KATHRYN VANCE STAIANO A Semiotic Definition of Illness The discipline or ‘doctrine’ of semiotics in general and medical semiotics (semeiology)! in particular derives from a concern among the ancient Greeks with the translation or interpretation of signs of bodily disfunction.? Medical semiotics (semeiology), as a tradition separated from the linguistic and philosophical traditions, has generally been regarded as that aspect of the medical sciences prin- cipally concerned with diagnosis, although signs of dis-order point to @ past (etiology) and a future (prognosis). Generally lacking the technology to produce and evaluate the broader range of ‘signs’ of health and disease and the therapeutic skills and materials necessary to treat cases with consistent success, the Greeks tended to empha- size the accuracy with which the physician prognosticated the course of the illness. Hippocrates, for example, is supposed to have stated during the fourth century B.C.: It appears to me a most excellent thing for the physician to cultivate Prognosis; for by foreseeing and foretelling in the presence of the sick, the present, the Past, and the future, and explaining the omissions which patients have been Builty of, he will be the more readily believed to be acquainted with the circum. stances of the sick, so that men will have confidence to entrust themselves to such a physician, (The Book of Prognostics) But diagnosis, prognosis, and etiology constitute, at one level of analysis, but a single sign whose triadic nature has important socio- logical implications. These sociological and humanistic implications, however, have been ignored or minimized by a medical tradition which has failed to recognize the historical and necessary links between semeiology and semiotics. Semiotica 28-1/2, 1979108 . KATHRYN VANCE STAIANO- In current medical practice, signs of dis-order, both objective (produced or observed by the diagnostician) and subjective (offered by the ‘patient’), to the degree that observations and technologies are accurate and consistent and symptoms fully and honestly presented, are generally regarded as non-arbitrary in the relation of sign (or in Peirce’s terminology, which is awkward but allows greater precision than that of Saussure, representamen) to “that for which it stands”; that is, the sign is indexical, directly motivated by its object. Determination of ‘meaning’ for such a sign then becomes dependent upon its inclusion within a system of signs (syndrome, symptom complex), produced synchronically or diachronically, which point to a ‘disease’ or labeled dis-order. In the medical model? of illness, signs are always regarded as empirically classifiable* given sufficient information and the necessary technology to generate and evaluate that information. Medical science thus has as one of its goals the development of ever more sophisticated informa- tion-gathering techniques. Such an approach to sign (the objective phenomenon) and symptom (the subjective phenomenon, the patient's presentation of his perceived state)® leaves semeiology generally devoid of con- siderations of the social matrix in which all illness must occur. But illness is always a cultural event or experience, inseparable from social ‘and political realities.* Illnesses’ may not only result from cultural practices and be treated within a specific cultural milieu utilizing techniques which derive from or conform to certain cultural expectations, but may ‘express’ or imply culture itself. This paper, then, intends to explicitly re-unite ‘semeiology’ with the semiotic traditions derived from Peirce and Saussure,” and to propose a definition of illness which both maintains this unity and introduces into this unity certain anthropological and sociological insights. The divergence of a medical ‘semeiology’ from the philosophical ‘semiotic’ would seem to have its origins in the scientific revolutions of the late sixteenth and seventeenth centuries. There was, for example, Bacon’s emphasis on experimentation and Descartes’ distinction between the physical and spiritual elements of man, both setting the stage for medicine as the science of the body. The British Royal Society was much influenced by Bacon, as was Thomas Syndeham, physician and close friend of Locke, who, interestingly, was also well trained in the medical theories-and praxis of the time. Syndeham’s work did much to promote a reformation within clinical practice. “It is necessary,” he stated, “that all diseases be reduced to definite and certain species, and that, with the same care which we i | i |A SEMIOTIC DEFINITION OF ILLNESS 109 see exhibited by botanists in their phytologies.”® The ‘discovery” and apparent success of a germ theory of disease in the mid-1800s furthered the division, for, as Ackerknecht noted, with the develop- ment of the field of bacteriology “for the first time in history causes of numerous diseases became known” (1955:171). With these developments and with the implementation of the 1910 Flexner Report, which so radically altered (and standardized) medical education, the role of the physician became increasingly that of ‘curer’ of disease, rather than ‘healer’ of iliness.? The sign of dik order was thus seen increasingly as indexical rather than symbolic, and the object of illness was tied in a non-arbitrary and compulsive way to its manifestation. The cause-effect relationship was to be determined through scientific experimentation, which, by defini- tion, is assumed to be devoid of cultural biases. Furthermore, the signs of physical and, to a large degree, of emotional or mental distress were considered to be non-intentionally produced ~ and therefore of little interest to social scientists and, in general, to most semioticians, who tended to view such signs as existing at the boundaries of a semiotic. Certain persons, however, occasionally bridged the gap between a medical semiotics and a philosophically and linguistically oriented semiotics.!° The common denominator here generally appears to be either an interest int patient- therapist_ communication or in the commuriicative aspects of ‘illness’. The debt to Freud is frequently acknowledged (even while denying an orthodox psychoanalytic approach), for Freud, while never using the term ‘semiotic’, was always concerned with the interpretation of signs and the relation of sign to object; he further recognized the, arbitrary (non-indexical) relation between the symptom and some ‘object’ or ‘event’. A compulsive act might, for example, have several potential ‘objects’. He questioned, in fact, the very nature of the symptom, for each apparent symptom was merely a mask disguising the ‘real’ disturbance. Thus mental disturbances were symbolic disturbances, their cause-effect relationship to be dis- covered by the trained diagnostician and unavailable, by definition, to the sufferer. In addition, many ‘mental’ disturbances exhibited themselvés in disturbed communication; the concept of disturbed communication, of course, refers to all communicative efforts, regardless of the channel chosen for transmission, but for the most part the phrase has been used to refer to language behavior. Thus psychology and psychiatry were tied directly to the linguistic aspect of ‘illness’ states, and language was regarded historically as the semiotic system110 KATHRYN VANCE STAIANO par excellence. For the most’ part, however, the mind/body dichotomy was lirgely maintained. The focus of psychiatrists, psychologists, and others on ‘mental’ disturbances or ‘emotional’ or ‘communicational’. disorders tended to perpetuate the division between somatic and mental.!" Even psychosomatic medicine, while having the potential to bridge the gap in its concern with the mind/ body interaction, seems to have given precedence, as has generally been true with medicine, to the psyche; that is, psychosomatic illnesses have been, once ‘discovered’, relegated to the category of mental disfunctions. A semiotic definition of illness is proposed in this paper which does not necessitate a distinction among physical, mental, and psychosomatic disorders and which avoids the usual medical defini- tion of illness as any deviation from the normal or steady state; this definition supposes that medical semiotics is most properly a bio- social science or discipline, and it will be argued that the signs which point to dis-order may be arbitrary in the relation between represen- tamen or sign-vehicle (Morris 1964) and their objects. Philosopher of medicine Arthur Kleinman has made the same point on several occasions without making reference to the sign- object-interpretant relation directly: Modern socio-cultural studies of medicine demonstrate the symbolic character of much of medical reality. This symbolic reality can be appreciated as mediating the traditional division of medicine into biophysical and human sciences. Comparative studies of medical systems offer a general model for medicine as a human science. These studies.document that medicine, from an historical and cross-cultural perspective, is constituted as a cultural system in which symbolic meanings take an active part in disease formation, the clas- sification and cognitive management of illness, and in therapy. (Kleinman 1973:206) Within the literature of medical anthropology - or, more specifically, ethnomedicine — there exists the recognition that the symptom (the introspective sign) may be a form of cultural expres- sion certainly influenced by existing cultural ‘codes’, if not totally determined. As one anthropologist has stated, though symptoms “are subjective in nature, they are the first step of a process toward reducing vague chaotic feelings to more orderly culturally sanctioned domains” (Janzen 1973). One of the potential contributions of anthropology to medical semiotics, then, is the provision of exten- sive data allowing cross-cultural comparisons which must further point up the arbitrary nature of the symptom.‘A SEMIOTIC DEFINITION OF ILLNESS mi All societies or cultural systems have ‘semeiologies’, that is, they take cognizance of the signs which indicate disease or illness and they have ‘medical’ theories or ideologies which both. provide an etiology and allow prognostication. Because all such theories are ultimately ‘logical’ (Horton 1967, Young 1976, Kleinman 1973) such signs also prescribe therapies, that is, they function as signals within a given cultural context, producing desirable and expected action. Signs utilized for evaluation in other societies may be extra- neous to the body. Evans-Pritchard’s work among the Azande Provides us with an excellent example of a society in which many, if not most, of the signs that refer to illness states are found outside the body, and yet such signs, as shown in the reports of Evans- Pritchard and others, often perceptively integrate biological signs produced by the body with ‘social signs’ indicating disturbances in the ‘social field’.’? That such systems of logic do not correspond to those of Western or cosmopolitan medicine is inconsequential. All that is required for their existence as medical theories is an internal consistency and a concer with cause-effect relationships. The ‘sign’ must be triadic in that it must both point backwards and forwards in time; it must be explainable in terms of past events (or it must explain them) and it must allow prognostication and (in most cases) Jead to therapeutic action. The symptom, then, as a cultural act is also a communicative act, an attempt to channel and express subjectively perceived states in culturally approved modalities; but the symptom is, moreover, an attempt to make some statement about the self. But the self is a social construct, an invention," and to state that the symptom is an attempt at self-expression in no way negates the prior assertion that the symptom is a form of cultural expression. The symptom becomes a ‘strategy’, a behavioral act of considerable importance, an inter- actional maneuver employed in a situation in which other forms of communication may have failed or are considered inappropriate."* ILLNESS AS A SEMIOSIC ACT Illness is defined as a semiosic act involving the production of signs which signify the intrasubjective perception, initially at the uncon- scious level, of changed internal relationships which must come to be regarded, at this same unconscious level, as potentially harmful to the organism (for example, a quantitative change in the rela~ tionship between a pathogen and host organism). In other words,112 KATHRYN VANCE STAIANO illness does not require a label for its existence, nor that event called diagnosis. The individuals’ information processing systems in their reaction to these intrasubjectively perceived changes institute responses which themselves constitute the majority of signs of dis- order utilized by the diagnostician; but such responses may, in fact, be based on misinformation. That certain psychological or mental dis-orders are characterized by such a response (i.e., one based on misinformation) is well known.'* The signs signify a response, an interpretant which is, in tur, a sign of a perceived change: but such signs are produced according to a code which is not devoid of cultural components save, possibly, at a strictly genetic level; the changed or changing relationship was evaluated by internal information processing mechanisms which, 1. argue, are culturally “influenced; and the signs are ‘symptomatized’ or described by a patient according to‘a culturally mediated code (that is, expressed through language, in terms of existing categories, and according to expectations associated with specific-roles) and they are intersubjectively evaluated by individuals who are themselves social constructs. Signs utilized by the physician (or any other person making an evaluation of bodily or mental states) are second order or higher level signs. A pathogen or other ‘causative’ factor does not, in fact, necessarily cause any ‘disease’ directly. Rather, the signs which we label as designating disease are most Often produced by the body in response to the perception of changed or changing relationships; they generally represent the body’s attempt at self-regulation. It is argued that the diagnostician and physician are also sign- producers, both in terms of generating signs which signify illness and those which signify health, and operate under a restricted code both in their production and evaluation of signs. The physician’s diagnostic role requires that he evaluate the state of the patient; this task he begins by collecting information on the objec tive and subjective signs which may point to illness. That the patient’s presentation of complaints (symptoms) may be symbolic Ge., the relation between the representamen: [the symptom] and that which is denoted or connoted by the symptom) is constituted of an arbitrary link has already been argued. But the physician is also a social being or construct, and therefore operates under a restricted code. The diagnostic event, therefore, is also ‘symbolic’, although the link between the representamen and the interpretant may be so conventionalized as to appear indexical. In fact, it is the conventionality of this link that allows the patient confidence in the practitioner. The underlying assumption is that several diagnosticians‘A SEMIOTIC DEFINITION OF ILLNESS 113 faced with the same sign or sign systems will ‘see’ the same event and provide the same diagnosis. If illness seems indicated, the physician first seeks a label and then attempts, where possible, to intervene in the patient’s production of signs. The physician’s therapeutic role, by extension, becomes that of producer of signs (generally through reversal, elimination, ot neutralization of existing signs of dis-order), signs which point to the so-called normal (healthy) state. In that set of verbal (and non-verbal) transactions which con- stitute the psychotherapeutic act, in the ordering of an X-ray, in the application of a visual sequential memory test, the diagnostician is, in fact, producing signs which he evaluates as pointing to a state of ‘health’ or ‘illness’ (or incipient health or illness) but which other- wise would not have existed had it not been for his production of them, a point rarely considered. The argument, of course, is that the ‘signs’ existed, but were unperceived and required the skill or technologies of the diagnostician for their uncovering, Peirce claimed always that a sign could exist without an interpreter, and in certain of his later writings he stated that it could exist without an inter- Pretant; the sign must simply have the potential for producing an interpretant. Nevertheless, all potential signs are not interpreted within any one medical system. As Einstein stated, “it is the theory which decides what we can observe.” It would seem the task of the semiotically oriented medical anthropologist or sociologist to discover the code which governs the production, both by the patient and by the physician, of some signs but not others. Once the signs are produced, or existing signs are ‘observed’ and noted, for them to take on meaning, to point to a certain’state which is conducive to therapy, they must be evaluated or assigned to categories known as diseases or syndromes. This categorization is clearly affected by the diagnostician’s: ‘philosophical’ bias, whether that philosophy involves the notion that ancestors attempt to make their wishes known by inflicting disease (as is true for- much of traditional Africa) or is the ‘logical positivism’ underlying Western medicine. Classification of disease is, then “the first therapeutic act” (Kleinman 1973). Because diagnosis must normally involve communication, the physician becomes inseparable from the ‘system’ that he attempts to observe. Moreover, the personal need for observations to coincide with the structured cognitive guidelines which are his cultural and intellectual heritage may interfere with’ his assessment; ‘the diagnostician must, in Bateson’s words, wish things to be as he ‘knows’ they are. Additionally, the intemal events114 KATHRYN VANCE STATANO taking place within the patient are not directly available to the diagnostician. He must, indeed, ‘mediate’ them, either through verbal transactions, observations of intersubjective signs (which, ‘as stated earlier, are not necessarily directly referable to a pathogen or to a changed relationship, but are the body’s response to the percep- tion of such), or through the acquisition of those signs which are ultimately interpreted by the diagnostician but initially ‘observed’ through the diagnostician’s technological extensions. Further, I wish to argue that the so-called objective signs of dis-order as produced by the patient may be arbitrary in the relation of representamen to object (in other words, such signs are symbolic), that the initial evaluation of change or process takes place intra- subjectively (within the malade), and that cultural mediation may affect this evaluation even at the level of the unconscious prior to the occurrence or manifestation of either introspectively produced or intersubjectively evaluated signs. I have thus far stated that symptoms (or introspective signs) are part of a communicative act. I have also argued that intersubjective signs are evaluated by individuals who are themselves social constructs. But if certain signs always stand for certain objects and point to certain contents (interpretants) in a consistent way, such signs would seem to be indexical, in other words, the link is a ‘natural’ one. I suggest that when there is a direct and consistent relationship bet- ween the sign (sign-vehicle, representamen) and its object, unmediated by the social self, the sign is indexical. However, little is known about the mediating process, the intervention of a self, specifically a social self, in the process of perception and interpretation of sensory inputs. Correlational studies, however, indicate an increasing array of links between ‘predisposing’ factors of a social, cultural, or personal nature, and certain illness states. The relation between representamen and object may be an arbitrary one, even in those cases in which we are dealing with organic or physical signs of dis- order, signs supposedly immune to cultusal or social interpretations at the unconscious level. The system of internal codification by which sensory inputs (both exteroceptive and proprioceptive) and organized and made meaning- ful is not available for examination. It is, nevertheless, clear that a codifying system exists, and that this-system reduces, summarizes, and organizes sensory impressions. The opinion is offered here that perception — whether thé reference is to an ‘awareness’, , percep- tion which reaches some conscious level, or perception at theA SEMIOTIC DEFINITION OF ILLNESS 11s unconscious level — is influenced or mediated by the self, which is a product of the social and cultural milieu. T have suggested that social and/or idiosyncratic factors may cause one to misperceive an event, that is, that the sensory impressions may be miscoded, the abstraction derived may bear no relation to reality, etc. As was stated earlier, that certain psychological or mental disorders are characterized by a response based on mis- information is unquestioned, or, as Gregory Bateson (in Ruesch and Bateson, 1968) notes, the condition which the psychiatrist has labeled as psychosis is essentially the result of the patient's mis- interpretation of messages received. The suggestion made here is that illness of an ‘organic’ nature may represent similar responses. In defining illness I stated that the definition offered did not require a distinction amongst physical, mental, and psychosomatic dis-orders; yet I went on to state that illness was defined as involving the Perception (or misperception) of changed internal relationships, a definition which would seem to exclude certain so-called ‘mental’ disorders, at least those perceived to be precipitated by changing social or environment-elf relationships. Nevertheless, ‘mental’ dis- orders of this sort can be included within this definition if such changed relationships between self and environment (which includes other ‘selves’) are regarded as internalized. The self, I have stated several times, is a social product, a synthesis of interactions in which externally derived information becomes internalized. The individual integrates information about its relationships with others, obtained through social transactions, and with the physical environment, obtained through person- or organism-environment transactions, into a self, which evolves out of this process of integration and mediation of opposition: When signs are manifested, either as symptoms or as inter- subjective signs, and made available for evaluation by self or others (the patient may also be diagnostician), the act is, in part, a com- municative act, an attempt to order the disordered pronoun, the unstructured ‘I’,'* to define and communicate a self. The sign, in this sense, is a metonym for the self and should be viewed as an act of social import, an attempt to communicate a self to an other, and in the process develop a further concept of self in opposition to the other (“Ica describe my pain to you", the patient may be saying, “but you cannot suffer my pain”). It follows from the previous discussion that all illnesses are psycho- somatic in that a self must always involve itself in the illness event at some stage, although perhaps only at the stage of symp-116 KATHRYN VANCE STAIANO tomatization, But the possibility exists that the changed relationship was precipitated by the self, or that there was no change but a mis- perception of such, triggering the signs associated with an illness state. It is argued that all illnesses are psycho-somatic at some level, that the psyche and body interact, each having some effect upon the other. Inthe so-called ‘true’ psychosomatic illnesses, a social’ self initiates signs or intervenes in the process of evaluation in such a way that some sort of negotiation or ‘re-cognition’ of events takes place. That there is considerable difficulty in deciding which of the above events has occurred should be obvious. I suggest, therefore, that the term psychosomatic be dropped as no longer useful, at least in its almost automatic application to certain illness states. 1 use the term socio-somatic to refer to any illness in which the intersubjective or introspective signs are presented or manifested in a culturally approved or channeled way, or in which certain disrup- tions in the social field or in interpersonal relations are expressed in specific somatic terms because this is a culturally sanctioned form of expression. Illnesses are sociosomatic to the degree that they conform to this definition; but in that the self has been defined as a social invention, all illnesses which are psychosomatic, in the broadest sense, are also sociosomatic. Finally, medical signs, or signs so classified, are future-oriented (prescriptive) and past-oriented (appraisive or evaluative) and thus potentially exploitable for social ends, both self-serving and com- munal. The ‘sick role’ which the patient fills, or attempts to fill, may also represent an effort to manipulate and control his environment, to alter in some way the set of rights and obligations which define his position within the society and his links to others in his social environment. The sign of illness may thus come to indicate some alteration in the individual's roles which can, in many cases, be manipulated to his benefit. But innumerable persons have documented ways in which par- ticular societies or political systems may utilize or redefine signs to serve communal or state interests.'7 To give an example, Ruth and Victor Sidel (1972) report on an interesting case within Communist China. A woman had been admitted to a psychiatric ward suffering from auditory hallucinations. After considerable indoctrination into Maoist philosophy, she was pronounced cured. She still, in fact, suffered from hallucinations “but she quickly recognizes they don’t really exist as a result of an investigation based on the works of Mao” (28). In such a case, the change in political philosophy has been incorporated into the sign, that is, the auditory hallucinationsA SEMIOTIC DEFINITION OF ILLNESS 117 do not stand by themselves as a sign, but rather particular beliefs regarding the origin of the sign have become part of the symptom itself. If such signs do not already exist which are capable of such manipulation, signs which normally point to other (non-illness) states may have new referents attached. __ The tendency of physicians (and administrative personnel in positions where decisions as to allocations of monies for research and applied medicine-are made) to define an ever broader range of signs as indicative of illness, and thus to gain control over increasing aspects of our lives; has been fairly well described elsewhere. Alco- holism and drug addiction are not defined as personal moral dilemmas, but as illness states. What some have referred to as “the failure to learn appropriate communicative techniques” is inter- preted elsewhere as mental illness, requiring the intervention of a Physician and frequently the extensive utilization of psychotropic drugs, a move which, in its broadest implications, has come to be known as the “medicalization of life”."* The tendency is toward a proliferation of named disorders which will require treatment, almost invariably by professionals. The signs that come to represent illness are multireferential; they ‘stand for’ a particular physiological or mental state, but at the same, time they indicate or point to a past event, some supposedly causative factor; they imply an etiology. Signs of illness, then, are appraisive or evaluative. The illness of a Mexican child may. for example, refer to his father’s sexual promiscuity. A young African woman's failure to recover from an illness may be diagnosed as resulting from her lover’s failure to complete marriage payments to her family. Since a diagnosis in many societies, inchiding our own, is often a moral statement, a judgment about past actions of the individual or those who surround him, the evaluative aspect of signs is of considerable sociological importance. The same sign, however, Points to the future. It implies certain expectations as to the future social status of the ‘victim’ as well as to his future state of health oF lack of it; this is prognosis, the code which governs the expected course of events or sequencing of signs. It generally indicates a therapy, or, in other words, is prescriptive; and as medical science ‘improves’, almost all illness states would seem to indicate therapies. Diagnosis is thus irrevocably linked to a prognosis and an etiology even though those links have been shown to vary considerably from generation to generation and from culture to culture. These links to the past and to the future are sometimes indexical (automatic, natural), sometimes arbitrary (symbolic), but since signs of illness118 KATHRYN VANCE STAIANO are polysemous, they may be both at the same time, making the ‘illness’ sign a potentially powerful and manipulatable tool, leading to therapies which conform the patient to certain biomedical and social standards, or to actions in which the patient attempts to conform the environment to his perceived needs and wishes NOTES + The term is still ‘semeiology’ in medical texts when it appears and is defined as ‘symptomatology’; both terms are further equated with the terms ‘pathognomic’ and ‘pathognomy’. Pathognomy, in turn, is defined as the “science of signs and symptoms of disease” and pathognomonic as a sign or symptom on which a diagnosis may be made; the two terms are of Greek origin (as is semiotic, semeiotikos); gnomonikos — fit to give judgment, and gndmz — 2 means of knowing (see Dorland’s Mlustrated Medical Dictionary, 25th ed., p. 1148), ? “Semiotics”, according to Sebeok, “is an ancient discipline, stemming from @ pre-Socratic clinical tradition, which then led to the development of three fundamental sémiotic traditions — the medical, the philosophical, and the linguistic — that have thoroughly intermingled at various periods in Western intellectual history, although there have been times when they strove for autonomy” (Sebeok 1978:viii), The medical model of illness conceives of diseases as natural entities reducible to physiological terms. This is the paradigm which dominates all of medical education * As noted by Crookshank several decades ago: “Teachers of Medicine ... seem to share the implied belief that all known, or knowable, clinical phenomena are resumable, and to be resumed, under a certain number of categories or general references, as so many ‘diseases’: the true number of these categories, references, or ‘diseases’ being predetermined by the constitution of the universe at any given. moment. ... In this way, the diseases supposed to be extant at any one moment are capable — so it is thought — of such categorical exhaustion as are the indigenous fauna of the British Isles and the population of London. That our grouping of like cases as cases of the same disease is purely a matter of justification and convenience, liable at any moment to supersession or adjust- ment, is nowhere admitted; and the hope is held out that one day we shall know all the diseases that there ‘are’, and all about them there is to be known.” (1923:342). In this paper I have maintained. the distinction frequently found in the medical literature between the ‘sign’ (‘physical’, ‘diagnostic’, ‘intersubjective’, ‘clinical’, ‘direct’, etc.) and the ‘symptom’. Within this literature, the term ‘sign’ refers to the objective denotatum of an illness state (evidence perceptible to the diagnostician, either directly or through utilization of special tech- nologies), the term ‘symptom’ to subjective evidence (that perceived and describable by the patient), Bar (1975:173) suggests the terms be replaced by “introspective” sign (symptom) and “intersubjective” sign (sign), but would not collapse the two terms into one as is common in much of the literature‘A SEMIOTIC DEFINITION OF ILLNESS 119 and lay language. I shall follow Bar's usage of “intersubjective” to refer to the so-called objective signs; when the term ‘sign’ appears by itself it will generally refer to both intersubjective signs and symptoms, since, in fact, both are species of signs as the term ‘sign’ is used in the semiotic literature. The term ‘symptom? will be replaced by Sntrospective’ only when there is 2 chance for confusion, as, for example, there may be when certain authors use the term ‘symptom’ to refer to both intersubjective and introspective signs. The distinction between terms is retained here, despite @ frequent and obvious blurring of boundaries, because it is at least occasionally useful. There is considerable confusion, however, on the ‘meaning’ to be attached to ‘sign’ and ‘symptom’, or whether, in fact, there is a meaningful distinction bet. ween the two. See, for example, a discussion of the nature and meaning of the fymptom’ and the distinction between symptom and other species of signs in the following: Bar (1975:173), Barthes (1972:39), Bateson (in Ruesch and Bateson 1968), Eco (1976:16-17), Deeley (1976, on Eco’s use of the concept, 184), Freud (1926 and others), Janzen (1973MS), Kahn (1978), Lacan (1968, and Bar's discussion of Lacan, 1975:37, 62), Sebeok (1976:117-42, esp. 124), « Shands and Meltzer (1977), Watziawick et al. (1967:43-45), JA Point perhaps best made in the writings of Eisenberg (1977), Fabrega G272, 1974), Foucault (1965, 1973), Iich (1976), Kleinman’ (1973), Kleinman, Eisenberg and Good (in press), Sedgwick (1973), Sontag (1978), Szasz (1970, 1973, 1974, 1976). This point of view is implicit, if not always explicit, within the work of the vast majority of medical anthropologists and medical sociologists. 1 | This unification is explicit in the works of the following authors. Bar (1975, 19762, 1976b), Barthes (1972), Kahn (1978), Ostwald (1964, 1968), Ruesch (1957, 1975), Sebeok (1976), Shands (1970, 1971, 1977), Shands and Melteer (1973, 1975, 1977). Crookshank (1923) wrote ‘an inttiguing essay on ihe language of ‘symptomatology’ and the influence of preexisting labeled Sttezories of disease on diagnosis, but never utilized the term “semiotic” Syndeham (1848: 13). J follow here the distinction made by Cassell (1976), Eisenberg (1977), Kleinman (1973), Kleinman, Eisenberg and Good (in press). The physician generally believes that he ‘cures’ disease, which is a biologics) event, while he who ‘heals’ treats illness, which is defined as the social and personal experience Gf bodily or emotional disfunction. Iliness, in this model, may be a response to disease or it may occur without the presence of disease. '© For example, see the early work of Kasanin et al. (1944), as well as the more UEgeMs Work of Bandler and Grindler (1975), Lacan (1968, 1972), Irigaray (1973), Piro (1971), Ruesch (1961, 1972, 1975), Ruesch and Bateson (1968; Shands (1970, 1971, 1977), Shands and Meltzer (1973, 1975, 1977), Veron and Sluzki (1970), Watzlawick ef al. (1967). B There are some exceptions, Shands (1966) brilliantly examined, in semiotic terms, the effect of terminal cancet on self-concept of individuals who had knowledge of their state. Bahnson (personal communication) compares, without making the usual mind/body distinctions, the reactions of individuals fo external and internal (disease) threats. Kahn (1978) is principally concerned with the ways in which signs and symptoms are produced and become cate- Borized, regardless of the type of ‘disease’ process they would seem to represent,120 KATHRYN VANCE STAIANO Her approach is explicitly semiotic and recognizes the effects of cuilture on the production of a shared “*bio-socio-technological code for the expression of illness and health”. Barthes (1972) deals with the process of translating ‘symptoms’ ito ‘signs’ (the terms differ from their use in this paper), and his discussion applies to all disorders. However, for Barthes the disease process is only recognized or accepted as such with. the intervention of the diagnostician and the verbal transaction between patient and physician. While not explicitly forcing him into the ‘medical model’ it implies that what Kleinman, Cassell ef al. refer to as ‘illness’ (see note 7) cannot be treated as a semiotic phenomenon, Crookshank’s early (1923) essay on ‘signs’ and language in medicine made clear the problems of categorization of disease entities and the historical and social factors affecting such labeling processes, but he does not speak specifically to the issue of the distinction (or non-distinction) between diseases of the mind and those of the body XB In fact, there is a tendency within Western therapies to refer signs ‘outward’, especially within psychiatric practice where many of the signs which lead to diagnosis can only be obtained by examining the total social field of the patient. The work of Harley Shands and James Meltzer seems most useful in ‘claborating this point, though they acknowledge their debt to G.H. Mead. “... to be human is to speak in symbolic formulation. But as soon as we accept this notion, we find an immediate implication that there can then be no such thing as an ‘individual’ human being; to speak in symbols requires that one ‘address oneself to a similarly trained respondent, and this means that the human unit is a dual unit.” (Shands 1970:356-7). “What is perhaps most startling as we begin to understand self-function is the realization that the self, that ‘innermost Part" of the human condition, is in fact a social institution.” (Shands and Meltzer 1977). “... within this cultural setting, the self becomes an object only by becoming susceptible to description in a series of human relationships in which seif-description is the recognized goal. The eventual form of the self is that of @ comprehensive symbol of the universe, reciprocally related to the universe ... . The self appears as the master symbol reflecting and representing the complexity of the universe ... . (Shands 1970:250). If one accepts this view, any emotional disturbances must be influenced by or occur during the process of the development of the self, or, more explicitly, the development of the ‘I’. While the symptom must, therefore, be arbitrary in nature, Shands and Meltzer (and others) seem to hold that there are a limited number of forms of expression, i.e., ways in which sign and object are linked. It is not clear in much of the literature concerned with ‘mental dis-orders™ whether these links are to be regarded as ‘conventionalized’, that is, culturally constrained, or are the result of some ‘deep structure’ which prescribes the Ygriety of links or modes of expression, See, for example, the works of Zola (1966) and Zborowski (1952) on American ethnic groups and variations in presentations of complaints, as well as numerous authors on what have variously been labeled “folk illnesses? (Rubel 1964), ‘ethnic psychoses’, and (Yap 1977). See also Veith (1965) ani influences on presentation of complaints. ** To give but one example, the disorder usualy labeled ‘paranoia’ is, in certain of its stages, said to be characterized by intense fear or suspicion of others, Such ‘eulture-bound reactive syndromes’ 1d others on historical and socialA SEMIOTIC DEFINITION OF ILLNESS. 121 Zeactions' are generally supposed to be based on inaccurate evaluation of ine coming information. It would seem that this notion of ‘miscoding’ underlies all of those models of mental disturbances referring to ‘disturbed communication’, Uist is, that one is unable to send socially appropriate signs and/or to interpret signs received appropriately X6 The work of Fernandez is of some importance in understanding this point, Actording to Fernandez (1974:122): “In the growth of human identity, the inchoate pronouns of social life ~ the ‘I’, ‘you', *he’, “it” gain identity by predicating some sign-image, some metaphor upon then. These pronouns uct im Meads (1934) terms, become objects to themselves, by taking the point of ‘Yiew of ‘the other’, before they can become subjects to themselves” 1 This is a major focus within the literature of medical anthropology, but has svorecah ently become a concern of ‘politicized’ observers of the American medical scene '® ‘See, for example, tllich (1976). Illich expresses concern with the loss of autonomy of the individual over his own body as life becomes increasingly Gmcdicalized’’. He divides iatrogenic diseases or disorders into thee bead Gieedees (Only the first is usually recognized by physicians): clinical iatrogenic disorders which are defined as “all clinical conditions for which remedies, physicians, or hospitals are the pathogens or ‘sickening agente’ ™ (27); such disorders result from the replacement of the “organic, coping capacity” by “heteronomous management” (127); social iatrogenic disorders, his second auger, are “produced by a sociopolitical mode of transmission” ond Vall impairments to health that are due precisely to those sou. include by the inna ormations which have been made attractive, possible, or necessary by the institutional shape health care has taken” (40); the third category, cul- tural iatrogenic dis-orders, occur because “professionally organized medicine 2as come to function as.a domineering moral enterprise that advertises indie ¢RPansion as a war against all suffering” (127). ¥ See, for example, Illich (1976), Szasz (1970, 1973, 1974, 1976, and others), jad Sedgwick (1973). 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