SYMPTOMS
Signs and Symbolism in Medical Discourse
by Maryann Delea
Whether it is regarded as disease or illness, whether it occurs in a society practicing biomedicine or a culture practicing indigenous medicine, sickness is universal. Diseases and illnesses of all types plague each and every society throughout the world. Central to the idea of sickness is the diagnostic element of the symptom. Although many cultures have unique ideologies regarding sickness, healing, and efficacy, these cultures use the symptom as the primary instrument to maintain their culturally constructed idea of health. Regardless of the healing system or society, globally, people tend to use the symptom as a tool to communicate illness to the appropriate medical practitioner. In seeking the healing action of practitioners and the advice of friends and family, the sick communicate their symptoms as a way of receiving social legitimization for their illness. Thus, symptoms are also used by the sick to gain legitimization of the sick role from society.
Just as culture is integrated in the beliefs and behaviors of every society, symptoms are deeply embedded in the concept of sickness and healing. Symptoms add clarity to the complex ideas of sickness and healing in such a way that it is difficult to discuss either process without touching on these symbols. The symptom is regarded as a vital part of the illness experience because it offers insight into the physiological and psychological aspects of the patient’s body. In this way, the symptom symbolizes the roots of a tree, anchoring a societal understanding of medical knowledge and healing etiologies. Therefore, it is the purpose of this paper to explore the significance of symptoms and determine their centrality to a culture’s ideas of sickness and healing. Related topics such as the symptom’s significance in the process of social legitimization of illness and its symbolic nature will serve to supplement and support the argument that symptoms are, in fact, central in the process of healing.
Definition and Importance of the Symptom
Due to the intricacy of the symptom, it is difficult to construct a simple definition. Illness symptoms are “differently labeled by individuals in dissimilar social situations” (Browner 1983: 494). Certain etiologies such as those found in biomedicine maintain that disease occurs when an external pathogen enters the body and disrupts physiological homeostasis. Therefore, symptoms are not believed to be part of the “patient’s concept of his intact body” (Casell 1976: 145). In this rite, symptoms are viewed as the manifestation of bodily malfunction. On the other hand, non-western ideologies explain disease causation as an object intrusion, spirit intrusion, an act of witchcraft, or the result of soul loss or neglected/transgressed social taboos (Low 1985). Therefore, in non-traditional health care systems, symptoms are believed to be manifestations of the intrusion of the supernatural. Although it may seem logical that different civilizations with diverse illness ideologies would have different definitions for symptoms, certain commonalities regarding the definition of symptoms exist among these civilizations. For instance, most cultures do support the belief that symptoms are the manifestation of illness, whether it is the cause of a pathogen or a spirit invasion. Therefore, the symptom enables a person to report self-experiences of health on a day-to-day basis. These self-reported experiences can be used to “establish relationships between physical symptoms, psychological factors, and health actions” (Brown et al. 1994: 378).
Having a clear definition of the symptom is imperative, but just as vital is having an understanding of why symptoms are important. The symptom is of great significance because “everywhere, sickness and healing are primal human concerns” (Telles and Pollack 1995: 1). The concept of feelings, in the form of symptoms, also becomes important because they often act as threads that bind the aspect of health to the personal concept of human emotion. In this rite, feelings are important in the definition of health and illness. The way an individual feels is a “prime criterion of health, illness, and recovery” (Telles and Pollack 1981: 243).
The symptom is of great social significance in the way it “reflects both the individual’s relations in the social system and represents cultural participation; it is a help-seeking behavior of individuals or families attempting to re-establish a balanced sociocultural state” (Low 1985: 190). These statements are important because they shed light on the social and cultural component of the symptom.
While the personal significance of the symptom is important, the vitality of the symptom extends beyond personal emotions and cultural boarders. Symptoms function as a linguistic bridge that strengthens not only communication and understanding between the patient and the practitioner, but also communication between cultures and within society in general. The symptom plays more or less the “role of language action…” (Foucault 1973: 92). Without the linguistic support of the symptom, it would be interesting to imagine how the patient would convey the feelings of the discontinuity of health to his or her practitioner. It would also be interesting to imagine how the patient’s perception of sickness, healing, and treatment would be altered due to this lack of linguistic communication. It may be argued by some that certain professional health practitioners would be nonexistent altogether. Therefore, if for no other reason, the symptom is vital for the communication of illness between many people in many health care systems.
On the other hand, it may be argued that the vocal communication of symptoms is not important. Rather, it is the interpretation of these symptoms that become vital to health care. For instance, when communication of symptoms seems to “taint the truth behind the illness,” (Ohnuki-Tierney 1984). Symptoms are often powerful enough to speak for themselves. This is evidenced by Emiko Ohnuki-Tierney’s observation of kanpo physicians who request that their patients not tell them their self-perceived symptoms before they have had the chance to observe them (1984). Although this lack of communication of symptoms may be important to the kanpo system, this muting may be detrimental to other health care systems such as biomedicine. Without the verbal communication of symptoms, biomedical physicians may not be able to collect vital information regarding a particular illness. Biomedical physicians have become so dependent on the five senses that it would be easy to overlook important biological information that did not manifest itself in visible symptoms or test results. Therefore, many cases would result in erroneous treatment therapies that were themselves a shot in the dark.
The linguistic communication of symptoms may also reveal the cultural construction of health ideology within a culture. The manner in which a person presents his or her symptoms may communicate how a person within the society views illness. Eric J. Cassell discovered the language of doctor-patient interaction within a biomedical health care system revealed that symptoms are frequently signified by the impersonal “the” or “it” forms (1976). For example, a forty-three-year-old woman in Cassell’s study impersonally referred to her cancer when she asked her physician to “Make it go away” (Cassell 1976: 144). Cassell’s research on the linguistic presentation of symptoms disclosed the “reflection of the mind-body relationship” (1976: 143). The presentation of the impersonal pronouns suggests that patients within the biomedical system view symptoms as external indications of disease pathogens. However, different cultures may not share this belief in the Cartesian dualism; these cultures may hold the disease to be a natural process that the body goes through in order to rid itself of a toxin or a possessed spirit. In this situation, the disease and the symptom may be regarded as one with the self.
Other researchers, such as Setha M. Low, have pointed out that the verbalizing of symptoms communicates more than just bodily discomforts. Low believes that verbalizing symptoms is a “communication about self and the self’s relation to the social systems expressed through a disturbance or ‘discontinuity’ of the body perception” (1985: 190). In this sense, the personal experience of enduring a symptom becomes extended to the social system.
As many of these great minds have pointed out, it is very difficult to even discuss health and sickness without calling to mind the concept of the symptom. The extent to which the linguistic implications have on a given health care system does not matter. What does matter is that the communication of the symptom—whether that is a verbal presentation of symptoms or merely the silent healer’s interpretation of the manifested symptoms—is a key influence in the healing process. Therefore, the symptom is regarded not only in many cultures and countless medical systems as the indicator of sickness, but the core concept to which diagnosis, treatment, and legitimization attend.
Symptoms as Symbols
Contrary to Deborah R. Gordon’s belief that symptoms are merely a “patient’s [somatic] complaints,” (1988: 25), the argument presented in this paper holds that this definition of the symptom is too simple. Symptoms are symbolic and complex explanatory tools. Symptoms provide the sick person and the practitioner an opportunity to understand the cause behind a physiological or psychological ailment. The symptom is the form in which the disease is presented: “of all that is visible, it is the first transaction of the inaccessible mature of disease” (Foucault 1973: 90). However, the symptom is also symbolic of the activities that may be occurring inside the sick body. Indeed in this situation, that the “signs” of sickness are actual “signs of truth” (Foucault, 1973), and the symptoms themselves resemble a symbol of the illness. Through the process of interpreting symptoms, it is the work of medical practitioners of all types to perceive the invisible in the manifested symptoms (Foucault 1973). It is during this process of interpretation that the symptom “abandons its passivity as a natural phenomenon and becomes a signifier of the disease” (Foucault 1973: 92). Since individuals are not able to “see into [their] bod[ies], feelings [in the form of symptoms] provide the lay-person with a way to detect illness and to follow its course” (Telles and Pollack 1981: 247). This is evidenced by the numerous individuals who take zinc lozenges at the onset of a sore throat.
In the same way symptoms are symbols of illness, they are often symbolic of the extent to which illness may extend. For instance, somatic symptoms are often symbolic of other psychological, social, or interpersonal problems (Low 1985). The complexity of a symbol and the complexity of a symptom go hand in hand. Different types of health practitioners can also interpret symptoms differently. Although criteria defining sickness may differ between cultures, most practitioners do rely on symbols and symptoms to help them determine what is ailing their patient. Disease is the collection of symptoms, and the definition of disease depends on the health practitioner’s interpretation of the symptoms (Foucault 1973). The interpretation of the symptom is culturally constructed, and the cultural interpretation of the symptom plays a crucial role in the diagnosis and treatment of the symptom. Therefore, several ambiguities may result from the consultation of a single patient between several differing medical systems.
What is considered a proper diagnosis for a given set of symptoms in one culture may be construed as inappropriate in another culture. For example, in France, systematic prescription of lactobacillus to accompany the prescription of antibiotics is a common practice (Payer 1982). Although French theory supports that lactobacillus prevents the nausea caused by the destruction of good bacteria in the stomach by the antibiotic, this theory has yet to be experimentally proven. Therefore, this prescription of lactobacillus for nausea in patients receiving antibiotics may be viewed by some societies as the act of over-prescribing, and the symptom of nausea may be overlooked.
Culture and Legitimization of Symptoms
Healing is viewed differently across cultures and “in different sectors of health care” (Kleinman and Sung 1979: 8). The perception of symptoms and the way in which they are integrated into the healing process of a culture distinguishes the concept of health and healing between these cultures. Although each person may perceive sickness in a unique way, (Hahn 1995) symptoms allow the “invariable form of the disease to show through” (Foucault 1973: 90). This theory of invariability is the basis for the universal treatment that allopathic biomedical physicians give for a given set of symptoms.
As previously discussed, culture is imperative to the perception of a symptom. While some cultures, such as those supporting biomedicine, depend solely on physically visible symptoms, other more non-traditional cultures give value to inner workings of the body in the form of invisible symptoms. Cultural factors often dictate the severity of symptoms, therefore influencing the treatment a patient may receive. Cultural ideas play a “central role in determining who seeks medical attention, for what conditions, when, and with what results” (Hahn 1995: 68). For example, diarrheal diseases are taken seriously in many African societies because they are closely related to dehydration, and ultimately death. However, in most western cultures, diarrhea is not considered a severe symptom; therefore, most children do not seek medical care for this problem that can easily be remedied in the home environment.
Different aspects of symptoms affect the healing process of the patient in several ways. For example, if a biomedical physician does not believe the patient is presenting socially legitimate symptoms, the physician may choose to deliver a placebo to the patient. The placebo effect is an example of the power of culture on a person’s perception of symptoms. The beliefs of the patient manifesting the placebo effect illustrate how culture can shape the healing process. If western biomedical societies did not stress the importance of taking medication as part of the effective healing process, the psychological benefits of the placebo would cease to exist. Therefore, the placebo effect is closely tied to the legitimization process.
Like the placebo effect, the legitimization process is culturally constructed and socially controlled. In biomedical health care systems, when individuals visit the physician, they are often examined “in light of reported feelings, behavior and other symptoms in order to establish whether or not illness exists” (Telles and Pollack 1981: 247). People may also seek others within their culture in regards to the management of their illness, and in doing so; they also seek legitimization for the symptoms they manifest before seeking the help of a practitioner. The actual presentation of symptoms “absolves the individual of responsibility and provides a culturally acceptable distress signal” (Low 1985: 191) to the community a signal that will legitimize the sick role.
The sick role is known as the title one receives when he or she has maintained social legitimization for his or her symptoms. Benefits of the sick role occur when the presentation of the symptoms “absolves the individual of responsibility and provides a culturally acceptable distress signal” (Low 1985: 191). However, the benefits that a patient may receive while participating in the socially legitimized sick role may be put to an end by the healer (Finkler no date). This termination of the sick role often occurs when the patient and the healer have different concepts of efficacy, as evidenced by the numerous occasions in which the healer fails to eradicate the disease before terminating the sick role. When this occurs, the disease often re-emerges in the form of a “somatized syndrome” (Finkler no date). Abuse of the socially prescribed sick role occurs quite often. This abuse occurs when individuals perceive “some psychological or social reward from occupying a sanctioned sick role, these symptoms represent illness in the absence of disease” (Kleinman 1980: 366). The abuse of the sick role occurs when people linger within the role beyond the socially legitimated length of time. Patients assigned to the sick role are “anticipated to pass through the system, not to remain within it” (Alexander 1982: 351). The social legitimization of disease, the assignment of the sick role, and the abuse of the sick role are all discussed here to illustrate the crucial role that the manifestation and presentation of symptoms play in the cultural legitimization of illness and the process of healing.
Culture is a vital element in medicine because it helps determine not only what a legitimate symptom may be, but it also dictates how the practitioner should treat the symptom, and the extent to which the treatment therapy should be employed. For example, before repetition injury syndrome (RSI) and chronic fatigue syndrome were researched and socially accepted as legitimate illnesses, the biomedical society was quick to judge people suffering from these illnesses as malingerers and would often order a psychological consult (Reid 1990). It was difficult for societies supporting biomedicine to categorize these syndromes as illnesses due to the lack of visible symptoms. RSI has been described as “an illness for which there was no pathogen, characterized by symptoms in the absence of signs, and pain without discernible damage” (Reid 1990: 170). This example also sheds light on the importance of signs. Without bodily signs, symptoms are difficult for society to legitimate. The sign is the larger truth that announces and “indicates that which is further away” (Foucault 1973: 91). Every culture has rules for “translating signs into symptoms, for linking symptomatologies to etiologies and interventions, and for using the evidence provided by interventions to confirm translation and legitimate outcomes” (Telles and Pollack 1981: 245). The presence and interpretation of these signs indicates underlying truths regarding the symptoms present.
As opposed to biomedicine, societies supporting non-traditional health care systems take more stock in “invisible symptoms” (Foucault 1973). Charles L. Briggs’s investigation of the Warao curers of the Delta Amacuro of east Venezuela illustrates the importance of invisible symptoms in this Venezuelan society. In his investigation, Briggs sheds light on the fact that the Warao curers treat many invisible symptoms such as those inflicted by a “ray whipping around inside their [patient’s] bodies…” (1994: 149).
From the aforementioned examples, one can see that culture absorbs information about symptoms and signs and dictates what diagnoses and treatments would be culturally acceptable. In this sense, symptoms are given “sociocultural meaning based on the [cultural] values” (Low 1985: 188) that dictate the social and health care systems. Therefore, symptoms are valued in many cultures as the key to health and healing.
Conclusion
Symptoms are an integral part of the healing process in numerous ways. While the concept of the symptom may seem straightforward, one can see that the symptom is deeply embedded in many aspects of an integrated culture. The symptom may initially seem to merely “play a simple role, primary in nature,” (Foucault 1973:91) but without this vital actor, the cast of the healing process would be incomplete. The presence of the symptom not only indicates to the patient that illness is present, but it also initiates the process of healing when presented to the practitioner. The healing process is thus considered complete when the symptoms and the illness disappear. While some may argue that symptoms are merely somatic complaints, these people are blind to the intricate details that assemble the process of healing.
The argument presented in this paper would be deficient without the discussion of the enormous bearing to which symptoms have on culture and the legitimization of illness as a social process. The specific examples and discussions of research projects and case studies presented in this paper offer supplemental evidence of the symptoms centrality to the healing process. Just as it would be difficult to discuss the process of healing without mentioning the symptom, a thorough discussion of the symptom itself would be incomplete without a discussion of the healing process. As discussed in the previous sections of this paper, the symptom functions similarly within many otherwise different cultures. Although the copious societies throughout the world maintain assorted ideologies regarding sickness and health, the significance placed on the symptom by each of these cultures creates the impression that the symptom is universally central to the concept of healing. Therefore, as long as sickness and healing remain universally important concepts, the symptom itself will remain a vital attribute to the ideologies of health and healing.
References
Alexander, Linda (1982). Illness maintenance and the new American sick role. In
Clinically Applied Anthropology. N.J. Chrisman and T.W.W. Marezki, eds. Pp 351-366: D. Reidel Publishing Company.
Briggs, Charles L. (1994). The sting of the ray: Bodies, agency, and grammar in Warao
Curing. Journal of American Folklore 107)423): 139-166.
Brown, C., S. Rowley, and P. Helms (1994). Symptoms, health, and illness behavior in
Cystic Fibrosis. Social Science and Medicine 39(3): 374-379.
Browner, Carole H. (1983). Male pregnancy symptoms in urban Columbia. American
Ethnologist: 494-510.
Cant, Sarah, and Ursula Sharma (1996). Demarcation and transformation within
homeopathic knowledge: A strategy of professionalization. Social Science and Medicine 42(4):579-588.
Cassell, Eric J. (1976). Disease as an “it”: Concepts of disease revealed by patient’s
presentation of symptoms. Social Science and Medicine 20:29-37.
Finkler, Kaja. Non-Medical treatments and their outcomes. 271-310.
Foucault, Michel. (1973). Birth of the Clinic. Random House.
Gordon, Deborah R. (1988). Tenacious assumptions in Western medicine. In
Biomedicine Examined. M. Lock and D.R. Gordon, eds. Pp 19-56.
Hahn, Robert A. (1995). Sickness and Healing: An Anthropological Perspective. Yale
University Press.
Hunt, Linda M., et al. (1989). Compliance and the patients’ perspective: Controlling
symptoms in everyday life. Culture, Medicine, and Psychiatry 13(315-334).
Kleinman, Arthur (1980). Patients and Healers in the Context of Culture: An Exploration
of the Borderland between Anthropology, Medicine, and Psychiatry. Berkley: University of California Press.
Kleinman, Arthur, and Lilas H. Sung (1979). Why do indigenous practitioners
successfully heal? Social Science and Medicine 13B:7-26.
Low, Setha M. (1985). Culturally interpreted symptoms or culture bound syndromes: A
cross-cultural review of nerves. Social Science and Medicine 21(2):187-196.
Melmed, R.N., et al. (1986). Montaigne’s insight: Placebo effect and symptom
anticipation are two sides of the same coin. The Lancet:1448-1449.
Montogmery, Kathryn (1991). Doctor’s Stories. Princeton University Press.
Ohnuki-Tierney, Emiko (1984). Illness and Culture in Contemporary Japan: An
Anthropological View. Cambridge University Press.
Payer, Lynn (1982). Medicine and culture: Varieties of treatment in the united States,
England, and France. Clinically Applied Anthropology: Anthropologists in Health
and Science Settings. Noel J. Chrisman and Thomas W. Maretzki, eds. Boston: D. Reidel Publishing Company.
Reid, Janice (1990). Requiem for RSI: The explanation and control of an occupational
epidemic. Medical Anthropology Quarterly 4(2):162-190.
Telles, J.L., and M.H. Pollack (1981). Feeling sick: The experience and legitimization of
Illness. Social Science and Medicine 15A:243-251.
Yoder, P. Stanley, and Robert C. Hornik (1996). Symptoms and perceived severity of
illness as predictive of treatment for diarrhea in six Asian and African sites.
Social Science and Medicine 43(4):429-439.
