Anthropology and the Theory Of

8/8/2019 Anthropology and the Theory Of

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A N T H R O P O L O G Y A N D T H E T H E O R Y O F M E D I C I N E

T H U R E V O N U E X K O L LUniversity of Ulm,Germany

AB STR AC T. Instead o f presupposing real i ty as the "real ists" do, a geneti~c theory o f knowl-edge at tempts to understand scient i f ic knowledge through the psych ological origins of boththe concepts, and the operat ions on which these concepts are based. Adop t ing the viewpointof genet ic epistemology, the envisage d theory o f medicine w i l l have to perform a threefoldtask: (1) A revision and reformulat ion of the psyc ho-p hysic al problem and the developm entof a model for the l i v ing body; (2) A rev i s ion of our v i ews concern ing the re l a t ionshipbetween humans and the inanimate and animate environment ; and (3) The development ofa concept for the const ruct ion of individual real i ty and i t s consequences for the pat ient -physi -cian relationship.Key words: genet ic theory of knowledge, l iving body, pat ient -physician relat ionship, rela-t ionship humans and ( in)an imate envi ronment , t he psycho-phys ica l p roblem, theory ofmedicine

I would say the fol lowing about a scientist: i f he com es across a gap in our kno wledge hewil l not f lee into the supernatural . T hat would in fact mean panic, fear of the unknown, whichwe do not recognize as scient i f ic]

1. T H E Q U E S T I O N O F T H E S T A R T I N G P O I N T

The ques t ion whe the r the sc i ences have b rought us c lose r to a so lu t ion o fthe g rea t m ys te r i e s o f l if e and hum an ex i s t ence canno t be answered unam -biguous ly . On the one hand , t he sc i ences have g iven us ins igh t s which wereh idden f rom m ankind in ea r l i e r t im es . On the o the r hand , t he ques t ion o fm a n ' s na tu r e and the m eanin g o f l if e s ti ll pose m ore p rob lem s now thanwhen r e l ig ion p rov ided answer s tha t sa t i s f i ed m ankind .

The un ce r t a in ty abou t our se lves , i n tu rn , a f f ec t s t he va lue o f our sc i en-t i fi c knowledg e , f o r it i s we w ho in ven te d sc i ence and i t i s we w ho pu r suei t. I n o rde r to answer the ques t ion c once rn ing the va l id i ty o f our sc i en t if i cknow ledge w e m u s t f i rs t answer the ques t ion a s to the va l id i ty o f the f r am e-work in which sc i ence was c r ea t ed .

The o r ig ins o f sc i ence p rom ise an answ er to th i s ques t ion , f o r t he beg in-n i n g , a s W i n n i c o t p u t s it , i s o u r h o m e . S i n c e t h e b e g i n n i n g s o f h u m a nhi s to ry a r e known to us on ly in f r agm ent s , we m us t l ook to and ques t ionthe ea r ly s t ages o f ch i ldhood in o rde r to ga in knowledge about t i l e deve l -

Theoretical Medicine 16:93-114, 1995. 1995 Kluwer Academic Publishers. Printed in the Netherlands.


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94 T H U R E V O N U E X KI ~I LLopment of our questions and the methods we use to provide those answers.Only then can we avoid that we leap into the supernatural used to cir-cumvent our fear of the unknown.

A "genetic theory of knowledge" attempts to understand scientificknowledge through its history, and more notably through the psycho-logical origins of both the concepts, and the operations on which theseconcepts are based. 2 Instead o f presupposing reality as the "realists" do, agenetic theory of knowledge begins with the question: How do we arriveat what we call reality?

2 . F R E U D ' S G E N E T I C A N S W E R 3

An answer to the question above is given in Freud's Formulations on theTwo Principles o f Mental Funct ioning, published in 1911. He writes:W e a r e n o w co n f r o n t ed w i t h t h e t as k o f ex am i n i n g t h e d ev e l o p m en t o f t h e r e l a t io n s h i pbe tween the neuro t i c and the human be ing in genera l , wi th tha t o f the r ea l ou ter wor ld , andthus in tegra te the psycholog ica l mean ing of the r ea l ou ter wor ld in to the f r amewo rk of ourtheory . In a psychology which i s based on psychoanalys i s we have become accus tomed toaccep t ing unconsc ious menta l ac t iv i t i es as the st a r t ing po in t . . . The h ighes t t endency towhich these p r imary proces ses obey i s easy to r ecognize ; i t is ca l l ed the p lea sure-pa in p r in -ciple (or for shor t , the pleasure pr inciple) . These processe s s t r ive to acquire pleasure; m entalac t iv i ty avo ids ac t ions w hich may cause pa in . 4

Freud then expands his theory. In the early stages of humankind, bothrational thinking and the idea of "reality" emerged from this primarypsychic state:I m a i n t a i n t h a t t h e st a t e o f p s y ch i c p eace was o r i g i n a l l y d i st u r b ed b y t h e co m m an d i n gdemands , o f inner needs. In th i s case , what w as ima gined (des i r ed) was s imply prono uncedhal luc ina tory , as i t s t i l l happens every n igh t in our d ream thoughts . However , s ince theexpec ted gra t i f i ca t ion f a i ls to appear , the 'psyc h ic ap para tus ' h ad to dec ide to imagine therea l s t a te o f the ex terna l wor ld and to s t rive fo r r ea l change . Thus a new pr inc ip le o f menta lact ivi ty w as introduced. 5

In 1911, at the height of an age dominated by belief in human progressthrough science and technology, the deeper meaning of these words was -even for Freud - simply "unthinkable:" it was suppressed by the unrelentingcensorship of "a socially produced unconscious. ~ After the discovery ofquantum mechanics and the insight that we cannot make statements aboutobjects and processes that are unobservable, 7 our naive trust in scienceunderwent a sober awakening. It was only after this awakening that the far-reaching implications of these words could be understood. They are asfollows.


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A N T H R O P O L O G Y A N D T H E T H E O R Y O F M E D I C I N E 9 5T h e r e i s n o r e a l it y . T h e r e a l s t a te o f th e o u t s i d e w o r l d m u s t b e c o n -

s t r u c t e d , u n d e r p r e s s u r e f r o m t h e p l e a s u r e p r i n c i p l e , b y o u r i m a g i n a t i o n ,w h i c h b o r r o w s i ts c r e a t iv i t y f r o m t h e d r e am . U n k n o w n i n t he r e s t o f n a t u re ,t h e p o w e r o f i m a g i n a t i o n a p p e a r s t o b e a s p e c if i c h u m a n a b il it y . P i a g e th a s s h o w n t h a t a c h i l d d o e s n o t , u n t i l s o m e t i m e b e t w e e n i t s s i x t e e n t h a n dt w e n t i e th m o n t h , l e a r n t o c o n s t r u e m e n t a l i m a g e s o f o b j e c ts a n d e v e n t s .I n t h e e a r l y li f e o f th e c h i l d t h i s a b i l i ty g i v e s r i s e t o s o m e t h i n g o f a C o p e r n i c a n r e v o l u t i o n : "One last essential consequence of the development of the imag ination is . . . tha t the childfinally and totally reverses its initial wo rld, its mo ving ima ges (till this point), being focusedaround its own un conscious (motor) activities, re-arranging them into a solid wo rld of coor-dinated objects which includes, as an element, its own body. This eoncludes the process ofconstructing objects in the sensory-motor field. Th e d evelopment of refleetion and abstractthinking w ill continue this elaboration on other, newer levels?

3 . T H E C O N S E Q U E N C E S F O R T H E T H E O R Y O F M E D I C IN ET h e s e i n si g h ts h a v e f a r - r e a c h i n g c o n s e q u e n c e s f o r t h e t h e o r y o f m e d i c in e .T h e y w i l l b e c o m e p r o g r e s s i v e l y c l e a r i n th e f o l l o w i n g d i s c u s si o n o n t h et h r e e p r i m a r y t a s k s t h a t a t h e o r y o f m e d i c i n e ( a s e n v i s a g e d b y u s ) w i l l h a v et o p e r f o r m :( 1 ) A r e v i s io n a n d r e f o r m u l a t i o n o f t h e p s y c h o - p h y s i c a l p r o b l e m a n d t h e

d e v e l o p m e n t o f a m o d e l f o r t h e l i v i n g b o d y .( 2) A r e v i s io n o f o u t v i e w s c o n c e r n i n g t h e re l a t io n s h i p b e t w e e n h u m a n s

a n d th e in a n i m a t e a n d a n i m a t e e n v i r o n m e n t ; a n d( 3 ) T h e d e v e l o p m e n t o f a c o n c e p t f o r t h e c o n s t r u c t io n o f i n d i v i d u a l r ea l it y

a n d i ts c o n s e q u e n c e s f o r th e p a t i e n t - p h y s i c i a n r e l at i o n sh i p .

3 .1 . A R e v i s i o n a n d R e f o r m u l a t io n o f t h e P s y c h o - P h y s i c a I P r o b l e m a n dt h e D e v e l o p m e n t o f a M o d e l f o r t h e L i v i n g B o d y

T h e b d y - m i n d p r o b l e m a s a c o r p s e - m i n d p r o b le m . I t is o u r b e l i e f th a t am e t a p h y s i c a l d u a l i s m w h i c h s e p a r a t e s t h e s p i r i t u a l f r o m t h e m a t e r i a l w o r l di s i n f a c t (a s a ll m e t a p h y s i c s ) a f li g h t f r o m t h e d i s t u r b i n g r e a l i t y o f o u ri g n o r a n c e - i t t r ie s to b r i d g e t h e g a p s i n o u r k n o w l e d g e b y l e a p i n g t o t h es u p e r n a t u ra l . O n t h is a s s u m p t i o n , i t b e c o m e s p o s s i b l e t o d i s c u s s t h eb o d y - m i n d p r o b l e m i n a m e a n i n g f u l m a n n e r . W e h a v e b e e n t a u g h t t h atD e s c a r t e s w a s r e s p o n s i b l e f o r th e d u a l i s t i c t h e o ry . H o w e v e r , i f w e l o o km o r e c l o s e l y a t t h e id e a s D e s c a r t e s h a d a b o u t h is o w n b o d y , w e f i n d t h a tw e w e r e o b v i o u s l y m i s i n f o r m e d . I n h i s M e d i t a t i o n s w e r e a d :


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96 TH U R E V O N U EX K LLI assume not without reason, that my body, which due to some special authority I callmy own, belongs closer to me than any other body. I could never separate from it like Icould separate from other bodies, all desires and emotion I felt within it, and for it, andfinally, I felt pain and the thrill of lust within its limbs, which I have not felt in other externalobjects.9

Another passage reads:Furthermore, Nature teaches m e . .. that not only am I present in my body like a sailorin his ship, but that I am closely connected with it, intermingled as it were, so that weconstitute a unit.

Weiner 1 believes that medical dualism - the dualism of corpse and mind- was fashioned by physicians (beginning with Galen, then Virchow, andincluding those of today) who developed their concept of the human bodyby dissecting corpses. This knowledge, carried to its proper conclusion,shows that the body-mind problem of dualistic medicine is in reality acorpse-mind problem. As physicians usually only consider the criteriawhich are relevant to filling out a death certificate, it was to be expectedthat they would turn a blind eye to the distinction between a corpse and aliving body.ll

A practical model for the living body is a prerequisite for both a prac-tical theory of medicine and a practical concept of humanity. Such a modelshould not adhere to a preconceived scheme that separates the physical andthe mental. Rather, it should help us to understand both concepts - "body"and "mind" - as concepts which derive their meaning from the whole, thatis, the integrating concept of which they are part.

By upholding such an integrating concept or model I do not mean tosuggest that we compile the contents of various disciplines, such as internalmedicine, psychiatry, and sociology, into a compendium of knowledge ofvarious fields required of physicians. Such compendiums undoubtedlyfulfill an important role for students, either in a curriculum or in furtheracademic courses. As a rule, however, they do not contain an integratingconcept in the sense I envisage.

True, within the somatic disciplines we find integrating concepts foranatomy and physiology. The contents of these disciplines are, so to speak,drawn together, summarized in an integrating picture - namely, that of anorganism which consists of spatially connected organs, the functions ofwhich are interconnected according to the principle of the division of labor.Thus a common framework is achieved. The effect of this framework istwofold: First, it determines the limits of responsibility in both researchand the care of patients; second, it provides a set of rules for cooperation.Which specialist should treat a patient, when his/her condition is primarilycardiac related, orthopedic, or neurological, poses no greater difficulties


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A N T H R O P O L O G Y A N D T H E T H E O R Y O F M E D I C I N E 9 7t h a n t h o s e t h a t a t e c h n i c a l c o m p a n y c o n f r o n t s w h e n d e c i d i n g w h e t h e r t h ep lum be r , e l e c t r i c i a n , o r p r e c i s ion e ng ine e r i s r e spons ib le f o r a ppr opr i a t er e pa ir s . I n bo th c a se s the r e e x i s t s a n in t e g r a ting c on c e p t io n o f the wh o le- m or e p r e c i se ly pu t - a p i c tu r e in w h ic h bo th the spa t i a l a nd func t iona lc ohe r e nc e o f the pa r ts i s c l e a r ly d i sp l ye d .

T h e w e a k s i d e o f s u c h q u a s i - i n t e g r a t i v e c o n c e p t i o n s , h o w e v e r , u s u a l l yb e c o m e s m a n i f e s t w h e n o n e i s c o n f r o n t e d w i t h q u e s t i o n s o f a n i n t e r d i s c i -p l ina r y na tu r e , t ha t i s , que s t ion s wh ic h p r e sup pos e a l e ve l o f c onc e p tua li n t e g r a t io n i n m e d i c a l t h o u g h t s u r p a s s i n g t h a t o f th e m o r e s u p e r f i c i a l,"p ic to r i a l, " qu a s i - in t e g r a t ion r e f e r r e d to a b ove . F o r e xa m ple : I s t he pa t ie n t ' sc o n d i t i o n p r i m a r i l y s o m a t i c , p s y c h o l o g i c a l , o r s o c i a l ; h o w a r e t h e s ep r o b l e m s r e l a t e d a n d h o w d o t h e y i n f l u e n c e e a c h o t h e r ? T h i s i s t h e s o r to f in t e g r a t io n t h a t c o n c e r n s u s . F o r s o m e t i m e n o w t h e n o t i o n o f a" b i o - p s y c h o - s o c i a l m o d e l " h a s b e e n u s e d in p s y c h o s o m a t i c l it er at ur e. A sl o n g a s t h i s m o d e l ' s a c h i e v e m e n t i s n o t h i n g m o r e t h a n a d m o n i s h i n g t h ep h y s i c i a n t o o b s e r v e , a p a r t f r o m t h e s o m a t i c , t h e p a t i e n t ' s p s y c h o l o g i c a la n d s o c i a l p r o b l e m s , i t d o e s n o t a n s w e r t h e q u e s t io n o f h o w t h e s eh e t e r o g e n o u s p r o b l e m s c a n b e m e a n i n g f u l l y r e l a t e d . I t i s w r o n g l y c a l l e da n " in te g r a t ing m ode l " - f o r i t o f f e r s no ba s i s f o r r e a l , t ha t i s , i n t e r d i sc i -p l i n a r y , c o n c e p t u a l i n t e g r a t i o n . M o r e o v e r , t h e c a l l f o r i n t e r d i s c i p l i n a r yc o o p e r a t i o n i s o f li tt le u s e a s l o n g a s it o f f e r s n o a l t e rn a t i v e o t h e r t h a ns t ri n g i n g t o g e t h e r t h e k n o w l e d g e a v a i l a b l e t o e x p e r t s i n b i o l o g y , p s y -c h o l o g y , an d s o c i o l o g y . A n i n t e g r a ti n g c o n c e p t m u s t a n s w e r t h e q u e s o n s :h o w b i o l o g y , p s y c h o l o g y , a n d s o c i o l o g y a r e r el a te d a n d h o w t h ei r r e le v a n c ef o r m e d i c i n e i s t o b e c o n c e i v e d .3.2. Me dica l -H is tory as Acce s s to the Conce p t o f a L iv ing BodyW e a r e s p a r e d t h e s e a r c h f o r t h e o r e t i c a l c o n s i d e r a t i o n s a b o u t h o w s u c h am o d e l s h o u l d l o o k , i f w e l o o k t o t h e p a s t. O n e h u n d r e d a n d f i f t y y e a r sa g o m e d i c i n e i n c l u d e d a n i n t eg r a ti n g c o n c e p t o f t h e l iv i n g b o d y . B u t t h em e m o r y a s w e l l a s t h e e n t ir e e r a in w h i c h t h is c o n c e p t w a s c o n c e i v e d h a sb e e n r e p re s s e d b y " m o d e r n " p h y s i ci a n s.

I n 1 8 4 0 , th e s e c o n d v o l u m e o f th e H a n d b o o k o f H u m a n P h y s i o lo g y w a sp u b l i s h e d . I ts a u t h or , J o h a n n e s M l l e r ( 1 8 0 1 - 1 8 5 8 )1 z w a s o n e o f t h e m o s tc e l e b r a te d p h y s i o l o g i s t s o f t h e t im e , a f o u n d i n g f a th e r o f p h y s i o l o g i c a tm e d i c i n e i n t h e 1 8 4 0 s . I n t h e h a n d b o o k , M l l e r a r g u e s t h a t t h e u s e o fphys ic a l , c he m ic a l , t he r m a l , o r e l e c t r i c a l s t im u l i ha ve ve r y s im i l a r e f f e c t so n t h e d e a d b o d y . Y e t, th i s p h e n o m e n o n d o e s n o t a p p l y t o th e l i v in g b o d y .He r e the se s t im u l i a r e t ra ns f o r m e d in to psyc ho lo g ic a l ly e xpe r i e nc e d se n so r yqua l i t i e s tha t d i f f e r a c c o r d ing to the se nso r y o r ga n invo lve d . C onse que n t ly ,


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9 8 T H U R E V O N U E X K L Lt h e l i v i n g b o d y d o e s n o t r e s p o n d t o p h y s i c a l s t i m u l i b u t , r a t h e r , t o t h es e n s o r y q u a l i t i e s p r o d u c e d b y t h e s t i m u l a t i o n .

T a k i n g t h e s e o b s e r v a t i o n s t o t h e i r l o g i c a l c o n c l u s i o n , i t b e c o m e s c l e a rt h a t w h a t i s c a l l e d f o r i s a re v i s i o n , n o t o n l y o f o u r c o n c e p t o f t h e li v i n gb o d y a n d i ts re l a t io n s t o th e e n v i r o n m e n t , b u t - e v e n m o r e r a d i c a l l y - t h ei d e a o f t h e w o r l d t h a t s u r r o u n d s u s o r, r a t h e r, o u r re a l it y . M l l e r s u m m a -r i z e s t h i s i n a s h o r t a n d c o n c i s e m a n n e r :A sensory impression is no t a transmission o f a quality or the transmission o f a conditionof the outside world to consciousness. It is rather the transmitted quality of a conditionin the sensory nerves to consciousness, induced b y an external cause. Additionally, thesequalities (sensory energies) differ from each other in the various sensory nerves. 13

T h i s s t a t e m e n t i m p l i e s t h a t o u r s e n s o r y o r g a n s p r o v i d e p e r c e p t u a lq u a l i t i e s w h i c h , b e i n g a s s u m e d t o b e c a u s a l l y r e l a t e d t o o b j e c t s a n dp r o c e s s e s i n t h e o u t s i d e w o r l d , a r e n a t u r a l l y i n t e r p r e t e d b y u s a s s i g n s o ft h e o u t s i d e w o r l d . I n a s e n s e t h e s e a c t s o f i n t e r p r e t a t i o n c a n b e s a i d to b ea c ts o f c re a t i o n w h i c h b r i n g i n t o e x i s te n c e t h e w o r l d w e p e r c e i v e .

M l l e r ' s p h y s i o l o g y o f t h e s e n s e s , b a s e d a s it i s o n th e o r g a n i c i s to n t o l o g y o f th e l i v i n g b o d y ( th a t is , t h e b o d y c o n c e i v e d a s th e c r e a t o r o ft h e w o r l d i n w h i c h i t b r e a t h e s , m o v e s , e a ts , l i v e s ), c o n t a i n s t h e m o s t m a t u r ea n d c o n s e q u e n t i a l f o r m u l a t i o n o f t h e e a r li e s t " e p i s t e m o l o g i c a l m o d e l " ( o rp a r a d i g m ) o f h u m a n k i n d . G i n z b u r g d e s c r i b e s t h e g e n e s i s o f t hi s p a r a d i g mi n t h e f o l l o w i n g m a n n e r :For thousands of years man was a bunter. In the course of countless hunts he learned tofollow the trail left by tracks in the mud, broken branches, excrement, tufts of hair, tangledfeathers, and lingering smells. From these he learned to reconstruct the size and direction ofhis prey. From clues as thin as cobwebs he learned to form ideas, observe, interpret, andclassify. W ith lightning speed he learned to perform com plex mental operations in the thickof the wood as weil as in dangerous clearing.TMT h e h u n t e r s d i s c o v e r e d t h e p a r a d i g m o f t h e " s i g n . " I t s f o r m u l a i s a s to n -i s h i n g l y s i m p l e . L e i b n i z d e s c r i b e d i t t h u s: " T h e s i g n is s o m e t h i n g p e r c e i v e df r o m w h i c h m a n c a n i n f e r t he e x i s te n c e o f s o m e t h i n g w h i c h c a n n o t b ep e r c e i v e d . 15

T h e k n o w l e d g e a b o u t a h i d d e n r e a l i t y r e v e a l e d b y t h i s m e t h o d o fr e a d i n g s i g n s i s d e s c r i b e d b y G i n z b u r g i n m o r e d e t a i l : " C h a r a c t e r i s t i c o ft h i s k n o w l e d g e i s t h e a b i l i t y t o e l i c i t a c o m p l e x r e a l i t y f r o m a p p a r e n t l yt r iv i a l e m p i r i c a l d a t a , w h i c h o t h e r w i s e i s n o t d i r e c t l y i n f e r a b l e . ''1 6

F r o m t h e p a r a d i g m o f t h e " t r ia l ," " s i g n , " a n d " c i r c u m s t a n t i a l e v i d e n c e "a r o se t he p a r a d i g m o f e a r ly m e d i c i n e : t h e s y m p t o m . S y m p t o m s a r e p e r -c e p t i b l e , a p p a r e n t l y m i n o r e m p i r i c a l d a t a f r o m w h i c h t h e p h y s i c i a n e l i c i t sa c o m p l e x r e a l it y w h i c h i s n o t d i r e c t l y o b s e r v a b l e . F o u c a u l t e x p r e s s e d t h isi n t h e f o l l o w i n g m a n n e r :


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A N T H R O P O L O G Y A N D T H E T H E O R Y O F M E D I C I N E 99The symptom is the form in w hich the sickness presents itself. Consequ ently it plays animp ortant role. O f all that is visible it is the closest thing to the intrinsic, It is the first depic-tion of the sickness's inaccessible nature. Coughing, fever, pain in the side, and breathingproblems do not in themselves constitute the pleurisy - as pleurisy itself cannot be observedby the senses. It reveals itself only through the po wers o f the intellectJ 7

B o t h i d e a s - t h a t o f th e l iv i n g b o d y ( s u c h a s p r e s u p p o s e d i n J o h a n n e sM l l e r ' s d o c t r i n e o f t h e s p e c i f i c e n e r g i e s o f t h e s e n s e s ) a n d t h a t o f th e e a r l yb u n t e r - p r e s e n t a s t ri k i n g p a r al le l . T h e h u n t e r c o n s t r u c t s t h e w o r l d h ep e r c e i v e s a n d to w h i c h h e r e s p o n d s a c c o r d i n g t o th e n e e d s a n d k n o w l e d g er e q u i r e d o f a h u n t e r. M l l e r ' s m o d e l r e s e m b l e s b a s i c a l l y t h e o n e t h a t J a k o bv o n U e x k l l d e v e l o p e d a l m o s t o n e h u n d r e d y e a r s l a t er fo r u n d e r s t a n d i n gt h e i n t e r a c t i v e u n i t y o f t h e o r g n i s m a n d i ts e n v i r o n m e n t . I8'19 T h i s m o d e ia l s o c o n t a in s t h e b i o l o g i c a l b a s i s f o r a s c i e n t if i c a n t h r o p o l o g y a n d a t h e o r yo f m e d i c i n e . Y e t, it a ls o s e ts u s a t a sk : T o d e t e r m i n e ( a t l e a s t r o u g h l y ) t h ed i f f e re n c e b e t w e e n a n i m a l s a n d h u m a n s , b e t w e e n b i o l o g y a n d a n t h r o p o l o g y ,b e t w e e n v e t e r i n a r y m e d i c i n e a n d m e d i c i n e . A s w a s e a r li e r in d i c a te d , t h ed e v e l o p m e n t o f t h e p o w e r o f i m a g i n a t i o n p o i n t s u s i n t h e r ig h t d i r e ct i o n .I t i s n o a c c i d e n t t h e n t h a t th e m o m e n t o f a c h i l d ' s f i rs t w o r d s c o i n c i d e sw i t h t h e d e v e l o p m e n t o f t h e i m a g i n a f i o n , z3 . 3 . The "Scientif ic Re volution" o f the 19th Century, an d the Exp ulsion

o f the Sou l f rom the BodyT h e c l o s e c o n n e c t i o n b e t w e e n p a r a d i g m s , ~~ s c i e n t i f ic m e t h o d s , a n t h r o p o -l o g i ca l i d e as , a n d t h e t h e o r y o f m e d i c i n e b e c o m e s e v e n c l e a r e r i f w e s t u d yt h e c h a n g e o f t h e n i n e t e e n t h c e n t u r y p a r a d i g m w h i c h l e d to th e d o g m at h a t m e d i c i n e h a d t o b e c o m e s c i e n c e a n d t h a t s c i e n c e w a s t o b e p h y s i c s .F o r e x a m p l e , c o n s i d e r t h e p a r a d i g m e s t a b l i s h e d b y G a l il e o , t h o u s a n d s o fy e a r s a f t e r t h e e a r l y h u n t e r s .

G a l i l e o d e r iv e d a m e t h o d o f d e d u c t i o n in w h i c h a p e r c e i v a b l e c a u s ep r o d u c e d a p e r c e i v a b l e e f fe c t , a n d v i c e v e r sa . I n m e c h a n i c s , N e w t o nd i s c o v e r e d a f o r m u l a w h i c h a l l o w e d h u m a n s t o s u b j e c t n a t u r e t o t h e i rm a n i p u l a t io n s . H o w e v e r , t h e n a t u r e th a t w a s m a d e s u b s e r v i e n t w a s a ni n a n i m a t e n a t u r e . H e r e w e n o t i c e th e c r u c i a l d i f f e r e n c e b e t w e e n t h ep a r a d i g m o f th e t r a c k e r a n d t h e p a r a d i g m o f th e " n e w s c i e n c e " f o u n d e db y G a l i l e o a n d N e w t o n .

T h e s i g n s r e a d b y a t r a c k e r r e v e a l t h e h i s t o r y o f a l i v i n g b e i n g . T h e s es i g n s n o t o n l y r e v e a l i t s s i z e , a p p e a r a n c e , p s y c h o l o g i c a l c o n d i t i o n , c o n -t e n t m e n t o r r e s tl e s sn e s s , a n d i ts a g i t a ti o n ( w h i c h c o u l d e n d a n g e r t h e h u n t e r )b u t a l s o i t s p a s t a n d , m o r e i m p o r t a n t , w h e n a n d w h e r e t h e h u n t e r c o u l de n c o u n t e r t h e a n i m a l . T o th e a d h e r e n t s o f N e w t o n , a s i g n o n l y r e v e a l s t h e


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1 0 0 T H U R E V O N U E X K L Lo u t c o m e o f a m e c h a n i c a l c a u s e , w h i c h m a y r e s u l t f r o m t h e i n f lu e n c e o fe i t h e r a l i v i n g b e i n g o r s o m e t h i n g m e c h a n i c a l .

E a r l y p h y s i c i a n s , b y r e a d i n g s y m p t o m s , d i s c o v e r e d t h e history of the i rp a t i e n t s . S y m p t o m s r e v e a l e d a p a t i e n t ' s p r e s e n t h e a l t h a n d p s y c h o l o g i c a lc o n d i t i o n , w h i c h a r e im p o r t a n t t o th e p h y s i c ia n . S y m p t o m s a l s o r e v e a l e dth i s h i s to r y o f t he s i c kne s s , o r how the i l l ne s s c a me a bou t , a s w e i l a s t hep a t i e n t' s f u t u r e a n d h o w t h e il l n es s w o u l d p r o g r e s s . F o r t h e " m o d e r n p h y s i -c i a n , " t h e s y m p t o m i s o n l y t h e l o c a l e f f e c t d u e t o p h y s i c a l o r c h e m i c a lc a use s , t he o r ig in s o f w h ic h a r e e ithe r ba c t e r i a l , v i r al , o r s t r uc tu ra l c h a nge sin the o r ga n i sm, suc h a s t hose due to a r th r i t i s o r a r t e r io sc l e r os i s .

Toe l lne r 22 de sc r ibe s h ow phy s ic i a ns a t t he be g inn in g o f t he e igh te e n thc e n tu r y w e r e c a p t iva t e d by a n ide a ( a t t ha t t ime to t a l ly un r e a l i s t i c ) w h ic ht h e y h o p e d w o u l d l e n d c e r ta i n t y a n d r e l i ab i li ty , a s p r o m i s e d b y p h y s i c s t ot h e a rt o f h e a l in g . T h i s i d e a w a s t o b e a c c o m p l i s h e d b y a d o p t i n g t h ep r i n c i p l e s o f t h e " n e w s c i e n c e " a s a b a s i s f o r a t h e o r y o f m e d i c i n e .C o n s e q u e n t l y , t h e e x p u l s i o n o f b o t h t h e s o u l f r o m t h e b o d y a n d t h e p at i e n t( a s a s u b j e c t ) f r o m m e d i c i n e w a s i n e v i t a b l e . U n d e r t h e s e c i r c u m s t a n c e s ,t h e s h o r t e r a o f " R o m a n t i c m e d i c i n e " a n d i ts s e q u e l ( w h i c h i n c l u d e d t h ew o r k o f J o h a n n e s M l l e r) c a n b e c o n s i d e r e d t o h a v e a d v a n c e d t h e e s ta b -l i s h m e n t o f m e d i c i n e a s a n i n d e p e n d e n t s c i e n c e . T h i s s c i e n c e d i d n o tc ons ide r N a tu r e a hos t il e f o r c e to be sub juga te d , no r d id i t r e ga r d the sub je c ta s a d i s tu r b ing e l e me n t t ha t ha d to be e l imina te d , bu t r a the r a s t he c ons t i -t u t iv e e l e m e n t o f m e d i c a l t h o u g h t a n d p r a c t ic e .

T h e n i n e t e e n t h c e n t u r y b r o u g h t a b o u t t h e i n d u s t r i a l a g e , a n d w i t hi t c h a n g e s i n t h e s o c ia l c li m a t e . N o w t h e p h y s i c i a n s ' d r e a m o f a c o m -p r e h e n s iv e t h e o r y o f m e d i c i n e b a s e d o n N e w t o n i a n m e c h a n ic s c o u l d b er e a li z e d . W i t h i t, th e i d e a s o f R o m a n t i c m e d i c i n e d r o w n e d , a s d e s c r i b e db y E r d h e i m , i n a " c o l l e c t i v e l y p r o d u c e d u n c o n s c i o u s . " T h e s c i e n t i f i cr e v o l u ti o n w h i c h l e d t o t h e p a r a d ig m s h i ft b e g a n i n G e r m a n y w i t h t h e re v o l to f J o h a n n e s M l l e r ' s f o l l o w e r s a g a i n s t t h ei r m a s t e r ' s t e ac h i n g s.

B e r n f e l d d e s c r i b e s t h i s re v o l t o f M l l e r ' s f o l l o w e r s . I t i s a s t ri k in ge x a m p l e o f th e c o n n e c t i o n b e t w e e n Ze i tge i s t and the fa te of sc ien t i f ic ideas .The a s ton i sh ing suc c e s s s to r y o f t h i s re vo l t :b e g a n w i t h t h e fr i e n d s h ip b e t w e e n E m i l D u b o i s - R e y m o n d ( 1 8 1 8 - 1 8 9 6 ) a n d E r n s t v o n B r c k e( 1 8 1 9 - 1 8 9 2 ) . S h o r t ly a f te r , t h e y w e r e j o i n e d b y H e r r m a n n v o n H e l m h o l t z ( 1 8 2 1 - 1 8 9 4 ) a n dC a r l L u d w i g ( 1 8 1 6 - 1 8 9 5 ) . F r o m t h e v e r y b e g i n n i n g t h i s g r o u p w a s i n s p i r e d b y a t r u ec r u s a d e r ' s s p i r i t . I n 1 8 4 2 , D u b o i s w r o t e : " B r c k e a n d I h a v e d e v o t e d o u r s e l v e s t o o r t e a i m ,t o m a k e t h e t ru t h k n o w n t h a t i n a n o r g a n i s m t h e r e a r e n o o t h e r p r o c e s s e s a t w o r k t h a n t h ec o m m o n p h y si c al -c h e m ic a l o n e s . . . "T h e s e m e n f o r m e d a s m a l l p r i v a t e c l u b , w h i c h i n 1 8 5 3 w a s e n l a r g e d a n d n a m e d : ' T h eB e r l i n S o c i e t y o f P h y s i c s . " M o s t o f t h e m e m b e r s w e r e y o u n g d i s c ip l e s o f J o h a n n e s M l l e r,p h y s i c i s ts a n d p h y s i o lo g i s ts , u n i t e d b y o n e c o m m o n a i m : t o d o a w a y w i t h v i ta l i sm , w h i c hi s w h a t th e y c a l le d t h e i r v e n e r a t e d m a s t e r ' s t h e o r y . . .


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A N T H R O P O L O G Y A N D T H E T H E O R Y O F M E D I C I N E 101Within twenty-five years thei r ideas came to dominate the thinking of German physiol -

ogi st s and phy s i c i an s . . . As for v it a l ism, they l ived long enough to wi tness i ts rev iva l?3This theory - that in an organism there are no processes other than the

common physical-chemical ones - became the dogma of modern medicine.With it, the soul's expulsion from the body was scientifically sanctioned.No one showed further interest in questions concerning the differencebetween a living body and a corpse, in which there are, in fact, no otherprocesses at work.3.4. The Rise o f an "Actual Dualism ." Freud's Definition o f the " S o u l ''2 4Bernfeld's remark about the "revival of vitalism" refers to the teachingsof Freud. For a theory of medicine that acknowledged no processes in thebody other than those of the common physical-chemical kind, Freud's ideasmust have been construed as pure vitalism. Freud (as, incidentally, alsohis contemporary Pavlov) tried to reconcile this dilemma by viewingpsychology as a preliminary stage of physics. Both Freud and Pavlovbelieved that psychology would eventually discover the formulas governingphysical processes which were said to be hidden in all mental processes.

This conviction reflects the power of the Zeitgeist to which even Freud,in spite of his astute analyses of society's influence, succumbed. It there-fore did not occur to him that his discovery of the psychoanalytic methodwas in reality a rediscovery of an old paradigm (now suppressed by modernmedicine) of "tracking," circumstantial evidence, or more specifically, thesign.

Ginzburg describes how at the end of the nineteenth century, almostunnoticed, a new paradigm appeared. In art history it presented itself as anew method for identifying the works of old masters; in literature it wasthe detective novel; in medicine it was psychoanalysis. In all these casesit was a method by which a hidden reality could be identified by non-descript, apparently trivial empirical data.

Ginzburg concludes that medicine has always been a "science ofcircumstantial evidence."Circumstan t ial -evidence sciences ar e . . , to a great extent qual i tat ive sciences, deal ing wi thth e ind iv idual aspec t s of cases, s i tuat ions, and documents. Therefore they cannot avoid adegree of uncertainty in thei r resul ts . . . . Conversely, [Gal i lean sciences] imply, by applyingmathemat ics and experimental m et ho ds . . , that the results achieved can be repeated. Sciencesdeal ing wi th individual aspects , however, have by defini t ion excluded the possibi l i ty ofrepet i tion, and qu ant i f icat ion is only acceptable as a funct ional a idYIt is no surprise then that the method of circumstantial evidence devel-oped by Freud to define the "soul" and soul-related processes could not


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1 0 2 T H U R E V O N U E X K L La p p r o a c h t h e b o d y ( a s in t e r p r et e d b y m o d e r n m e d i c i n e ) a c c o r d i n g t o t h eG a l i l e a n p a r a d i g m . I t i s a l s o n o s u r p r i s e t h a t t h e m e e t i n g o f th e s e t w om e t h o d s r e s u l te d i n " a c t u a l d u a l i s m " i n o u r h e a l th c a r e s y s t e m , i n w h i c ht h e r e w a s a m e d i c i n e f o r b o t h s o u l - l e ss b o d i e s a n d b o d i l e s s s o u l s .

4 . A R E V I S I O N O F O U R V I E W C O N C E R N I N GT H E R E L A T I O N S H I P B E T W E E N H U M A N S A N D

T H E A N I M A T E / I N A N I M A T E E N V I R O N M E N T

T h e i d e a o f a l i v in g b o d y t h a t c r e at e s its o w n e n v i r o n m e n t c o m p e l s u s t oa n s w e r t h e f o l l o w i n g q u e s t io n s : H o w a r e w e t o im a g i n e a n o b j e c t i v ee x t e r n a l w o r l d ? ( i n w h i c h w e a l l l i v e ) ; w h a t i s t h e r e l a t i o n s h i p b e t w e e nt h is o b j e c t i v e e x t e r n a l w o r l d a n d t h e s u b j e c t i v e e n v i r o n m e n t o f a li v in go r g a n i s m ? T h e m i s c o n c e p t i o n o f so l i p s i st i c a ll y i n t e r p r e t i n g th e b o d y ' sc r e a t i v i t y as o m n i p o t e n t ( a s w e d i d i n a n e a rl i e r p h a s e o f o u r d e v e l o p -m e n t ) i s f r a u g h t w i t h s e r i o u s c o n s e q u e n c e s .

J a k o b v o n U e x k l l c o n s i d e r e d th e o b j e c t i v e " e x t e r n a l w o r l d " t o b e t h ec r e a ti o n o f t h e h u m a n i m a g i n a ti o n . I n i m a g i n a t i o n t h e r e i s r o o m f o r b o tht h e a n i m a t e a n d i n a n i m a t e n a t u r e o f o u r p l a n e t . A s t r o n o m e r s c a n i n f la t ei t i n t o a n in f i n i te c o s m o s e n c o m p a s s i n g b i l l i o n s o f l i g h t y e a r s . T h u s o u ri m a g i n a t i o n h a s c r e a t e d a c o m m o n f r a m e w o r k f o r i n d i v i d u a l r e a li t ie s .W i t h i n t hi s f ra m e w o r k , w e c a n o r i e n t o u r s e lv e s t o w a r d s o u r c o m m o n n e e d sa n d t h e n e ed s o f o u r c o m m o n e n t e r p r i se - " s c i e n c e . " V o n U e x k l l w a s ab i o l o g is t , w h o s e c e n t r a l c o n c e r n w a s t o d i s ti n g u i s h b e t w e e n t h e " o b j e c -t iv e e x t e rn a l w o r l d " o f th e h u m a n o b s e r v e r a n d s u b j e c t iv e e n v i r o n m e n t s[Umwehen] o f o b s e r v e d a n i m a ls - b e th e y e a r t h w o r m s o r m a m m a l s - e n v i -r o n m e n t s w h i c h h a d t o b e t a i l o r e d t o t h e s p e c i f i c s u b j e c t i v e n e e d s o f t h ea n i m a l s c o n c e r n e d i f t h e y w e r e t o l i v e a n d s u r v i v e .

N o t o n l y d o e s t h i s d i s t i n c t i o n a d d r e s s t h e q u e s t i o n o f t h e r e l a t i o n s h i pb e t w e e n s u b j e c ti v e e n v i r o n m e n t s a n d a n o b j e c t i v e e x t e rn a l w o r l d , i t al so ,i n t e r e s t in g l y e n o u g h f o r m e d i c i n e , a d d r e s s e s t h e q u e s t i o n , H o w s h o u l d" h e a l t h " b e d e f i n e d ? A t h e o r y o f m e d i c i n e w h i c h a d o p t e d t h e G a l il e a np a r a d i g m c o u l d d e f i n e h e a l t h o n l y a s a d i s tr i b u t i o n c u r v e o f c h a r a c t e ri s t icb i o c h e m i c a l v a l u e s w i t h s i c k n e s s a s it s t a il e n d . S u c h a d e f i n i t i o n c a n h a r d l yb e u s e d t o d e r i v e g u i d e l i n e s f o r o u r c o n t e m p o r a r y a t t it u d e t o w a r d s h e a l t h .O n t h e o t h e r h a n d , a t h e o ry o f m e d i c i n e w h i c h , b a s e d o n t h e c o n c e p t t h a ta li v i n g b o d y ( i f i t i s to l i v e a n d s u r v i v e ) h a s t o t r a n s f o r m t h e e x t e r n a l w o r l di n t o a s u b j e c t i v e e n v i r o n m e n t , p r o v i d e s a m o r e r e a l is t ic d e f i n i t i o n o f h e al th .W r i ti n g a l m o s t s i x ty y e a r s a g o , V i k to r v o n W e i z s c k e r p o i n t e d t h e w a y t os u c h a d e f i n i ti o n : " H e a l t h i s n o t a n a s s e t w h i c h w e c a n c o n s u m e . H e a l t h


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A N T H R O P O L O G Y A N D T H E T H E O R Y O F M E D I C I N E 1 0 3

i s o n l y p r e s e n t w h e r e i t i s c o n t in u a l l y p r o d u c e d . I f h ea l th i s n o t p r o d u c e d ,the pe r son i s a l r e a dy s i c k . ' ' z6

A n tono w s k i 27 c o ine d the t e r m " sa lu toge n e s i s , " i .e . " p r oduc t ion o f he a l th "w h i c h i s , co n t r a r y t o th e n o t i o n o f " p a t h o g e n e s i s , " r o o t e d i n n i n e t e e n t hc e n tu r y s c i e nc e . P a thoge ne s i s imp l i e s t ha t he a l th i s some th ing s t a t i c w h ic hc a n be lo s t a nd r e ga ine d .

T h e t e r m " s a l u t o g e n e s i s " c o n v e y s t h e v i e w t h a t l i v i n g s y s t e m s a r e" a u t o p o i e t i c , " i .e ., s e l f - c o n s t r u c t i n g a n d s e l f - o r g n i z i n g s y s t e m s 28 t h a tc o n t i n u a l l y a b s o r b e l e m e n t s f r o m t h e e n v i r o n m e n t a n d , in r em r n , e l im i n a t et h o s e e l e m e n t s t h a t a r e n o l o n g e r u s e f u l . T h i s c o h e r e s w i t h t h e v i e wt h a t a b o d y c o n s t r u c t s i t s o w n s u b j e c t i v e w o r l d . H o w e v e r , a m o r e p r e c i s eu n d e r s t a n d i n g o f t h e b o d y ' s r e l a t i o n s h i p t o t h e e x t e rn a l w o r l d i s s t il lr e qu i r e d .

F o r th i s , i t i s impor t a n t t o unde r s t a nd tha t he a l th ( a nd s i c kne s s ) a r e no tc o nc e m s o f t he so l i ta r y o r ga n i sm o r the ind iv idua l . Th e y a r e , r a the r , t heo u t c o m e o f c o n s t an t i n t e r ac t io n s b e t w e e n t h e i n d i v id u a l a n d h i s/ h e r e n v i -r o n m e n t o n b i o l o g i c a l , p s y c h o l o g i c a l , a n d s o c i a l l e v e ls . I f fo r h e a lt h t o b ep r oduc e d in t e r a c t ion i s t o t a ke p l a c e , t he o r ga n i sm ' s a c t ions a nd the r o l e sa s s u m e d b y a n i n d i v i d u a l m u s t b e r e c i p r o c a t e d b y c o m p l e m e n t a ~ a c t i o nand comp lementary in f luence by the environment on a l l levels. F o r e x a m p t e ,o n a s o m a t i c l e v e l o f in t e g ra t io n , b r e a t h in g a n d m e t a b o l i s m p r e s u p p o s e as u p p l y o f a ir a n d a s u p p l y o f f o o d f r o m t h e e n v i ro n m e n t . O n a p s y c h o -log ic a l a nd so c ia l l e ve l o f i n t e g r a t ion , r o l e s t i ke spe a k ing a nd r e c e iv ing ,c a l l f o r c o m p l e m e n t a r y r o l e s l i k e l i s t e n i n g a n d g i v i n g , w h i c h n e e d t o b esupp l i e d by in t e r a c t ing pa r tne r s i n t he e nv i r onme n t .

O n e d e c i s i v e c ri te r io n f o r h e a lt h i s a s e n s e o f a u t o n o m y . A t t h e s a m et i m e , t h i s f e e l i n g i s , i n a " s e l f - e o n c e a l e d " m a n n e r , a s o c i a l r e g u l a t o r .C h r i s ti a n a n d H a a s h a v e d e v e l o p e d a m o d e l o f " b i p e r s o n a l i t y " w h i c hc l e a r l y f o r g e s a l i n k b e t w e e n t h e s o m a t i c , p s y c h o l o g i c a l , a n d s o c i a lp r o c e s s e s i n s a l u to g e n e s i s . T h e i r s u b t l e a n a l y s i s o f th e b e h a v i o r a n d t h ee x p e r i e n c e s o f t w o p e o p l e w o r k i n g w i t h a t w o - h a n d e d s a w s h o w s th a t ah a r m o n i o u s r e c i p r o c i t y o f a c t i o n a n d c o m p l e m e n t a r y a c t i o n i s n e e d e d i no r d e r t o e x p e r i e n c e a u t o n o m y . T h e y w r i t e :A t t h e h e i g h t o f c o o p e r a t io n , b o t h p a r t n e rs e x p e r i e n c e a s e n s e o f m a x i m u m i n d e p e n d e n c e .T h e a n a l y s is ( o f th e o b j e c t i v e p a rt s o f t h e o p e r a t i o n s ) s h o w s t h a t t h e y a r e o b j e c t i v e l y r el a t e dt o e a c h o t h e r t h r o u g h s t ri c t r e c i p r o c i t y o f a c ti o n . A s e n s e o f c o m p l e t e i n d e p e n d e n c e c a nt h e r e f o r e o n l y b e a c h i e v e d w h e n t h e r e i s c o m p l e t e r e c i p r o c i t y o f a c t io n . T h i s c o m p l e t e i n d e -p e n d e n c e o f t h e i n d i v id u a l i s b a s e d o n a c o m p l e r a e n t a r y , y e t c o n c e a l e d , r e la t i o n sh i p b e t w e e nt h e m .

C o n v e r s e l y , a n y d i s h a r m o n y , a n y d i s t u r b a n c e o f t h e q u a l i t y o f t o g e th e r , i s p e r c e i v e d a sa d i st u r b a n c e o f o n e ' s a u t o n o m o u s c o n t r o l o v e r o n e ' s o w n e n e r g i e s; t h e c o m p l e t e a b s e n c eo f t h e e x p e c t e d c o m p l e m e n t a r y a c t i o n m a y e v e n b e p e r c e i v e d a s p a r a l y s is . 29


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104 THURE VON UEXKL LT h e m o d e l d e r i v e d f r o m t h i s q u o t a t i o n n o t o n l y c l a r i f i e s h e a l t h , b u t a l s ot h e e p i s t e m o l o g i c a l a s p e c t s o f t h e r e l a ti o n s h ip b e t w e e n t h e s u b j e c ti v e e n v i -r o n m e n t ( o r i n d i v i d u a l r e a l i t y ) a n d t h e o b j e c t i v e e n v i r o n m e n t . I t s h o w st h a t h e a l th i s e x p e r i e n c e d a s a f e e l in g o f a u t o n o m y a n d e f f i c ie n c y . A tt h e s a m e t i m e , t h i s f e e l i n g is a n i n d i c a t o r o f b e i n g i n t e g r a t e d w i t h t h ee n v i r o n m e n t , i . e . t h a t o n e i n t e r p r e t s i t ( a s a s o u r c e o f c o m p l e m e n t a r ya c t i o n a n d c o m p l e m e n t a r y ro l e s ) " c o r r e c t l y ." T h i s e x p l a i n s w h y t h e c h r o n -i ca l l y hand icap ped can , desp i t e t he r es t r i c t ions as soc i a t ed wi th t he i r i t lnes s ,r e g a i n a s e n s e o f a u t o n o m y a n d h e a l t h i f t h e e n v i r o n m e n t re c i p r o c a t e sappropr i a t e ly .

F o r m e d i c a l e t h i c s t hi s g i v e s m e a n i n g t o t h e p r i n c i p le o f a s u p p o r ti v ec o m m u n i t y f o r th e s i c k a n d n e e d y . T h i s h a s b e e n i l l u s tr a t e d b y c o n v i n c i n gs t u d ie s t h a t s h o w , f o r e x a m p l e , h o w d i s r u p te d s o c ia l i n t e g r a ti o n c a u s e d b ythe l o s s o f v it a l r ec ip roca l ac t ions f rom the env i ronm en t , e.g . t h rough o b j ec tl o s s (dea th o f spouse , soc i a l dec l i ne , e t c . ) h inder s s a lu togenes i s and l eadst o i n c r e a s e d m o r b i d i t y a n d m o r t a li ty .

5. THE DEVELO PMEN T OF A CONCEPT FOR THECONSTRUCTION OF INDIVIDUAL REALITY AND ITSCONSEQUENCES FOR THE PATIENT-PHYSICIAN RELATIONSHIP

5.1. Sign-Processes as Feedback-CircuitsA s a n a l te r n a t iv e t o th e m e c h a n i s m - m o d e l o f m o d e r n m e d i c i n e , I n o ws u g g e s t a " l iv i n g b o d y " m o d e l . A s a g e n e r a l b i o l o g i c a l m o d e l it d e s c r ib e sl iv i n g o b j e c t s ( w h e t h e r t h e y a r e c e l ls o r o r g a n s i n a n o r g a n i s m , o r o r g a n -i s m s i n t h e e n v i r o n m e n t ) a s b e i n g s y s t e m s w h i c h , u n d e r t h e i n f l u e n c e o ft h e e n v i r o n m e n t , d o n o t r e a c t m e c h a n i c a l l y w i t h m e c h a n i c a l r e s u lt s . T h e ya r e , in s t e a d , d e s c r i b e d a s s y s t e m s w h i c h , w i t h t h e a i d o f t h e i r re c e p t o r s ,e n c o d e e n v i r o n m e n t a l i n f l u e n c e s i n t o s i g n s t h a t i n d i c a t e t h e b i o l o g i c a lq u a l i t y o f t h a t s y s t e m ' s e n v i r o n m e n t . L i v i n g s y s t e m s a r e n o t p a s s i v e l ya l t e r e d b y e x t e r n a l i n f l u e n c e s ; r a t h e r , t h e y r e s p o n d a c t i v e l y t o t h e s i g n sp r o d u c e d b y t h o s e i n f l u e n c e s . T h i s m o d e l s h o u l d r e p l a c e t h e t w o - d i m e n -s i o n al a n d l in e a r c a u s a l f o r m u l a o f c a u s e a n d e f f e c t w i t h a t h r e e - p a r tfo rmu la : t he s i gn , t he i n t e rp re t an t (o r code) , an d t he s i gn i f i ca t e (P e i rce : S eeW . N t h 3) T h e s i m p l e s t o f t h e s e f o r m u l a s i s t h e f e e d b a c k c i r cu i t.I s h a l l i l l u s t r a t e t h i s i n a m o d e l f o r t h e c e l l w h i c h i s s h o w n i nF igu re 1 .

T h e c e l l ' s r e c e p t o r s m e a s u r e ( l i k e t h e f e e l e r s i n t h e f e e d b a c k c i r c u i t -m o d e l ) d e v i a ti o n s b e t w e e n t h e e n v i r o n m e n t ' s a ct u a l v a l u e a n d a t a r g e t v a lu e


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A N T H R O P O L O G Y A N D T H E T H E O R Y O F M E D I C I N E 1 05

- - - - - 4 -4 - + 4 - - - - -

- - - f - 4 - - t - -

( r e c e p t o r ) ( e f fe c t o r ) ] ~ ~ _ - - + " t - -

4 - - 4 - - - - -- p

_ " 4 - 4 - -- - - - - - - - m e m b r a n e - ~ _ _ " ~ - ~ " _ _ - -

d w e l J i n g i n t e g u m e n t

CELL

Fig. 1. The cell's m em brane has a t its disposal receptors and effectors for its behavioralresponse. Thes e facilities correspond to the feeler and the sign al box o f the feedbackcircuit-model. Representing the ce ll 's "biological need" is the feedback circuit's "targetvalue" sy mb olized in the three -part form ula by the "interp retant" (or code).

( as a s y m b o l o f th e c e l l ' s b i o l o g i c a l n e e d = i n t e rp r e ta n t ) . A t t h e s a m e t im e ,t h e re c e p t o r s e n c o d e t h e m e a s u r e d v a l u e i n t o a s i g n. T h i s s i g n i n f o r m s t h ec e l l o f t h e m e a n i n g t h e e n v i r o n m e n t h a s i n r e l a t i o n t o i t s n e e d s ( t a r g e tv a l u e ) .

A s a r e s p o n s e t o t h e s e s i g n s , t h e b e h a v i o r o f th e c e l l ' s e f f e c t o r s ( th es i g n a l b o x i n t h e f e e d b a c k c i r c u i t - m o d e l ) c o r r e s p o n d s t o t h e s i g n i f i c a t e .T h e r e s p o n s e , f o r e x a m p l e , m a y b e t h e r e le a s e o f a s e c r e ti o n w h i c h m o d i f i e st h e s y s t e m ' s p H - l e v e l, t h e r e b y s a t i s f y i n g th e s y s t e m ' s n e e d s ( o r b r in g s t h ea c t u a l v a l u e i n l i n e w i t h t h e t a r g e t v a l u e ) . T h i s i s h o w t h e c e l l , r e s p o n d i n gt o i ts n e e d s , p r o d u c e s i ts " r e a l i t y . " T h i s " r e a l i t y " s u r r o u n d s t h e c e l l a s v o nU e x k l 1 3 1 p u t s i t , l i k e a " h a b i t a t i o n c a p s u l e " o r " d w e l l i n g i n t e g u m e n t "[Wohnhlle] a s w e s h a l l n o w c a l l i t .

T h e p r in c i p le o f p r o d u c i n g r e a l it y t h r o u g h " p e r c e p t i o n " a n d " a c t i o n "i s, a l b e i t i n a p r i m i ti v e f o r m , a l r e a d y i n t i m a t e d i f o n e t a k e s i n t o a c c o u n tt w o p o i n ts :1. L i v i n g s y s t e m s h a v e t h e ir o w n t a r g e t v a l u e , w h e r e a s c y b e r n e t i c

m a c h i n e s a r e g i v e n t h e i r t a rg e t v a l u e b y a n o u t s i d e s o u r c e ( t h r o u g h i tsc o n s t r u c t o r ) .

2 . L i v i n g s y s t e m s m o d i f y t h e ir ta r g e t v a l u e a c c o r d i n g t o t h e i r b e h a v i o r ,


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1 0 6 T H U R E V O N U E X K L Lwi th the r e su l t t ha t a f t e r a c e r t a in be ha v io r ( e .g . i n t a ke o f f oo d) thesa m e inpu t ( e . g . supp ly o f f ood) no longe r r e su l t s i n t he sa m e ou tpu t( in t a ke o f f o o d ) . 32F o r t h e o u t s i d e o b s e r v e r , t h e s y s t e m a p p e a r s t o h a v e c h a n g e d . F r o mt h e v i e w p o i n t o f t h e s y s t e m , h o w e v e r , i t i s t h e q u a l i t y o r m e a n i n g o f t h ee n v i r o n m e n t t h a t h as c h a n g e d : a n o b j e c t w h i c h h a d t h e m e a n i n g " f o o d "b e f o r e f e e d i n g b e c o m e s , a f t e r t h e f e e d i n g , s i m p l y a n o b j e c t t h a t i s a nobs t a c l e .A s e m i o t i c i n t e r p r e t a t i o n i s a l w a y s a n i n t e r p r e t a t i o n w h i c h v i e w s t h eo b s e r v e d i n d i v i d u a l a s b e i n g t h e i n t e r p re t e r o f i ts e n v i r o n m e n t . T h e

o b s e r v e r t a k e s t h e r o l e o f " m e t a - in t e r p re t e r. " V o n U e x k l l m a k e s t h is c l e a rb y d e p i c ti n g s i g n p r o c e s s e s ( s e m i o s e s ) a s b e i n g c i r c u l ar p r o c e s s e s i n w h i c hthe in t e r a c t ion be twe e n a l i v ing be ing a nd i t s e nv i r onm e n t i s de f ine d a s :( 1 ) t h e m e a n i n g a s s i g n m e n t ( e n c o d i n g o f t h e r e c e p t o r ' s c h a n g e s t h r o u g he x te r na l i n f lue nc e s in to a s ign ) ; ( 2 ) t he u t i l i z a t ion o f m e a n ing ( be ha v io r a lr e sponse ) ; a n d ( 3 ) t o l e r a t ion o f m e a n ing o r fa c i l i ta t i on o f m e a n ing ( th rought h e e n v i r o n m e n t ) .5.2. The Sign Process as a Functional CycleI n m u l t i c e l lu l a r o r ga n i sm s the ind iv idua l c e l l s a r e su r r ounde d by a n ou te rm e m b r a n e . T h i s m e m b r a n e s e p a r a t e s a milieu intrieur f r o m a milieuextrieur. T h e f o r m e r c o n s i s t s o f a n i n t e r c e l l u l a r f l u i d w h i c h c o n s t i t u t e st h e m e d i u m f o r t h e s t re a m o f s i gn s . T h e c e l ls , s u r r o u n d e d b y t h e ir d w e l l i n gi n t e g u m e n t s , a r e c o n n e c t e d b y t h is s t r ea m o f s ig n s .T h e r e l a ti o n s h i p o f milieu extrieur r e qu i r e s a ne w o r ga n iz a t iona l f o r m .T h i s f o r m c o n s i s t s o f s p e c i a l i z e d c e l ls f o r r e c e p t o r a n d e f f e c t o r or g a n s a sw e i l a s a n e r v o u s s y s t e m t h a t c o n n e c t s t h e t w o . T h i s n e r v o u s s y s t e m i se n d o w e d w i t h a c o m m o n " t a r g e t v a l u e " w h i c h f u n c t i o n s a s " i n t e r p r e t a n t "( o r c o d e ) . T h i s s y s t e m a l lo w s f o r t h e o c c u r r e n c e o f s ig n p r o c e s s e s w i t h i nth e milieu extrieur. N o w t h e a c q u i s i ti o n o f e l e m e n t s i n th e e x t er n a l w o r l dc a n t a k e p l a c e , t h e r e b y s a t i s f y i n g t h e s y s t e m ' s n e e d s .T h e s y s t e m ' s r e c e p t o r s p r o v i d e m e a n i n g r e g a r d i n g t h e i n f l u e n c e sp r o d u c e d b y t h e e n v i r o n m e n t . T h e m e a n i n g i s t h e n " u l ti l iz e d " t h r o u g h t h ee f f e c to r ' s re sponse . Th a t m e a n s tha t t he func t ions o f t he re c e p to r s a nd e f f e c -to r s c oope r a t e i n the p r oc e s s o f r e a l i t y t e s t ing : The e f f e c to r ' s u t i l i z a t iono f m e a n i n g c o n t r o l s t h e a c c u r a c y o f t h e r e c e p t o r ' s m e a n i n g a s s ig n m e n t .T h e f u n c t i o n a l c y c l e m o d e1 3 3 d e s c r i b e s t h is c o n n e c t i o n a n d a n t i c i p a t e st h e f e e d b a c k c i r c u i t - m o d e l w i t h n e g a t i v e f e e d b a c k - a l b e i t w i t h o u t i t sm a t h e m a t i c a l f o r m u l a t i o n ( F i g u r e 2 ) .B o t h m o d e l s ( f e e d b a c k c i r c u it a n d f u n c t i o n a l c y c l e ) d e s c r i b e h o w l i v in g


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ANTHROPOLOGY AND THE THEORY OF MEDICINE 107perceiving

subject / ~ UMWELT ~L~ ) env[ronm entope ration al rga n~ " ~ o p era tio n Nue

operatingFunctional cycle

Fig. 2. The funcfional cycle. Jakob von Uexkl134 describes this model (in 1936) in thefollowing manner: "Metaphorically speaking.. , each subject seizes its object with the twoarms of a forceps - a receptor - arm and an effector-arm. With one arm it imparts to theobject a distinct perceptual value, that is, it assigns to it a meaning as perceptual cue[Merkmal]; with the other arm it imparts a distinct operational value (in the sense ofutilization of meaning) through which it becomes an operational cue [Wirkmal]. In otherword, the operational cue {Wirkmal] deletes the perceptual cue, [Merkmal]. This sentenceexpresses the principle of negative feedback. This model shows how the subject and objectfit into each other and together form a greater system.

systems temporarily incorporate segments of their environment which aremeaningful to the system. Wh en the utilization of meaning has ended, theenvironmental elements that have not been utilized return once more tothe "meaningless nothing " o f things and processes that do not exist for thesystem.

The difference between the two models is their degree of complexity.The feedback circuit describes sign processes in living systems which, likeplants, belong to a vegetative level of organization. On this level there areno receptors specializing in long-distance perception, no effectors fit for"trapping" and, more notably, no nervous system connecting receptors andeffectors. These living systems do not construct "environment;" rather, theyare satisfied with their dwelling integuments. On the other hand, the func-tional cycle describes sign processes on an animal level. Living systemson this level, using perception and movement, construct spatio-temporalenvironments.

The advantage of these two models is that they permit one to describeprocesses within the organism as vegetative, and processes between theorganism and its environment as animalistic, without introducing the dif-


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108 THURE VON UEXKLLf e r e n c e b e t w e e n t h e m e n t a l a n d p h y s i c a l re a l m s . I n s t ea d o f a d d r e s s in g t h ep s y c h o - p h y s i c a l p r o b l e m , t h e s e t w o m o d e l s r a i s e t h e q u e s t i o n : H o w a r es i g n s y s t e m s a t t h e v e g e t a t i v e l e v e l t r a n s l a t e d i n t o s i g n s y s t e m s a t t h ea n im a l l e v e l (e .g . e l e c t r o - p hy s io lo g ic a l s igns o f the b r a in t r a ns la t e d in tos e n s o r y - p h y s i o l o g i c a l s i g n s o f th e e n v i r o n m e n t ) , a n d v i c e v e r s a ? W i t h t h isq u e s t i o n , s y s t e m t h e o r e t ic a l p r o b l e m s c o m e i n t o p l a y. P r i o r to a d d r e s s i n gt h is p r o b l e m , I s h al l r e s p o n d t o t h e p r o b l e m o f h o w h u m a n s c o n s t r u c t t h ei rind iv idua l r e a l it i e s .5 .3 . The Situational CycleB o t h t h e f e e d b a c k c i r c u i t a n d t h e f u n c t i o n a l c y c l e d e s c r i b e h o w l i v i n gs y s t e m s c o n s t r u c t t h e i r r e a l i t i e s a s " d w e l l i n g i n t e g u m e n t s " o r " s u b j e c t i v ee n v i r o n m e n t s . " A l o n e t h e y c a n n o t e x p l a i n h o w h u m a n s c o n s t r u c t t h e i rind iv idua l r e a l i t i e s ; t he y c a n , howe ve r , l e a d the wa y to suc h a m ode l .

T h u s i t i s h e l p f u l t o e s t a b l i s h h o w c l o s e l y t h e f u n c t i o n a l c y c l e m o d e lc o r r e s p o n d s t o F r e u d ' s t h e o r y o f in s t in c t s d e v e l o p e d i n h is e a r l y w o r k ,Psychology for Neurologists ( 1 8 9 5 ) , b e t t e r k n o w n a s Project. 35In Instinctsand Their Vicissitudes ( 1 9 1 5 ) . 36 F r e u d e l a b o r a t e s o n t h is m o d e l w i t h ad e s c r i p t i o n o f f o u r a s p e c t s o f i ns t in c t. T h i s m o d e l o u t l in e s t w o l e v e l s o fi n t e g r a t i o n i n a h i e r a r c h i c a l l y s t r u c t u r e d s y s t e m . O n t h e m o r e p r i m i t i v el e v e l , c e l l u l a r s y s t e m s w i t h i n t h e b o d y s a t i s f y t h e i r b i o l o g i c a l n e e d s i n amilieu intrieur c ons i s t ing o f " in t e r c e l lu l a r c he m ism s . ''37 Th e se p r oc e sse sc a n b e d e s c r i b e d i n e i t h e r p h y s i o l o g i c a l l a n g u a g e o r i n t h e l an g u a g e o f t h el iv ing sy s t e m ' s m o de l , in wh ic h s ign p r oc e sse s f unc t ion l ike those de sc r ibe din the f e e dba c k c i r c u i t .

I f t h e n e e d s o f t h e c e l lu l a r s y s t e m a t t h is l e v e l ( " i n s ti n c t u a l s o u r c e " )c a nno t be sa t i s f i e d , t he y a r e " t r a ns la t e d" in to a n " ins t inc tua l d r ive " on apsyc ho log ic a l l e ve l . A t th i s l e ve l t he in s t inc t ( o r d r ive ) c ons t r uc t s a sub -j e c t i v e r e a l i t y o u t o f s e n s o r y s i g n s w i t h a n " i n s t i n c t u a l o b j e c t " a n d a n" ins t inc tua l a im . " I n th i s r e a l i ty , t he r e sour c e s wh ic h a r e una va i l a b le inth e milieu intrieur c a n b e s o u g h t a n d f o u n d . T h e p r o c e s s e s a t t h i s l e v e lo f i n t e g r at i o n c a n b e d e s c r i b e d i n ei t h er p s y c h o l o g i c a l l a n g u a g e o r i n t h el a n g u a g e o f fu n c t i o n a l c y c l e s .

A s f o r h u m a n s , F r e u d h a s g i v e n u s a d e t a i le d d e s c r i p t i o n o f ho w , i n t h es o u r c e o f p s y c h o l o g i c a l d e v e l o p m e n t , t h e s e s i g n p r o c e s s e s g r o w m o r es o p h i s t ic a t e d . H e h a s a l s o s h o w n u s a w a y i n w h i c h t o m o d i f y a f u n c t i o n a lc y c l e m o d e l i n t o a " s it u a t io n a l c y c l e " m o d e l ( F i g u r e 3 ) .


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A N T H R O P O L O G Y A N D T H E T H O R Y O F M E D I C I N E 109

percevng ' ~ probemuaton

Situat ional cycleF i g . 3 . O n e o n l y n e e d s t o q u o t e F r e u d t o d e s c r i b e h o w a s i t u a t i o n a l c y c l e m o d e l d i f f e r sf r o m a f u n c t i o n a l c y c l e m o d e l . I n An Outline of Psychoanalysis 38 F r e u d w r i t e s : " B e t w e e ni n s t i n c t u a l d e m a n d a n d t h e a c t o f g r a t i f i c a t i o n t h e e g o a c t i v a t e s i n t e l l e c t u a l a c t i v i t y . T h i si n t e l l e c t u a l a c t i v i t y t h e n a t t e m p t s , a f t e r e v a l u a t i n g t h e p r e s e n t s i t u a t i o n a s w e l l a s p a s te x p e r i e n c e s , t o p r e d i c t t h e s u c c e s s o f t h e i n t e n d e d a c t i o n t h r o u g h t e s t a c t i o n s : I n t h i s w a yt h e e g o d e c i d e s w h e t h e r a n a t t e m p t a t g a i n i n g g r a t i f i c a t i o n s h o u l d b e c a r r i e d o u t o r p o s t -p o n e d , o r w h e t h e r t h e i n s ti n c t u a l d e m a n d s h o u l d b e c o n s i d e r e d t o o d a n g e r o u s a n d t h e r e f o r er e p r e s s e d . "

5.4. The Situational Cycle as an "Historical" ProcessS i g n p r o c e s s e s t h at r u n a c c o r d i n g t o t h e f e e d b a c k c i r cu i t o r t h e fu n c t i o n a lc yc le a r e inna te . The y ha ve no h i s to r y . On the o the r ha nd , s ign p r oc e sse sde sc r ibe d in the s i tuat iona l c yc le sc he m e a r e no t innate . T he y ha v e a h i s to r ywhic h to a l a r ge e x te n t i s t he h i s to r y o f a n " in t e l l e c tua l a c f iv i ty" tha t , ont h e b a s i s o f th e r e s u lt s a c q u i r e d f r o m " t e s t a c t i o n s , " d e c i d e s w h e t h e r o rno t the "u t i l i z a t ion o f m e a n ing " a c t iv i ty i s t o be re l e a se d .

T e s t a ct i o n s a l s o p r o d u c e a " r e a ti t y " f r o m " p e r c e p t i o n " a n d " a c t io n . " I nt h i s c a s e , h o w e v e r , t h e " p e r c e p t i o n a n d a c t i o n " b e l o n g t o t h e r e a l m o fm e m o r i e s a n d i m a g i n a t i o n w h i c h p r o d u c e a n " i n n e r r e a t i t y . " I n t e r v e n i n gb e t w e e n m e a n i n g a s s i g n m e n t a n d t h e u t i li z a t io n o f m e a n i n g , t h is " i n n e rr e a l i ty" t r a ns f o r m s the "p r im a r y p r oc e ss o f r e a c t ion " ( a s in the f unc t iona lc yc le m e c ha n i sm ) in to a " se c o nda r y p r oc e ss o f a c t ion" ( a s in the s i tua t iona lc yc le ) . We c o ns ide r th is inne r r e a l i ty a p r odu c t o f ou r f a n ta sy . Our f a n ta sy ,h o w e v e r , a c q u i r e s t h e a b i l i t y t o p r o d u c e a n " i n n e r r e a l i t y " o n l y i n t h ec o u r s e o f p s y c h o l o g i c a l d e v e l o p m e n t i n e a rl y c h i l d h o o d . T h e r e s u l t i s o u ri m a g i n a t i v e f a c u l t y . T h e i m a g i n a t i o n p r o d u c e s a m e d i u m i n w h i c h a b s e n to b j e c t s a n d p a s t e x p e r i e n c e s r e m a i n c u r r e n t .


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1 1 0 T H U R E V O N U E X K L LI n th e c o u r s e o f t h e l as t t w e n t y y e a r s , d e v e l o p m e n t a l p s y c h o l o g y h a s

u n d e r g o n e r e v o l u t i o n a r y c h a n g e s . S l o w m o t i o n a n d v i d e o r e c o r d i n g s h a v ei m p r o v e d t h e m e t h o d s o f d i r e c t o b s e r v a t i o n o f m o t h e r ( o r c ar e t ak e r ) a n dchi ld in te ract ion . 39'4 As a re su l t o f th ese im pro vem ents , the f oc us o f in te res ti s no long e r t he i so l a t e d c h i ld b u t r a the r t he " de ve lop ing sys t e m '4~ in w h ic hthe mo the r a nd c h i ld a r e - f i r s t t h r ough non - ve r ba l a nd on ly l a t e r t h r oughv e r b a l s i g n p r o c e s s e s - c o n n e c t e d t o e a c h o th e r.

The r e su lt s o f t he se obse r va t ions a l low us b r oa d ly to ou t l i ne the " h i s to r y"o f th e s i t u a t io n a l c y c l e a s a p r o c e s s o f m u t u a l i n t e r p r e t a t io n o f s i g n se x c h a n g e d b e t w e e n m o t h e r a n d c h i l d . H e r e , t h e m o t h e r a s s u m e s f o r t h ec h i l d t h e r o l e w h i c h t h e o u t e r w o r l d w i l l l a t e r o c c u p y .F i g u r e 4 s h o w s h o w a c h i l d i n a " s y m b i o t i c f u n c t i o n a l c y c l e " g i v e s t oc e r t a in s e nsa t ions ( e . g . hunge r ) t he me a n ing , " p r ob le m s i tua t ion . " The sese nsa t ions a r e the n e nc ode d in to s igns . The mo the r i n t e r p r e t s t he c h i ld ' ss igns , a nd in he r r e sponse r e so lve s the p r ob le m s i tua t ion . The c h i ld ' s s ignsa r e , so to spe a k , r e que s t s f o r t he s ign i f ic a t e , t o w h ic h the mo the r r e spond s .I n i t i a l l y t h i s " g a m e " t a k e s p l a c e w i t h i n a c e r t a i n f r a m e w o r k i n w h i c ht h e c h i l d d o e s n o t p e r c e i v e t h e m o t h e r o r h e r g r a t i f y i n g r o l e s a s a p h e -n o m e n o n s e p a r a t e f r o m i t s e l f .

I n t h e c o u r s e o f ti m e " s e l f a n d o b j e c t i s la n d s " b e g i n t o d e v e l o p a n d e v e n -tua l ly , i f a l l goe s w e l l , g r ow in to a n inde pe nde n t sub je c t a nd a n inde pe n -de n t ob je c t .

baby 1 1e l f i s land s ob jecct - is lands m o t h e r

4 % " C " ~ / ~ ~ ,'

Symbiotic functional cycleF i g . 4 . S y m b i o t i c f u n c t i o n a l c y c l e o f t h e " m o t h e r - c h i l d s y s t e m . " N o t e t h a t t h i s c i r c u l a rp r o c e s s b o t h p a r t n e r s l e a r n f r o m e a c h o t h e r . F r o m t h e g e n e r a t i o n o f a c o m m o n s e m i o t i cs y s t e m b o t h g a i n a " s e m i o t i e c o m p e t e n c e . "


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ANTHROPOLOGY AND THE THEORY OF MEDICINE 111From the aspect of a theory of signs, the "intermediary space" (described

by Winnicott42 in the "mother-child system") can be characterized as areality for two partners which gradually grows more sophisticated. In thecommon medium of this reality, each partner answers the other's ques-tions and in this manner helps the other to construct his or her individualreality. Seen from this viewpoint, the model of the situational cycle can beconsidered a model for a living system that consists of two (or more)people.

6. GENERAL SYSTEMS THEORY AND THE CONCEPTSOF "EMERGENCE" AND "HIERARCHY"The three models - feedback circuit, functional cycle, and situational cycle

- describe how, on a vegetative, animal, and human level, "reality" isproduced from very different signs. But how do we visualize the relationsbetween these levels? In order to answer this question, we taust reviewconcepts contained in the general systems theory.

A central feature of the general systems theory is located in the ancientformula rediscovered by Chr. von Ehrenfels, and after hirn, brought to lifeagain by L. von Bertalanffy: "The whole is more than the sum of its parts."With the integration of parts into the whole (of system), new, unforeseenfeatures suddenly emerge. These features are "more" than the sum of theparts. This process is termed "emergence."

This term also implies the presence of a hierarchical order. It describes,for example, how physical particles on a "higher level" are integrated withmolecules, and molecules integrated on a still higher level with cellorganelles. The cell organelles are then integrated with cells, the cells withorgans, the organs with the organism and, finally, the organism with socialsystems. Consequently, different "levels of integration" can be discerned.From these levels other sign systems emerge which, if we are to "under-stand" them, must be translated into human language, It is understandabtewhy so very different terminologies had to be used in out sciences. Therelationship between the different levels of integration are reflected inthe relationship between physics, chemistry, biology, psychology, andsociology.

How are these levels of integration related? The answer to this questionmust use "emergence" as its starting point. "Emergence" means the appear-ance of new signs along with new "meanings" as fresh systems are gen-erated. With this aspect in mind, we can view the connection betweendifferent levels of integration as "translations," that is, a "linking of


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1 1 2 T H U R E V O N U E X K L Lm e a n i n g " o r , i n p s y c h o a n a l y t i c a l t e r m i n o l o g y , " h y p e r c a t h e x i s . " A s a b i o -l o g ic a l p h e n o m e n o n , t h e p r o c e s s o f " l in k i n g o f m e a n i n g " w a s f i r st o b s e r v e dby P a v lov , w h ic h he de sc r ibe d a s " c ond i t ion ing . ''43W e h a v e s e e n h o w e l e c t r o c h e m i c a l s i g n s w i t h w h i c h t h e c e l l s o fo u r b r a i n " c o m m u n i c a t e " a r e , o n a m o r e c o m p l e x l e v e l , " t r a n s l a t e d " i n t os e n s o r y s i g n s f ro m w h i c h o u r re a l it y i s cr e a te d . T h e q u e s t i o n o f h o w t h el i n k i n g o f m e a n i n g b e t w e e n t h e e l e c t r o p h y s i o l o g i c a l s i g n s i n o u r b r a i na n d t h e p s y c h o l o g i c a l s i g n s o f o u r p e r c e i v e d r e a l i t y t a k e s p l a c e i s an e u r o p h y s i o l o g i c a l c o n c e r n . F u r t h e r m o r e , a s w e h a v e s e e n , i n t h e c o u r s eo f p s y c h o l o g i c a l d e v e l o p m e n t , p e r c e i v e d r e a l i t y i s i n v o l v e d i n a c o n s t a n te x c h a n g e w i t h t h e " i n n e r r e a l i t y . " T h i s e x p r e s s e s a n e w " l i n k i n g o fm e a n i n g " o r " h y p e r c a t h e x i s , " a n d t h e r e f o r e i t a c q u i r e s a p r e v i o u s l yu n k n o w n d i m e n s i o n o f d e p th . I t is i m p o r t a n t t o re a l iz e t h a t t h is d i m e n s i o nof de p th i s a p r e c ond i t ion f o r t he in t e g r a t ion o f i nd iv idua l r e a l i t i e s w i thsoc ia l r e a l i t i e s . I t i s i n t h i s soc i a l r e a l i t y t ha t hum a n be ings c a n c om m u-n ic a t e w i th one a no the r a nd s t i l l a c knowle dge the i r i nd iv idua l i t y .

7 . C ON C LUS I ON : TWO C ONS EQUENC ES F ORTHE C ONC EP T OF HEALTH

T h e m o d e l o f l i v i n g s y s t e m s h a s t w o c o n s e q u e n c e s f o r o u r c o n c e p t o fhe a lth . The f i r s t i s obv iou s , and ha s a l r e a dy be e n d i sc usse d : L iv ing sys t e m sa r e " a n topo ie t i c sys t e m s . '44 Thr oug h c ons t a n t s e l f -ge ne r a f ion , t he y ge ne r a t ea nd a r e a b le to m a in ta in the m se lve s .T h e s e c o n d c o n s e q u e n c e c o n c e r n s i l l n e s s a s a r e a l i t y o f t h e p a t i e n t -phys i c i a n r e l a t ionsh ip . F i r s t , a n a na logy : I n the sc he m e o f t he sym bio t i cf u n c t io n a l c y c l e a c o m m o n r e a l i ty i s p r o d u c e d i n th e m o t h e r - c h i l d s y s t e mt h ro u g h t h e c h i l d 's e n c o d i n g o f in c o m p r e h e n s i b l e b o d y s e n s a ti o n s i n to n o n -ve r ba l s igns in a p r ob le m s i tua t ion wh ic h the m o the r , i n t u r n , i n t e r p r e t s( i n a n o n - v e r b a l m a n n e r ) a s s h e s o l v e s t h e p r o b l e m . I n t h i s m a n n e r t h em o t h e r i n t e r p re t s , f o r e x a m p l e , t h e n o n - v e r b a l s i g n s w h i c h t h e c h il d c o m -m u n i c a t e s f o l l o w i n g s e n s a t io n s t h at i t h a s w h e n i t is h u n g r y ; s h e p r o v i d e snour i shm e n t a s t he s ign i f i c a t e . The m othe r i n t e r p r e t s t he non- ve r ba l s ignsw h i c h t h e c h i l d c o m m u n i c a t e s f o l l o w i n g s e n s a t i o n s w h e n i t l a c k s w a r m t h ;s h e p r o v i d e s w a r m t h , t h e r e b y s h o w i n g t h e c h i l d w h a t t h e s i g n s s ig n if y .I n t h e p h y s i c i a n - p a t i e n t r e l a t i o n s h i p , w e c a n o b s e r v e a n a n a l o g u o u sprocess , the only d i f fe rence be ing tha t th is process , to a ce r ta in ex tent , takesp l a c e o n a v e r b a l a n d c o g n i t i v e l e v e h T h e p a t i e n t e n c o d e s s e n s a t io n s ( e. g.p a in ) , w h i c h a r e t r o u b l i n g a n d b e y o n d h i s o r h e r u n d e r s ta n d i n g , i n to s i g n sw h i c h a r e p o s e d a s q u e s ti o n s f o r t h e p h y s i ci a n . T h e p h y s i c i a n m u s t i n te r-


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A N T H R O P O L O G Y A N D T H E T H E O R Y O F M E D I C I N E 113

p r et t h e s e s i g n s b y i n f o r m i n g t h e p a t i en t o f t h ei r s i g n i f ic a n c e w h i c h i s t h es o u r c e o f t h e p a t i e n t ' s e n q u i r y . A n y o n e w h o b e l i e v e s t h a t t h i s i s n o t h i n gm o r e t h a n a d i s c o u r s e o n d i a g n o s i s f a i l s t o u n d e r s t a n d h o w " s i c k n e s s "r e v e a l s i t s e l f a s a r e a li ty i n a " s e l f - d e v e l o p i n g s y s t em . " A s f o r m u l a t ed b yB a l i n t , 45 t h i s s y s t e m t a u s t c o n s i s t o f t h e p a t i e n t , t h e p h y s i c i a n , a n d t h es i c k n e s s .

R E F E R E N C E S

1 . W i n n i c o t t D W . Home is Where We Start From: Essays by a Psychoanalyst.H a r m o n d s w o r t h : P e n g u i n B o o k s , 1 9 8 6 : 1 3 .2 . P i ag e t J . Genetic Epistemology. N e w Y o r k : C o l u m b i a U n i v e r s i t y P r e s s , 1 9 73 .3 . U e x h l l T h . v o n . F r e u d , d i e P s y c h o a n a l y s e u n d da s p s y c h o s o m a t i s c h e P r o b l e m . Psyche

1 9 9 0 ; 4 4 : 4 4 5 - 4 5 8 .4 . F r e u d S . F o r m u l a t i o n s o n t h e tw o p r i n c i p l e s o f m e n t a l f u n c t io n i n g ( 19 1 l ) . I n : F r e u d S .

The Standard Edition of the Complete Psychological Works of Sigmund Freud 12.L o n d o n : T h e H o g a r t h P r e s s , 1 9 5 8 : 2 1 3 - 2 2 6 .

5 . Ib id : 2136 . E r d h e i m M . Die gesellschaftliche Produktion von Unbewusstheit. Eine Einfhrung inden ethnopsychoanalytischen Prozess. Fr an k f u r t a .M. : Su h r k amp , 1 9 8 2 .7 . B a l in t M. The Doctor, His Patient and the lllness. 2 n d e d . L o n d o n : P i t m a n M e d i c a l ,

1964.8 . P i ag e t J . DerAufbau der Wirklichkeit beim Kinde. G e s a m m e l t e W e r k e , v o L 2 . S t u t tg a r t:

Kle t t , 1975:89 .9 . D e s c a r t e s R . Meditationen ber die Grundlagen der Philosophie. P h i l o s o p h i s c h e

B i l i o t h e k 2 5 0 a . H a m b u r g : F e l i x M e i n e r , 1 9 6 2.1 0. W e i n e r H . D i e G e s c h i c h t e d e r p s y c h o s o m a t i s c h e n M e d i z i n u n d d a s L e i b - S e e l e -

P r o b l e m i n d e r M e d i z i n . Psychotherapie und medizinische Psychologie 1 9 8 6 ; 3 6 : 3 6 1 -391.

1 1. U e x k l l T h . v o n . P s y c h o s o m a t i k a l s S u c h e n a c h d e m v e r l o r e n e n le b e n d e n K r p e r .Psychotherapie, Psychosomatik, Med. Psychologie 1 9 91 ;4 1 :4 6 5 - 5 0 0 .1 2 . M l l e r J . Handbuch der Physiologie des Menschen fr Vorlesungen. v o L 1 . Ko b len z :

V e r l a g J . H o l s c h e r , t 8 3 5 .1 3 . M l l e r J . Handbuch der Physiologie des Menschen fr Vorlesungen. v o l . 2 . Ko b len z :Ver l ag J . Ho l sch e r , 1 8 4 0 .1 4 . Gin z b u r g C . Spurensicherung. B e r l i n : V e r l a g K l a u s W a g e n b a c k , 1 9 8 3 .1 5 . N th W . Handbuch der Semiotik. Stu t tg a r t : I .B . Me tz l e r , 1 9 8 5 :2 6 .1 6. G i n z b u r g C . Spurensicherung.1 7. F o u c a u l t M . The Birth o f the Clinic. An Archaeology of Medical Perception. t ransl .

S e r i d a n S m i t h A M . L o n d o n : T a v i s t o c k P u b l i c a t i o n s , 1 9 8 1 .1 8 . Ue x k l l J . v o n . Theoretische Biologie. Fr an k f u r t a .M. : Su h r k amp , 1 9 7 3 .1 9. U e x k l l J . v o n . Der Sinn des Lebens. Gedanken ber die Aufgaben der Biologie,mitgeteilt in einer Interpretation der zu Bonn 1824 gehaltenen Vorlesung des Johannes

Mller: Von dem Bedrfnis der Physiologie nach einer philosophischen Natur-betrachtung (1947) . Stu t tgar t : Ernst Kle t t , 1977 .2 0 . L a n g e r S K . Philosophy in a New Key: A Study in the Symbolism of Reason, Rite andArt. 3 r d e d. C a m b r i d g e : H a r v a r d U n i v e r s i t y P re s s , 1 95 7.2 1 . K u h n T S . The Structure of Scientific Revotutions. 2 n d c d , C h i c a g o : U n i v e r s i t y o fC h icag o Pr ess , 1 9 7 0 .


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1 1 4 T H U R E V O N U E X K U L L2 2 . T o e l l n e r R . Medicina Theoretica - Medicina Practica. Das Problem des Verhltnisses

von Theorie und Praxis in der Medizin des 17. um 18. Jahrhunderts. W i e s b a d e n : F r a n zSte in e r Ve r l ag , 1 9 82 .2 3 . B e r n f e l d S , C a s s i r e r - B e r n f e l d S . Bausteine der Freudbiographik. F r a n k f u r t a . M . :Su h r k amp , 1 9 8 1 .

2 4 . S e e U e x k l l T h . v o n . Paradigma und Paradigmawechsel in den Naturwissenschaftenund der Medizin. Die Aufgabe der Psychosomatik. V o r t ra g a u f d e r T a g u n g d e r D K P Min Dr es d en , 1 9 91 .

2 5 . S e e G i n z b u r g C . Spurensicherung: 7 3 .2 6 . W e i z s c k e r V . v o n . S o z i a l e K r a n k h e i t un d s o z i a l e G e s u n d u n g ( 1 9 30 ) . In : Gesammelte

Schriften 8. F r a n k f u r t a . M . : S u h r k a m p , 1 9 8 6 : 3 1 - 9 1 .2 7 . A n t o n o w s k y A . Health, Stress and Coping: New Perspectives on Mental and PhysicalWeUbeing. San Fr an s i sco : Jo ssey - B r ass , 1 9 7 9 .2 8 . M a t u r a n a H R . Die Organisation und Verkrperung von Wirklichkeit. Wissenschafts-

theorie, Wissenschaft und Philosophie. B r a u n s c h w e i g - W i e s b a d e n : V i e w e g V e r l a g , 1 98 2.2 9 . C h r i s t i a n P , H a a s R . W e s e n u n d F o r m e n d e r B i p e r s o n a l i t t . G r u n d l a g e n f r e i n e

m e d i z i n i s c h e S o z i o l o g i e . I n : W e i z s c k e r V . v o n , e d . Beitrge aus der allgemeinenMedizin 7. Stu t tg a r t : Fe r d in an d En k e Ver l ag , 1 9 4 9 .3 0 . N t h W . Handbuch der Semiotik. Stu t tgar t : I .B . Metz ler , 1985 .

3 1. U e x k l l J . v o n . B e d e u t u n g s l eh r e . I n : U e x k l l J . v o n . T h e t h e o r y o f m e a n i n g . Semiotica1 9 8 2 ;4 2 :1 .3 2 . U e x k U T h . v o n . N a t u r w i s s e n s c h a f t a l s Z e i c h e n l e h r e . Merkur 1 9 8 9 ; 3 : 2 2 5 - 2 3 4 .

3 3. U e x k l l J . v o n . Theoretische Biologie.3 4 . U e x k l l J . v o n , K r i s z a t G . Streifzge durch die Umwelten von Tieren und Menschen

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1 6 4 : 1 3 9 - 2 0 7 .3 6 . F r eu d S . I n s t in c t s an d th e i r v i c i s s i tu d es ( 1 9 1 5 ) . I n : F r eu d S , ed . The Standard Editionof the Complete Psychological Works of Sigmund Freud 14. L o n d o n : T h e H o g a r t h P r e s s,1 9 5 7 : 1 0 9 - 1 4 0 .3 7 . F r eu d S . Th e o r ig in s o f p sy ch o - an a ly s i s ( 19 5 0 ) . I n : F r eu d S , cd . The Standard Editionof the Complete Psychological Works of Sigmund Freud 23. L o n d o n : T h e H o g a r t h P re s s ,1 9 6 4 : 1 3 9 - 2 0 7 .

3 8 . F r eu d S . An o u t l in e o f p sy ch o - an a ly s i s ( 1 9 3 8 ). In : F r eu d S , ed . The Standard Editionof the Complete Psychological Works of Sigmund Freud 1. L o n d o n : T h e H o g a r t h P r e s s ,1 9 6 4 : 1 7 5 - 2 8 0 .3 9. P a p o u s e k M . F r h e P h a s e n d e r E l t e m - K i n d - B e z i e h u n g . E r g e b n i s s e d e r e n t w i c k l u n g s -b i o l o g i s c h e n F o r s c h u n g . Praxis der Psychotherapie und Psychosomatik.

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theorie, Wissenschaft und Philosophie.4 5 . B a l in t M. The Doctor, His Patient and the lllness.

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