consequently, it clinically affects only males and is inherited through female carriers of the gene. Although affected boys have abnormally elevated concentrations of muscle cell enzymes such as creatine phosphokinase in their blood, this abnormality is also found in about three-fourths of the asymptomatic female carriers. DMD appears to have a rather uniform incidence worldwide, with a mean incidence estimated to be about 1 case per 4,000 live male births, or 15 to 33 cases per 100,000. Most surveys have been of predominantly Caucasian populations, but the results of a study in Japan were consistent with the others. A family history of DMD can be obtained in only about one-third of cases. The others are attributed to either a previously unexpressed carrier state or to a new mutation.