¿Qué es la semiótica médica?

What is medical semiotics?

Recibido: mayo 11 de 2016 | Revisado: julio 15 de 2016 |

Aceptado: agosto 18 de 2016

John Tredinnick-Rowe1

1 Plymouth University, Inglaterra

Correo: john.tredinnick-rowe@plymouth.ac.uk

DOI: http://dx.doi.org/10.24039/cv20164268

Ab s t r ac t

This paper attempts to provide insight into a basic

question, what is Medical Semiotics? Semiotics as

a subject has been applied to many areas of work

ranging from Art, Biology, Education, Music, and

Zoology to name just a few. However the medical

side of semiotics, despite having an intricate con-

nection to the origins of semiotics itself has not

drawn as much attention as other disciplines wi-

thin the science of signs. This paper starts by gi-

ving an overview of the historical foundations of

Medical Semiotics, its use in 18th and 19th cen-

tury European Pathology, Diagnostics and Noso-

logy, which is followed by examples of contempo-

rary literature on the subject, and concludes with

hypotheses on where the discipline may yet go. It

is the author’s assertion that Medical Semiotics has

a long and important history, which is often over

looked both in medicine and also in semiotics. And

if the discipline is going to continue to exist it will

have to incorporate both theory and practice into its

descriptions of pathology and diagnosis.

Key words: Medical semiotics, semiotics,

hos-pital semiotics, history of diagnosis

Re su m e n

Este documento intenta proporcionar una mirada

hacia una pregunta básica, ¿qué es semiótica mé-

dica? Semiótica como una materia se ha aplicado a

muchas áreas de trabajo que van desde arte, bio-

logía, educación, música y zoología para nombrar

solo algunas. Sin embargo el lado médico de la se-

miótica, a pesar de tener una conexión intrincada a

los orígenes de la semiótica en sí misma no ha

atraído tanta atención como otras disciplinas den-

tro de la ciencia de los signos. Este artículo co-

mienza dando una descripción de las fundaciones

históricas de la semiótica médica, de su uso en los

siglos dieciocho y diecinueve en patología euro-

pea, del diagnóstico y de Nosología, que es segui-

do por ejemplos de la literatura contemporánea en

el tema, y concluye con las hipótesis en donde la

disciplina puede todavía ir. Es la afirmación del

au-tor que la semiótica médica tiene una larga e

im-portante historia, que es a menudo pasada por

alto en la medicina como también en semiótica. Y

si la disciplina va a continuar existiendo, tendrá

que incorporar la teoría y la práctica en sus

descripcio-nes de la patología y el diagnóstico.

Palabras clave: semiótica médica, semiótica,

hospital semiótico, historia de diagnóstico

| Cátedra Villarreal | Lima, perú | V. 4 | N. 2 | 135-148 | julio-diciembre | 2016 | issn 2310-4767 135

John Tredinnick-Rowe

Introduction

This paper attempts to provide insight into

a basic question, what is Medical Semiotics?

Semiotic as subject has been applied to many

areas of work ranging from Biology (Biosemi-

otcs), Zoology (Zoösemiotics), Ethics (Semio-

ethics), Education (Edusemiotics) and many

other subdisciplines such as Mycosemiosis

(Kræpelin, 2003) – the semiotic processes in

fungi, or its Biosemiotic correlate Phytosemi-

osis (Krampen, 2003).

Just as others have tried to address exact-ly

what semiotics is in a more general context

(Deely, 1976, 2011; Eco, 1976; Laferrière, 1977;

Rattasepp & Kull, 2015; Sebeok, 1986; Sless,

1986). The author is not the first to attempt to

define their particular area of interest in se-

miotics, take for example the works that have

supposed the question, what is Biosemiotics?

Such as (Barbieri, 2008a, 2008b, 2009a, 2009b;

Martinelli & Bankov, 2008). This paper will at-

tempt to replicate some of the processes found in

these works, namely what literature exists on the

Medical Semiotics? How has it evolved and

changed? And what does the future hold for the

subject area? If one were to look for a textual

definition of Medical Semiotics, the Routledge

Companion to Semiotics provides and an excel-

lent overview of the subject from Greek antiq-

uity to modern praxis, explaining it as:

Semiotic comes to us exclusively out

of ancient Greek medical practice

where semiotike stood for the process

that professional physicians followed

in evaluating signs of body disorder

understanding their cause, offering

therapy where beneficial, and prog-

nosticating the patient’s future. Thus

semiotics as developed by Peirce and

others, medical semiotics as a subdis-

cipline of today’s semiotics, and diag-

nostic practice in Western medical

practice (sometimes referred to as

semeiology) trace their origins to the

same era... As indices, the signs pro-

duced by the body are typically con-

sidered to be semiotic phenomena, but

have been of lesser interest to most

semioticians because they are not

thought to be culturally constructed and

symbolic. Peirce spent little time

dealing with the sign or symptom of

bodily disorder (Cobley, 2009, p. 264).

The text goes on to list seven key

features of Medical Semiotics, an

abridged version of which is given below:

1. Every sign expressed on or within the

body is a form of communication.

2. Medical semiotics investigates

how healers know what they know

and to what extent this knowledge

is affected by events and beliefs

beyond the biol-ogy of the body.

3. Limitations are imposed by

technol-ogy, economics, politics,

and belief systems upon the

healer’s and the pa-tient’s ability

to generate and incorpo-rate signs.

4. Patients are often assigned to specific

categories of disease, deformity and

defect in order to create for them a

separate and undervalued identity.

5. The sign or symptom is always

polyse-mous.

6. A patient’s sign (objectively produced

clinical indications) and symptoms

(subjectively produced by the patient)

may bear little relationship to any in-

ternal event but are culturally/socially

constructed narratives.

7. Patients construct for themselves

stories of illness separate from

those narratives generated by the

physician (ibid., p. 265).

The definition given here by Cobley (2009)

encompasses the entire gamut of Medical Se-

136 | Cátedra Villarreal | V. 4 | No. 2 | julio-diciembre | 2016 |

¿Qué es la semiótica médica?

miotics, from its use in the old world up to the

present day. Whereas what the term consti-tutes

has altered through history, for example in the

18th century Hess (1998) suggests that Medical

Semiotics was an empirically driven and

theoretically informed precursor to the modern

science of diagnosis. And this last-ed up until

perhaps the last publication on semiotics in

medicine as a distinct topic was released-

Lehrbuch der Semiotik für Vorlesun-gen written

by Albers (1834). After which the subject was

subsumed into Diagnostics and Pathology

(Polianski, 2015). However, the Hellenic and

Mesopotamian approach (Ma-netti, 1993, 2010),

will differ from the empiri-cally driven pre-

Saussurean, Pre-Peircian 18th and 19th century

applications in Europe, just as other approaches

will have altered in relation to the current

practices of clinical reasoning.

That is not in any way to state that the clas-

sical application of Medical Semiotics is deval-

ued, as Cobley (2009, p. 264) stated “semiotic

comes to us exclusively out of ancient Greek

medical practice”. And so in many ways there is

any unavoidable invocation of Hippocrates and

the Greek tradition when talking of Medical Se-

miotics. Given that Semiotics and Medicine in

the Western tradition share a common founda-

tion, in that they both have a father in the works

of Hippocrates (Kleinpaul, 1893). That is to say

semiotics and medicine are both the progeny of

Hippocratic traditions, and hence there is a

tendency towards Western medical practice. But

as Manetti (2010) has shown, in realty Medical

Semiotic practices pre-date Greece, and so the

praxis of the Aymaras, Quechuas or Shipibo-

Conibo or other indigenous cultures is just as

important. From an anthropological per-spective

theses cultures are perhaps more valid because

their practices can still be observed, an-cient

Greece although fascinating is long dead.

Content

18th and 19th Century Literature

During the 18th century in Europe one

could still find German and Russian doctors

writing about Medical Semiotics, such as Fe-

odorovich and Hippius (1892)’s work Semiot-ics

and Diagnosis of Childhood Diseases (Semi-otik

und Diagnostik der Kinderkrankheiten). Or

Hufeland (1823) in the Journal of Obstetric

Practice who wrote On the value and impor-

tance of semiotics (Ueber den Werth und die

Bedeutung der Semiotik), similarly Becker

(1832) addressed the role of semiotics in rela-

tion to cardiology in his On the physiology and

semiotics of cardiac activity (Zur Physiologie

und Semiotik der Herzthätigkeit). Interesting-ly,

the first volume of Sundelin, Berends & Al-

bers’s (1830) publication Handbuch der prak-

tischen Arzneiwissenschaft oder der speziellen

Pathologie und Therapie is titled Handbuch der

Semiotik. Not to be confused with the lat-er

namesake by Nöth (2000). Other German and

Dutch Medical Semiotics works from this period

include (Boerhaave, 1751; Gaub, 1797; Nicolai,

1756). The legacy of the 18th and 19th century

German Medical Semiotics was per-haps an

influence on the works of Thure von Uexküll, as

one of the originators of a mod-ern movement in

Medical Semiotics and psy-chosomatic

medicine, see Von Uexküll (1979, 1982, and

1986).

Whilst there is ample literature on Medi-cal

Semiotics, the 18-19th century period rep-resents

an epoch of particular significance. It represents

the transition from Medical Semi-otics being a

discipline within medicine, to one that has come

into the purview of the Se-miotician Ordinaire

(Levy, 1999). For example, with the exception

of the psychiatric semiotic literature and the

works of Giorgio Prodi (Pro-di, 1981; Giorgio

Prodi, 1988; Giorgio Prodi, 1988) or Burnum

(1993) most of the authors in the literature cited

in following sections of this paper are

semioticians with an interest in medical topics,

rather than clinicians with an interest in

semiotics.

In this period, Hess (1998, p. 205) drawing

on Hufeland (1826) argued that when “semi-

otics was at once the grammar of nature’s lan-

guage and the linguistics of the physician’s art,

medical semiotics was to be entitled to partic-

| Cátedra Villarreal | V. 4 | No. 2 | julio-diciembre | 2016 | 137

John Tredinnick-Rowe

ipate in the theoretical basis of the sciences”.

Perhaps with the exception of the addition of

biosemiotics to contemporary discourses on

theoretical biology, Hufland’s depiction on se-

miotics no longer applies. This gives testimony

to the fact that Medical Semiotics is no longer on

the curriculum of medical schools, but has

passed into the remit of semioticians proper.

20th century Literature

In probably the only 20th century mono-graph

on Medical Semiotics Bær (1988, p. 1) states

that the “art of healing, in Greek antiqui-ty, was

called techne semeiotike, a craft of hav-ing to do

with signs”. This term he describes as meaning a

semiotic craft or “the skill to interpret semeia,

signs” (ibid., p.41). Although with the use of

technê he is clearly invoking Heidegger (1953,

1954), Bær progresses to Sebeok (1978, p. 181)

to give an effective definition of Medical

Semiotics as a tripod of medicine, linguistics and

philosophy. Baer went to suggest that the val-ue

of applying semiotics to medicine was that it can

provide medicine with: “A grammar of signs,

refining the syntax of symptoms, disclos-ing

their pluridimensional semantic richness, and

proposing a dialogistic pragmatics of how to

interact with the patient” (Bær, 1988, p. 2).

This grammar of signs could be related through

Peirce’s triadic system (Peirce, 1998) as Ladino

(2014) has done, or through Saussure (1916) or

another framework such as the ones given

previously that relate more to the Latin pe-riod.

Whichever paradigm one wishes to situtate a

system of medical signs in, the issues still re-mains

that “in medicine the many ways in which we talk

about symptoms constitutes our experi-ences of

them” (Bær, 1988, p. 5). Hence in the 20th century

we have come to view Medical Semiot-ics just as

Sebeok (1978, p. 181) defined it, as a mixture of

medicine, linguistics and philosophy.

Contemporary (late 20th and 21st century)

Medical Semiotic Works

In the Anglophone world Medical Semiot-

ics has not propagated a large body of litera-

ture in comparison to other semiotic disci-plines

of a more literary or typically biological nature.

Medical semiotic literature covers texts that are

concerned with general issues in the topic such

as (Bær, 1988; Brands, Franck,

& Van Leeuwen, 2000; Crookshank, 1923;

Hess, 1998; Kahn, 1981; Nessa, 1996; Rogers

& Swadener, 2001; Sebeok, 1985, 2001; Sko-

pek, 1979; Staiano-Ross, 2011; Staiano, 1979;

Van Den Broek, 1987; Von Uexküll, 1982,

1986), others focus on the semiotics of specif-ic

medical conditions and treatments such as

general issues in Neuro-linguistics (Andrews,

2011; Chernigovskaya, 1999; Laughlin, Mc-

Manus, & Stephens, 1981; Lavorel, 1984), or

specific conditions in neuro-linguistics such as

aphasia (Landzelius, 2009; Novaes, 2013; Price-

Williams & Sabsay, 1979; Volpe, 1991),

Dementia (Fleche, 2009), Alzheimer’s (Don-

nelly & Lilly, 1998; Gubrium, 1988). Similar-ly

Neuro-semiotics is covered by (Favareau, 2002;

Roepstorff, 2001), Psychiatry/Psycho-therapy

by (Ablamowicz, 1994; Aragno, 2011; Craig,

1997; Davtian & Chernigovskaya, 2003;

Donnelly, 1984; du Plessis, 2012; Keinänen,

2003; Kuperman & Zislin, 2005; Lee & Beat-

tie, 2000; Mildenberger, 2004; Peyrot, 1987;

Rausch, 1995; Shands, 1970a, 1970b; Stampfl,

2013). Other conditions addressed in the liter-

ate include:

• Suicide (Utriainen & Honkasalo, 1996)

• Diagnostics (Burnum, 1993; Kahn, 1978)

• Clinical Medicine (Chinen, 1988)

• Gerontology (Stafford, 1988)

• Psychosomatic medicine (Langewitz,

2009)

• Homeopathy (Schemm, Konitzer, Freu-

denberg, & Fischer, 2002; Walach,

1991), Menstruation (Mazaj, 1995)

• Anti-depressants/ Depression (Catt,

2012; Donnelly & Irvin, 1990)

• HIV (Ferguson, 2013; Namaste, 1993;

Rose, 1993; Scalvini, 2010; Tulloch, 1992)

138 | Cátedra Villarreal | V. 4 | No. 2 | julio-diciembre | 2016 |

¿Qué es la semiótica médica?

• Therapy (Kozin, 2003)

• Drug Therapy (Schonauer, 1993)

• Anorexia (Prewitt, 1992)

• Obesity (Anderson, 1993; Herndon, 2005;

Jutel, 2005; Murray, 2007), Schizophrenia

(Frow, 2001; Osatuke et al., 2010)

• Prescription of medicine (Nuessel, 2002)

• eHealth (Caiata & Schulz, 2010; Cameri-

ni, Diviani, & Tardini, 2010; Green, 2010;

Neuhauser & Kreps, 2010; Orizio & Ge-

latti, 2010; Schulz & Rubinelli, 2010)

• Autism (Oakley & Vidanović, 2014;

Smith & Bell, 2001)

• Osteopathy (Gaines & Chila, 1998)

• Nursing (Donnelly, 1987)

• The use of medical tools (McRoberts

& Sears, 1998)

• Health promotion (Brookes &

Harvey, 2014)

• Chronic disabilities (Connolly & Craig,

1996; Stockall & Stickels, 2000),

• William’s Syndrome (James, 2009)

• Sign theory in Greek Medicine

(Manetti, 1993)

• Fibromyalgia (Quintner, Buchanan,

Co-hen, & Taylor, 2003)

• Immunology (Sercarz & Celada, 1988)

• Chronic pain (Honkasalo, 2000, 2001;

Priel, Rabinowitz, & Pels, 1991)

• And Symptomology (Bær, 1982; Dom-

inick, 1980; Donnelly & Langley,

1987; MacBryde & Blacklow, 1971;

Sebeok, 1986; Staiano-Ross, 2012)

The literary semiotics of medical dis-

course is addressed by (Genosko, 1989;

Schmid-Bortenschlager, 2000), analysis of

medical texts by Kahn (1980) and semiotic

depictions of medical issues through other

media such as cinema (Hirschman , 1995),

and photography (Johnson,1994). There are of

course German texts on the subject from this

period primarily by the hand of Thure Von

Uexküll concerning psychosomatic medicine,

most prominently his Lehrbuch der psychoso-

matischen Medizin (Von Uexküll, 1979) and

Grundfragen der psychosomatischen Medizin

(Von Uexküll, 1985). A comprehensive list

Thure’s work, including many medical texts

can be found in Kull and Hoffmeyer (2005)

and Köhle (2003). More generally one could

point to Freud (1936) and other Germanic

psychoanalytic works. In addition one should

not neglect the contributions in Italian of the

oncologist Giorgio Prodi (Prodi, 1981; Gior-

gio. Prodi, 1988; Giorgio Prodi, 1988). There

are also Francophone contributions on the

topic such as Barthes (1972) Sémiologie et

médecine, or Foucault (1963) Naissance de la

Clinique. Again if one approached the

Spanish literature one can find papers in such

places as Signa. Revista de la Asociación

Española de Semiótica, such as Pensado

(2014) who an-alysed the diffusion of early

medical texts or Soláns (2014) who explained

the role of Alz-heimer’s in the novels of Iris

Murdoch. These publications are of course, of

a more gener-alised nature.

Some medical conditions have been covered in

more detail that others in the Medical Semi-otics

literature, such as breast cancer. For exam-ple

Wagner (2005) discusses the semiotic role of

breast cancer ribbons and their commercialisa-tion.

Breast cancer and identity as a literary-se-miotic

construct is addressed by Henriksen and Hansen

(2009), and as an auto-ethnographic experience in

Sontag (1977). Similarly De-Shazer (2012) covers

the semiotics of breast cancer from a photographic

narrative. More photographic data on the topic was

utilised by Jay (2012) in the SCAR project, and the

semiot-ic issues around mastectomy are addressed

by Cobb and Starr (2012). Authors such as Gry-

der, Nelson, and Shepard (2013) have worked on a

Biosemiotic explanation of cancer from a

| Cátedra Villarreal | V. 4 | No. 2 | julio-diciembre | 2016 | 139

John Tredinnick-Rowe

genomic perspective, with reference to breast

cancer. Crompvoets (2012) addressed the dis-

connect between the marketing literature of

breast prosthesis (as a result of mastectomy) and

the direct experiences of the patient. Elea-nor.

Donnelly and Klonowski (1994)’s paper in-

vestigated the intersection of breast cancer and

semiotics through a data driven, anthropolog-

ical approach. Other papers connecting breast

cancer and semiotics come from the 2012 So-

cial Semiotics Journal special issue on breast

cancer: (Ehlers, 2012; Ehlers & Krupar, 2012;

Krupar, 2012; Roskelly, 2012).

There are many related Biosemiotic, social

medicine and Medical Humanities texts that

could be cited in relation to Medical Semiotics.

Without doubt there are more publications in the

Medical Semiotic arena that the author has

omitted especially when one has to draw a line

between where disciplines such as psychiatry

and medicine become independent subjects.

Similar arguments can be made between the

boarders of Biology and Medicine in Biosemi-

otics, such as the work by Hoffmeyer (2008) on

the semiotics of the body, which could be the

body of any mammal, human or animal. Or the

work by Anna Aragno (2012) on the marriage of

Psychoanalysis and Biosemiotics. There will be

many topics in other languages that the author

does not have the skill to ac-cess, such as the

Russian language works of Веснин and

Терещенко (1990) on the se-miotics of breast

cancer. This short inchoate inventory does

highlight some of the subject areas covered in

Medical Semiotics and the dominance of

literature on psychiatry or psy-chotherapy

related topics.

Discussion - the Future of Medical Semiotics

As has been shown, the historical and cur-

rent application of Medical Semiotics has more

depth and breadth than one might initially think.

The future of the subject however is far from

certain. It may be possible that the Hu-manising

Turn in medicine that is occurring in North

America and Europe (Downie, Hendry,

Macnaughton, & Smith, 1997; Kimball, 1973)

could provide scope for Medical Semiotics to

play a greater role in the education and prac-tice

of medicine. Looking to the future, one way of

integrating Medical Semiotics into medical

practice could be to develop the work of Kahn

(1981) and her concept of Hospital Semiotics

which links Medical Semiotics with medi-cal

services and institutional research, creat-ing a

blend of praxis and theory; just as Bur-num

(1993) advocated that Medical Semiotics should

be applied. It is also this blend of theory and

science that Medical Semioticians in 18th

century such as Hufeland (1826) found so ef-

fective, and which would seem to be the correct

direction for the discipline to progress in.

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