And the Flesh in Between: Towards a Health Semiotics

Abstract

The call for a biosemiotic perspective within medical semiotics has been steadily increasing over the late twentieth and early twenty-first centuries. In Food and Medicine: A Biosemiotic Perspective, Yogi Hale Hendlin, Johnathan Hope, and the nine contributions in their edited volume boldly seek to bridge the segregation between nature and culture in the medical sciences as well as in the medical humanities. To a large extent, they achieve this aim by explicating the sign relations in food and medicine, the sign relations of medical theory and practice, and the sign relations between the biology in medicine and medicine of society. Taking up a semio-historical approach, I contextualize two select contributions from Hendlin and Hope’s Food and Medicine with the medical semiotics of the Hippocratic tradition. By comparing the biological semiotics from the contributions to the medical semiotics from the Corpus, I critically explicate the ways in which biosemiotics moves this subdiscipline forward and why the perspective is significant not only for the health of humans, but also for the health of other animals, and indeed for the health of the planet that we all inhabit together. On these grounds, I propose a turn from medical semiotics to health semiotics. This program for semiotics would encompass not only food and medicine, but also lifestyle and wellbeing, as well as the subjective, qualitative perspectivism that makes biosemiotics frontier research, thereby constituting a biosemioethics and promoting a semiotic fitness.

Food and Medicine: A Biosemiotic Perspective, edited by Yogi Hale Hendlin and Johnathan Hope, is the twenty-second title in the Biosemiotics series from Springer Nature. The nine contributions in this edited volume perceive the study of signs by a Janusian light. At one and the same time, the contributors gaze into the past and look to the future of the semiotic discipline. In other words, the perspective within this volume is not only a history, whereby the contributors record events and trace ideas, but also a manifesto, whereby they put forward a course of action. For the purposes of this review, therefore, I blend multiple scientific genres, including the book review that critiques and summarizes an individual work and the literature review that clarifies and synthesizes a group of works. Taking up a semio-historical approach, I contextualize two select contributions from Hendlin and Hope’s Food and Medicine, those by Simona Stano and by Dawn M. Nowlin, with the medical semiotics of the Hippocratic tradition. To establish the connection between contemporary biological semiotics and classical medical semiotics, Italian semiotician Susan Petrilli states, “implies a great responsibility for the semiotician,” because doing so goes beyond theoretical reason into “practical reason,” thereby conferring upon the study of signs “a commitment that is of an ethical nature [because it] concerns the health of life” (2003, p. 98).¹ Such a recovery of medical semiotics for biological semiotics is epistemically justified on a “genealogical” level as well as a “global” level, as Petrilli identifies (2003, p. 98), given the interest of contemporary biological semiotics, like classical medical semiotics, in semiosis and life as well as the involvement of sign functions, processes, and relations between the human organism and planetary health. By comparing the biological semiotics from Hendlin and Hope’s edited volume to the medical semiotics from Hippocrates’ Corpus, I critically explicate the ways in which biosemiotics moves this subdiscipline forward and why the perspective is significant not only for the health of humans, but also for the health of other animals, and indeed for the health of the planet that we all inhabit together.

Semiotics and medicine have long been interconnected. As Hendlin and Hope establish briefly at their beginning entrée (2021, p. 1), Hungarian-born American polymath Thomas A. Sebeok (1920–2001), one of the founders of biosemiotics, taxonomizes (1) medicine, (2) linguistics, and (3) philosophy as “‘the semiotic tripod’ [that] fashioned the field” (1979, p. 6). Across intellectual histories, these semiotic traditions have alternated between dependent and independent, Sebeok admits, yet medicine stands as the “uneven leg upon which semiotics rests” (1985 [1976], p. 181). Indeed, as John Deely illustrates in his Mouton D’Or Award-winning lexicography (2003, pp. 10, 26–27), the very etymology of semiotics itself (from the Latin sēmeîon after the Greek σηµεῖον) exemplifies the extent to which the diagnosis of disease and the study of signs have synchronously developed as scientific disciplines over the past two thousand five hundred years. The first usage of semiotic terms in English, rather than in Greek, Arabic, or Latin, traces to texts written by physicians in the seventeenth century, such as James Hart’s The Anatomy of Urines (1625, p. 13), Henry Stubbe’s Plus Ultra Reduced to a Non Plus (1670, p. 75), and, selectively lionized by the latest semioticians, John Locke’s An Essay Concerning Human Understanding (1700 [1690], p. 437). By applying the computational methods of corpus linguistics to medico-semiotic sub-corpora, some researchers, such as Kamran Karimullah (2020, pp. 13–14), demonstrate how it is more the translation processes and less the textual sources that have imbued classical medicine with contemporary semiotics. But whatever the degree of semantic drift for semiotic terminology, the semiotics in medicine certainly does constitute the first cause and the prime mover for all semiotics today, from the Continental, Saussurean, linguistic tradition, to the Anglo-American, Peircean, pragmatic tradition, and from cultural semiotics, to biological semiotics. Already looking back at the entangled histories between semiotics and medicine from the point of view of the emergent contemporary semiotics of the late nineteenth century, German non-fiction author Rudof Kleinpaul (1845–1918) explains how the “medical profession has a science they call semiotics” and eulogizes the Greek physician Hippocrates of Kos (c. 460 − 375 B.C.E.) as “the father and master of all semiotics” (1888, p. 103). Sebeok defines how semiotics described “the sensible indications of changes in the condition of the human body” (1985 [1976], pp. 3–4), was established in the Hippocratic Corpus in the fifth and fourth centuries B.C.E., and then expanded in the Galenic Corpus in the second and third centuries C.E. For instance, carrying forward the Hippocratic-Galenic institutes of Humoral medicine, Arnaldo de Vilanova classifies in A Mirror of Medicinal Introductions c. 1308 CE (Taurellus, 1585, p. vii, translated by the author) the way in which “Semiotics: The Prognostic Vision” (“Semuoticen [sic.]: De Prognosticatione viſionum”) constituted one of the several branches of medical science (Fig. 1). However, by the mid to late nineteenth century, medical historian Wolfgang Eckart notes, “the term ‘semiotics’ [was being] replaced by ‘diagnostics’” for title pages of medical textbooks (1998, p. 1704). Around the same time, semiotics began to take on new meanings as it gradually developed into a modern discipline. As Hendlin and Hope highlight, “the relation between food and medicine, as they both pertain to health and life” (2021, p. 2), has been discursively essential to the semiotic program from the earliest days of its historical progenitors. What is more, Hendlin and Hope illuminate in their introduction the fact that the classical authors of the Hippocratic Corpus considered “what is medicine and what is food” as belonging to one and the same category (2021, p. 2). In the medical semiotics of the Classical Mediterranean, not only the body of the patient but also the phenomena from their environment could offer up a sign, or at least something like a sign , for interpretation. Empirical observations about how the environment outside affects the health inside began to be evidentiarily organized during the paradigm shift from belief in supernatural causation to reason about natural correlation, that is, with the rise of natural philosophy, as exemplified by the proto-semiotics of “Hippocrates.”² By exploring the ways in which signs of health are determined not only in the body, or even from the environment to the body, but rather between these inner and outer environments, Hendlin, Hope, and the contributors to their volume Food and Medicine: A Biosemiotic Perspective revitalize this classical semiotics for contemporary medicine.

Fig. 1

This tree diagram represents the medical taxonomy for the Humoral medicine of the Hippocratic tradition and the hierarchical relation between proper medicine, particular knowledge, medical theory, and the semiotic gaze. The diagram is based on German medical philosopher Nicolaus Taurellus’s 1585The Complete Works of Arnald of Villanova that, in turn, is based on Catalan physician Arnald de Vilanova’s c. 1308 A Mirror of Medicinal Introductions (Taurellus, 1585, p. vii). © Schiller 2022

In their edited volume, Hendlin and Hope introduce a biosemiotic approach to medical semiotics on a specific as well as a general semiotic level. Of course, the specific, applied semiotics in the medical sciences, like when Vilanova classifies the semiotic gaze or what he calls “Semiotics: The Prognostic Vision” in the early fourteenth century (Taurellus, 1585, p. vii, translated by the author), is not at all the same thing as the general, theoretical semiotics of the medical sciences, like when French philosopher Michael Foucault characterizes “the medical gaze” in his knowledge archaeology for medical epistemology and the power relations of institutionalized medicalization (1994 [1963], p. 9). But while semiotics originally developed through medicine, it has also been recently applied to medicine. German medical doctor and philosopher of medicine Thure von Uexküll (1908–2004), who pioneered the fields of psychosomatics as well as biosemiotics, describes the difference between “semiotics in medicine” and “semiotics of medicine” as the difference between investigating “the meaning of signs for illness” and investigating “medicine itself as a sign system, i.e., with signs that make the interaction between patients, physicians, and nursing personnel possible” (1982, p. 207). However, the earliest call for a contemporary semiotics not just in but also of medicine was articulated by British epidemiologist Francis Graham Crookshank (1873–1933). A controversial figure in his day and in ours because he advocated for racism, eugenics, and ableism, Crookshank tends to be dependably referenced but not deeply read in semio-historical accounts of medical semiotics (Sebeok, 1985 [1976], pp. 13n23, 126). Perhaps ironically given his prejudiced ideologies, Crookshank recognizes how diseases do not “exist in rebus Naturae,” that is, in things of nature, and are neither “Platonic realities” nor “universals ante rem” (1923, p. 342), that is, timeless entities independent from the signs used to represent them, just out there, waiting to be discovered. Rather, Crookshank considers “disease-concepts” to be constructed through “general references” as a matter of “mental convenience” (1923, pp. 341–342). As French literary and semiotic theorist Roland Barthes (1915–1980) puts it fifty years later, in what is the first explicit usage of the term medical semiotics (or rather, of the term “medical semiology”), a symptom becomes a sign only through clinical discourse “by the mediation of language” (1972, p. 39). In other words, a sign of health or unhealth, as with many, if not most, other signs, is at least in part something culturally, historically, and socially constructed to stand for something else. Despite early insights from Kleinpaul (1888), and Crookshank (1923), among others, the contemporary subdiscipline of medical semiotics did not start to emerge until after the generalization and the globalization of the semiotic discipline in the mid to late twentieth century. Sebeok was determined that semiotic theory and medical practice should be subjected to what he describes as a “reconvergence” after the “decisive turn” at the Indiana University Conference on Paralinguistics and Kinesics in 1962 (1985 [1976], p. 182), a turn which he felt derived from the discussion that followed German-born American psychiatrist Peter F. Ostwald’s (1928–1996) presentation on patient-physician communication (1964). To this day, however, medical semiotics has received comparatively little application (for the latest review as of this writing, see Tredinnick-Rowe & Stanely, in press). And this semiotic subdiscipline is only just now being revitalized in parallel to the proliferation of the health or medical humanities. In the most recent monograph to bear the title Medical Semiotics, for example, Marcel Danesi and Nicolette Zukowski (2019) carry forward the verbocentric approach to medical semiotics that was first contemplated by Crookshank (1923), Foucault (1994 [1963]), and Barthes (1972). Certainly, health signs must be considered without contextomy or ahistoricism. But, as Danesi and Zukowsi also conclude, “events and states in the body that will lead to disease or illness” still have significance for patient-physician verbal interaction, the differentiation between the categories health versus unhealth, and metaphors for illness (2019, p. 85), especially when embedded with such encodings. American neo-pragmatist semiotician Charles W. Morris (1901–1979), who took a behavioral – even a biological – approach to Peircean semiotics, and was, therefore, one of the direct progenitors of the biosemiotics discipline, describes how semiotics has a “double relation” with the other sciences because “it is both a science among the sciences and an instrument of the sciences” (1938, p. 2). Consequently, the utility of semiotics for the unification of science, Morris demonstrates, comes from the ways in which semiotics is “a general language applicable to any special language or sign, and so applicable to the language of science and specific signs which are used in science” (1938, p. 3). To establish “a historical-theoretical link” between contemporary semiotics and classical semiotics, as Petrilli contends, is to expand the cross-inter-multi-poly-transdisciplinary study of signs from the human sciences to the natural sciences (2003, p. 97–98), and, indeed, vice versa. Biosemiotics, in contrast to semiology, centers around not only the verbal semiotic (from the Latin sêma after the Greek σῆµᾰ) but also the nonverbal somatic (from the Latin sôma after the Greek σῶµα). Cultural semiotics can address the ways in which social conditions and societal contexts, which in the medical sciences are referred to as social determinants of health (SDOH), affect not only our language for but also how we live with the triad of unhealth: disease, illness, and sickness (for a discussion of such terms, see Boyd, 2000). But only biological semiotics can account for the role and importance of the individual organism, organism-environment interaction, and environmental physiology within this making of meaning. It is in this way that Hendlin, Hope, and the other contributors to Food and Medicine: A Biosemiotic Perspective build upon as well as go beyond previous semiotic projects both in and of medicine.

The call for a biosemiotic approach to medical semiotics has been steadily increasing over the late twentieth and early twenty-first centuries, first implicitly (e.g., Sebeok 1985 [1976], p. 182; Uexküll, 1982, p. 205; Baer 1988; Schonauer, 1994, p. 8; Hucklenbroich, 2003, pp. 2699–2700), then explicitly (e.g., Petrilli, 2003; Colaguori & Danesi, 2017; Tønnessen, in press; Tredinnick-Rowe & Stanley, in press). Hendlin and Hope’s Food and Medicine: A Biosemiotic Perspective answers this call. Or, at least, it begins to. The intellectual genesis for this edited volume began with a panel on Food, where one of the editors and two of the contributors presented, during the Eighteenth Annual Biosemotics Gathering at the University of California, Berkeley in 2018. Continuing that conversation, the primary objective of the nine contributions is to explicate the entanglement of the environment in the health signs of living systems, thereby encompassing anthroposemiotic, ecosemiotic, phytosemiotic, as well as zoosemiotic semiospheres. Medicine, ultimately, Thure von Uexküll maintains, is “concerned with human beings, in whom processes of life from the molecular and biological to the psychological and social levels are merging into each other;” consequently, medicine “must try to grasp the unity of the life processes in question” (1982, p. 205). By completing the circle of life and by connecting the chain of being through a post-humanist, if not anti-humanist, view of humanity and its futures, Hendlin and Hope’s edited volume makes a truly significant contribution not only to semiotics but also to medicine. Food and Medicine: A Biosemiotic Perspective is extremely relevant for research areas such as medical bioclimatology, medical ecology, and medical geography, as well as food studies, the health or medical humanities, postcolonial studies, sugar studies, and trauma theory, to name but a few. As John Tredinnick-Rowe and Donald Stanley propose in their entry on the topic, “Semiotics in Health and Medicine,” in the latest multivolume reference series, Bloomsbury Semiotics (in press), one possible approach for bridging semiotics in medicine, semiotics of medicine, and between these semiotics and biosemiotics is via Estonian-born German biologist Jacob von Uexküll’s (1864–1944) Umweltentheorie (German for environmental theory). In what is perhaps the seminal monograph on medical semiotics, upon which Hendlin and Hope ground their endeavor (2021, p. 1), American philosopher and semiotician Eugen Baer (1937–) states that what “is of primary importance for a medical semiotics” is how life, from single-celled eukaryotic microorganisms, to Homo sapiens, and beyond, is “conceived in each case as a subject [that] constitutes the center of its Umwelt” (German for environment or surrounding), which, in turn, the organism “supplies with objective traits based on its own subjective capacities” (1988, pp. 27–28). Indeed, Baer investigates, what Uexküll introduces is the concept of the subject – that is, of the self – as the “organizing principle of the biological Umwelt” (1988, p. 282), and, thus, of the biosemiotic approach to medical semiotics. As Hendlin and Hope open their odyssey, a nutritious or medicinal substance as well as a nutritional or medical science can have meaning only in relation “to the constellation of other factors in the Umwelt or environment in which they occur” (2021, p. 2). The contributions to this volume seek to untangle certain Umwelten (German for environments or surroundings in the plural of the noun), insofar as they relate to a semiotics of health, without simplifying complexity through biological reductionism or environmental determinism. Given the current global environmental crisis, rising food and medicine insecurity, and the great climate migration that has already begun, this endeavor could not possibly be more urgent.

Several of the contributors to Hendlin and Hope’s Food and Medicine: A Biosemiotic Perspective contextualize their semiotics in relation to the physician Hippocrates and the Hippocratic Corpus, which includes not only the foundational theory in Western thought about food and medicine but also the proto-semiotic basis for this biosemiotic perspective. Today, the so-called Hippocratic Corpus survives as a heterogeneous collection of sixty or so medical treatises from the late fifth and early fourth centuries B.C.E., written in the Ionian subdialect of Ancient Greek, with different styles and diverse subjects. However, as classicist Elizabeth M. Craik evinces (2015, pp. ix, xx), not one of the many treatises from the Corpus can be definitively attributed to Hippocrates. Although Plato, Aristotle, and other contemporaries testify both to Hippocrates’ existence and his eminence. Given this distribution of authorship over individual textualizations and translational iterations, when one refers to Hippocratic semiotics, or more properly Hippocratic proto-semiotics, one does not refer to the semiotics concretized by Hippocrates during his lifetime, but rather one refers to the semiotics codified across the Hippocratic Corpus in the years around then. Within the Hippocratic Corpus, the authors commonly use terms from the word family for sign, sometimes, but not always, differentiating to a degree between sign (from the Latin sēmeîon after the Greek σηµείου), symptom (súmptōma after σύµπτωµα), and syndrome (sundromḗ after συνδροµή). But for the bulk of the aphorisms from the Corpus, classical philologist and medical historian Volker Langholf points out, “there is no explicit mention of signs” (1997, p. 914). Instead, Langholf infers, only “causal or temporal connections between facts are given” (1997, p. 914). Such connections, Langholf contends, can be interpreted “according to the scheme ‘post hoc ergo propter hoc’” (1997, p. 914). The informal fallacy of questionable cause (“After this, therefore because of this.”) can be expressed in the quasi-natural language of formal logic (“A occurred, then B occurred. Therefore, A caused B.”). In the Prognostics from the Corpus, a monograph-length work on the role of semiotics and “clinical signs” in medicine (Hippocrates, 2022, Vol. II, p. xii), “the concept of ‘sign’ (sēmeîon) does not play a more important role” than correlating that which co-occurs, Langholf concedes, and “there is no fundamental reflection on the process of semiosis” in the cognition of physicians beyond its predictive function (1997, p. 914). Even so, the semiotics can be seen to vary between the contributions to the Corpus. In the elementary semiotic model of the early Hippocratic Corpus, with its apagogical logic still from preclassical thought, Langholf explains, the physician classifies the patient symptomology into “one of several traditionally predetermined illness-sign complexes,” which are then “subdivided as necessary,” such that any “disease pattern” or “illness picture” (“Krankheitsbild” in German) can be differentiated from any other by the specific combination of classifiable symptoms (1997, p. 916). Whereas, in the advanced semiotic model of the later Hippocratic Corpus, such as in the Prognostics, Langholf expands, the physician analyzes the patient symptomology according to the “signs of the illness” and their specific combination, which can then be classified either as “one of the illness pictures from the older approach” or with other cases based upon the similarity between symptoms to “discover new, previously unknown” illness-sign complexes (1997, p. 917). Of course, the more nosological approach from the earlier Hippocratic Corpus, which classifies unhealth top-down from sign categories, as well as the more semiotic approach from the later Hippocratic Corpus, which analyzes unhealth bottom-up from signifying processes, have continued in practice. Now like then, Langholf notes, nosology also lingers, productively, “as one of several perspectives” (1997, p. 916). But the shifting of the paradigm led attitudes toward nosology to change. According to the author of On the Art of Medicine in the Hippocratic Corpus, which rhetorically functions as an epideixis on epistemology, “names are conventions,” whereas the “real essences [of disease substances] are not conventions but the offspring of nature” (Hippocrates, 1923, Vol. II, p. 193). The relationality, and indeed the oppositionality, between nature (physis in Latin after Φύσις in Greek) and convention (nomos after νόµος) has, if anything, only become more and more significant for semiotics both in and of medicine. In contemporary medical practice and theory, anthropologist Kathryn V. Staiano-Ross asserts, a symptom is “generally regarded as non-arbitrary” in relation to that for which it stands, and as “indexical, directly motivated by its object,” but still dependent for its semiotic meaning on “inclusion within a system of signs” or code, that is produced “synchronically or diachronically,” and that “point[s] to a ‘disease’ or labeled disorder” (1986, p. 2). Fundamentally, for the classical author(s) of the Hippocratic Corpus (Fig. 2), the physician observes the patient symptomology according to (1) the phenomena in the environment (E_n) and the specific combination of classifiable symptoms in the environment (± E_n); as well as (2) the phenomena in the body (B_n) and the specific combination of classifiable symptoms in the body (± B_n); and then (3) interprets the similarities more than the differences between patient cases and presenting combinations within a code of possibilities to make a semiotic – that is, a diagnostic or a prognostic – classification of a disease in the body (D_n), which can, of course, also be subclassified as necessary (D_n). The semiosis here amounts to little more than: “E in the environment occurred, then B in the body occurred. Therefore, E in the environment caused B in the body.” After all, Baer argues, “The Hippocratic Moment” construes signs as “bodily cues that allow inferences based on observation,” but this “medical sign tears itself away from philosophy and from divination” (1988, p. 47, see also p. 51), while being constrained by its oracularity. Nevertheless, it is through such a semiotics that several treatises in the Hippocratic Corpus, including On Places in Man, as well as On Airs, Waters, and Places, among others, interpret the relationality between the outer environment of the planet and the inner environment of the human.

Fig. 2

This network diagram represents the semiotic gaze in nosological classification as the Hippocratic author(s) describe in Airs, Waters, and Places (Hippocrates 2022, Vol. I, pp. 64–145). However, icons have been selected to exemplify this procedure based not on historical reference but rather contemporary relevance. Were the medical semiotics of the Hippocratic tradition still practiced today, the physician would observe the patient according to environmental phenomena (E_{climate/sunlight}, E_water, E_land/soil, E_n) and environmental symptoms (± E_{industrial agriculture}, ±E_{genetic modified organism (GMO)}, ±E_{chemical fertilizers}, ±E_{chemical pesticides}, ±E_n), as well as bodily phenomena (B_genetics, B_nutrition, B_{fitness/wellness}, B_n), and bodily symptoms (± B_neurologic, ±B_cardiologic, ±B_immunologic, ±B_dermatologic, ±B_n), and then interpret these signs to classify (D_n) or subclassify (D_n) a disease in the body. © Schiller 2022

Hendlin and Hope’s Food and Medicine: A Biosemiotic Perspective carries forward these foundational considerations about the complexity of the divide between the biological and the cultural as well as the continuity of the dualism between the natural and the artificial. For example, Simona Stano, in her chapter on “Food, Health and the Body: A Biosemiotic Approach to Contemporary Eating Habits,” refers to the classical authors of the Hippocratic Corpus and the way in which they understood that not only medicine (phármaka in Latin after φάρµακα in Greek) but also food (sition after σιτίον) “can be used to cause changes in the state of the body” (2021, p. 43). According to the author(s) of On Places in Man, which is thought to be one of the earliest treatises in the Hippocratic Corpus (Craik, 2015, p. 162), and which Stano cites but neither quotes nor references (2021, p. 43), all “substances that change the state of the patient” may function as medication, however it is possible “to bring about change by means of a medication [or] by means of foods” (Hippocrates, 1998, Vol. VIII, p. 89). As Stano proposes, Hippocratic theory is important today for the biosemiotic approach to medical semiotics because it assumes “a process of ‘interpretation’” of foods by bodies (2021, p. 44). In Places in Man, “Hippocrates” (1998, Vol. VIII, p. 85) asserts that when food is correctly measured, the body is nourished by food, and food is mastered by the body. However, when food cannot be changed into something different, that is, when food cannot be mastered by the body, then food takes mastery. And the same holds true for medicine. “Hippocrates” argues that “the correct measure is narrow,” and “when the physician goes beyond” it, the benefits of the medicine “turn to their opposites” (1998, Vol. VIII, p. 87). In other words, to “Hippocrates” as well as to Stano, the main question for medical semiotics is not whether a binary sign refers to a natural or an artificial object but rather how a triadic sign is transformed by interpretation. When food or medicine is changed by the body, as addressed in the Hippocratic Corpus, “then it follows necessarily that the person to whom it is administered also be changed,” given that “the body, being changed” (Hippocrates, 1998, Vol. VIII, p. 87), can indeed make the situation worse. To help prevent such adverse reactions, the Hippocratic author(s) of Places in Man claim that physicians have “a fixed principle” that preexists in nature from which to perceive “the forms in which correct measure in medicine [including food] is and is not to be recognized” (1998, Vol. VIII, p. 87). If such a final code did – or even could – exist across every circumstance and context, that is, between every subject, then it would encompass what are now called the recommended dietary allowance (RDA), prescribed daily dose (PDD), and other standard quantity measurements for food and/or medicine. But, as Stano bemoans about food in particular, the industrialization and globalization of agriculture have made “food processing opaque” (2021, p. 45). This lack of transparency has in turn led to a greater and greater concern not only in nutritional science but also in society at large about food composition and its health consequences. To semiotically unwrap such nutritional packaging, Stano draws upon Barthes’ mythologies (1977 [1961]) as well as Uexküll’s Umwelttentheorie (2010). Of course, to include the biological semiotic perspective is not to exclude the cultural semiotic perspective but rather to accept that one can inform and enhance the other (see, for example, Cobley, 2016). Many, if not most, contributions in Hendlin and Hope’s edited volume draw upon the Crookshank-Foucault-Barthes as well as the Sebeok-Uexküll-Baer medical semiotic traditions, albeit the logics between these levels can be more fuzzy than fine. As Stano demonstrates, to focus “exclusively on the properties of food, independently from its context of consumption and its interaction with the body consuming it” (2021, p. 50), cannot in and of itself provide insight into its interpretive processes.

Consider the case: Bioengineered food contains detectible genetic material that has been modified using technology in ways that do not occur naturally. Consequently, the naturalness of this food can be called into question. Stano explores the ways in which the biology of nutrition relates to the language for naturality. Institutional entities extensively adopt a code of classes that are based on the processes of the creation rather than on the characteristics of the product, which is to say, as Stano criticizes, on “arbitrary codes” (2021, p. 50), that depend not only upon biological materials but also upon cultural values. At least in part because of this confusion, the meaning of terms like bio(logical), natural, and organic, let alone the complex realities behind these related concepts, is communicated with neither clarity nor coherency across food production, distribution, and consumption. As Stano highlights (2021, p. 50), there is not yet sufficient evidence in the medico-scientific literature to support the claims that non-genetically modified organism (non-GMO) food is healthier. What is more, to evaluate ultimate healthfulness other health factors would have to be considered that relate not only to immediate human health but also to extended planetary health. For instance, the fungicides, herbicides, and pesticides used for treating natural foods can differ little from those used for treating artificial foods, resulting in potentially chronic health effects such as endocrine disruption or neurological toxicity. There is also still much debate over whether organic farming can directly lead to climate-smart agriculture or can indirectly lead to higher carbon dioxide emissions that intensify rapid global warming, resulting in increased complications to underlying conditions such as cardiovascular and respiratory diseases. Nonetheless, in talk about food, the natural-organic tends to be differentiated not only in relation but also in opposition to the artificial-synthetic. That is, Stano testifies (2021, pp. 52–55), food is described by characteristics that it does not possess and by processes that have not been used in its creation, such as when natural food is emblematized as free-from, or when artificial food is emblematized as Frankenfood. Across the spectrum of –isms that constitute early twenty-first century food ideologies, which Stano investigates, food tribes and their foundational totems “tend to emphasize the ‘poisonous’ character […] of food as a phármakon” or medicine (2021, p. 55). This romanticization of naturality can be traced back to antiquity, as exemplified by the Hippocratic Corpus, where it is only the “real essences” that are truly “the offspring of nature” (Hippocrates, 1923, Vol. II, p. 193; emphasis mine). Much like the Hippocratic authors of Places in Man, Stano concludes that nutrition “is necessarily a contextual act” (2021, p. 57), and, consequently, that food should not be considered only in relation to its substance. On the ecosystemic level of the exosemiotic Umwelten (outer environment in German), Stano claims, food relates to “the sociocultural environment in which one eats” and shares their experience with others (2021, p. 57). While, on the organismic level of the endosemiotic Innenwelten (inner environment in German), Stano contends, food is “not simply ingested, but more properly ‘incorporated,’ that is to say, interpreted” (2021, p. 57), as a biological material that has cultural meaning and as a cultural material that has biological meaning.

Perhaps the first systematic endeavor to explicitly set forth not only the correlative relations but also the causative relations between the ecological and the pathological is On Airs, Waters, and Places. Believed to have possibly been written by Hippocrates himself in the mid to early fifth century B.C.E. (Craik, 2015, pp. 8–11), Airs, Waters, and Places served as a prognostic treatise for traveling physicians. According to the author(s), “[a]nyone who wishes to investigate medicine correctly” should first and foremost “consider the seasons of the year and the effects they can have,” the “winds, both hot and cold,” and “the potencies of the waters” (Hippocrates, 2022, Vol. I, p. 73), among other environmental factors. Upon arrival to town, “Hippocrates” recommends that a traveling physician also should attend the “mode of life [that] the inhabitants prefer” (2022, Vol. I, p. 75), including, for instance, their drink, food, labor, and sport. The reason for this method, which infers wellbeing from lifestyle, the Hippocratic author(s) clarify, is that a physician can “find both the bodily form and the character of inhabitants assimilated to the nature of their land,” and, therefore, can “take these observations as [a] model” when drawing their conclusions (2022, Vol. I, pp. 141, 143), particularly those constituting part of a diagnostic, or a prognostic, – that is, a semiotic – procedure. However, in much, if not all, of the Hippocratic Corpus, little to no differentiation is made between correlation, causation, and indeed chronology itself. If A stands for an element of the environment, and if B stands for the health of a human, then the statements A entails B (A ⊨ B), A implies B (A ⇒ B), and A therefore B (A ∴ B), are relatively interchangeable. In other words, if a phenomenon in the environment occurs, and if a disease in a human occurs, then the phenomenon is understood to have caused the disease. The logic behind this anachronism, Langholf asserts, “lies in the nature of many signs of illness, [which] not only indicate things to come, but also has immediate consequences of its own” (1997, p. 913). Cause, sign, and the pathogenesis from cause to sign is interpreted synchronically as an indexical symptom. Of course, such an act of semiosis lacks the differentiation between sign and symptom that develops in more recent medical semiotics, both modern and contemporary. In On the Natural Part of Medicine in 1542, for instance, French physician Jean François Fernel categorizes a triad of types, which includes “natural” signs (“naturalis” in Latin), and signs that are “beyond nature” (“praeter naturam”), as well as “against nature” (“contra naturam”) (2003 [1567], pp. 464–465). A successor to Hippocrates and predecessor to Uexküll, writing between classical medical semiotics and contemporary biological semiotics, Fernel differentiates between natural signs, like those that relate to the “body constitution,” and non-natural signs, like those that relate to “the varied substance and faculty of foods,” that, consequently, have “the power of outside causes” (2003 [1567], p. 255). As medical historian Roger French details, Fernel describes how “[s]igns were the bigger category and included symptoms, so that every symptom was also a sign,” where a “symptom is not a symptom of a disease, but a sign that relates to causes, to disease or to accidental results of a cause” (1998, p. 1356), as with food, medicine, and other things that originate from the outer environment. But the development of a semiotics is not specifically determined in the Hippocratic Corpus. In fact, the Hippocratic author(s) only use “the term ‘sign’ (sēmeîon [or σηµεîa]) once” in Airs, Waters, and Places, Langholf highlights (1997, p. 918), when they make the conditional statement that if “the signs are regular,” then “the year is likely to be very healthy” physically (Hippocrates, 2022, Vol. I, pp. 101, 103), by which the author(s) mean not only environmental signs but also astrological signs. In this way, Langholf identifies, “Hippocrates” interprets the environmental factors behind illness causation to be “facts from which other facts inevitably followed” (1997, p. 918). For instance, “Hippocrates” infers that “if the winter is southerly, rainy and mind, and the spring is northerly, dry, and stormy,” then “women who happen to be pregnant and whose delivery is due toward spring are likely to have an abortion [or] children that are weak and sickly,” and men will have “dysenteries and dry ophthalmias” (2022, Vol. I, pp. 103, 105). Within the Hippocratic Corpus, the element of the environment does not stand for the health of the human. It is not an antecedent that relates to a consequent through the logic of implication (A ⊃ B | A → B), or something that stands for something else (aliquid stat pro aliquo), as in the Hellenistic Stoics’ definition of sign from the early third century B.C.E. Rather, an element of the environment leads to the health of the human. Something in activity, climate, medicine, nutrition, weather, or any other such factor (A) is a necessary and sufficient condition for dis-ease or ill-health (B) rather than a sign in and of itself (A ⇒ B ∧ B ⇒ A | A ⇔B). Given this logic and its limitations, Hippocratic proto-semiotics should be understood to be more an ancient progenitor to semiotics than an actual practice in semiotics, at least insofar as semiotic theory is seen today, when it is saturated with meta-analysis and self-reflexivity.

Hendlin and Hope’s edited volume builds upon and goes beyond Hippocrates’ Corpus by modelling signs of health, their functions, processes, and relations, and how they can be transformed by interpretation. For example, Dawn M. Nowlin, in her chapter on “The Role of Biosemiosis and Dysfunctional Signaling Processes in Human Pathology,” refers to the classical authors of the Hippocratic Corpus and the way in which they “recognized that foods can elicit inappropriate reactions that are idiosyncratic” (2021, p. 159). Indeed, the first account of food allergy, at least in occidental culture, is generally attributed to “Hippocrates” (Sampson, 2016, p. 363). According to the author(s) of Ancient Medicine in the Hippocratic Corpus, a food, such as cheese, “does not harm all people alike,” because some “can eat their fill of it without the least harm, indeed those with whom it agrees are wonderfully strengthened,” whereas others “have difficulty tolerating it” (2022, Vol. I, p. 53). Different people have different constitutions, “Hippocrates” argues, a difference that “lies in the constituent[s] of the body that is hostile,” and a difference that “is roused and stirred into action” under the influence of this or that food (2022, Vol. I, p. 53). Today, of course, the semiotic agency behind this specific “hostile humor” has been identified to be immunoglobulin E (IgE), an antibody produced by the immune system, that mediates the allergy (Cohen, 2008, p. 1521). As Nowlin considers in her novel contribution (2021, p. 158), adverse reactions to foods and/or medicines include the nonimmune-mediated reactions termed intolerances as well as the immune-mediated reactions termed allergies. These different adverse reactions demonstrate the degree to which a fallibilism of interpretation is a feature of semiosis, as American pragmatist Charles S. Peirce (1839–1914) made explicit in “Fallibilism, Continuity, and Evolution” in 1893. But already in Air, Water, Places, the Hippocratic author(s) differentiate how “if the [summer] weather is northerly and dry,” then it can be “very beneficial [to the phlegmatic]” but “very harmful to the bilious” (2022, Vol. I, p. 107). Despite the antiquated Humorism, the Hippocratic author(s) are correct: different bodies interpret differently, whether interpreting a sign that relates to disease, environment, food, or medicine. Especially given such variability, the Hippocratic author(s) write in Ancient Medicine that it is “not sufficient to learn simply [that some or other food] is a bad food, since it gives a pain, [but] one must also know what the pain is, the reasons for it, and to which constituent of the person [this food] is uncongenial” (2002, Vol. I, p. 53). Taking up this issue in her contribution to the volume, Nowlin confronts what she terms “errant defense” (2021, p. 158), or perhaps, more properly, aberrant defense, which she characterizes as any pathological, negative, or abnormal physiological response to a nonthreatening stimulus as if it is a threatening stimulus. Aberrant defense, to use a term consistent with medico-scientific lexicography (aberrant) rather than chivalric romance literature (errant), may be a response to a stimulus that originates exosemiotically, endosemiotically, or, ultimately, through an encoding between the two. And it may involve a response from one or more body systems. But certainly, Nowlin concludes, aberrant defense “can lead to perilous outcomes, as is seen in cases of anaphylaxis” (2021, p. 158), for example. Recently, aberrant defense has been only all-too-often attributed to immunological error, like with adverse reactions, or with autoimmune diseases. However, Nowlin (2021, pp. 159, 163) calls for a critical reevaluation of this current model, as she contends that aberrant defenses between diverse systems, in addition to the immune, need to be recognized and studied because this phenomenon may suggest a pervasive disorder for general pathology.

To this end, Nowlin classifies a triad of conditionings that contribute to pathology. Nowlin bases her typology on the study of conditioned learning in behavioral psychology, which began in earnest with Russian neurologist Ivan Pavlov (1849–1936) and the kennel of canines upon whom he conducted his experiments. According to Nowlin, types of pathological conditioning may include, for instance: (1) respondent conditioning, also known as Pavlovian conditioning, whereby a conditioned stimulus becomes associated with an unconditioned stimulus, primarily because of temporal co-occurrence, to the extent that both trigger the same response; (2) sensitized conditioning whereby repeated stimulus exposure causes amplified response; and (3) valuation conditioning whereby a previously neutrally or positively valuated stimulus is re-encoded into a negatively valuated stimulus, which Nowlin considers to be “likely the most common with pathological conditioning” (2021, p. 166). Fundamentally, the aberrant defense of pathological conditioning affects the interpretation of a sign and its object by the body and its systems in a manner that is harmful to the organism. Exploring such events, Nowlin (2021, pp. 156–157, 172) adapts Uexküll (2010) to articulate her pathological conditioning model by applying his functional cycle model. To model a hostile humor using classical Hippocratic medical semiotics, A in the environment occurs, then B in the body occurs, therefore A causes B. Whereas, to model an aberrant defense using contemporary Uexküllian medical semiotics, the subject interprets the stimulus not anachronically but synchronically. As Nowlin explains (2021, p. 172), the “conditioned stimulus” sensed by exteroceptive or interoceptive receptors (CS), the “unconditioned stimulus” or “drive activator” that activates the drive state (US), and the “drive state” response whether positive-appetitive or negative-aversive (R), link together via associative learning to alter the meaning and valuation of the authentic, original stimulus (S) – that is, the sign. Consider the case (Fig. 3): A mid-adolescent male is intentionally misdiagnosed with a mental health disorder by a child psychologist who is not only the father of this adolescent but also the perpetrator of his abuse. At the instigation of the abuser-caregiver-doctor, because of his exaggeration, fabrication, and induction of symptoms of illness, and due to this medical malpractice, psychiatrists misprescribe psychopharmacological treatment. Even after escaping from this harmful care and withdrawing from this unnecessary medicine, the adverse effects from the psychological misdiagnosis and the psychopharmacological misprescription (serotonin syndrome including, but not limited to, seizures) have become pathologically coupled with the sensory stimuli from the child abuse (post-traumatic stress disorder). For the survivor of medical child abuse (MCA), consequent to the pathology that combines respondent, sensitized, as well as valuation conditioning, traumatic stimuli in the environment subsequently trigger aberrant defenses in his body. Simply put, triggering language now causes seizure episodes. By highlighting the role and importance of “faulty signaling and learning processes” in the health conditions of the human population, Nowlin suggests that a biosemiotic approach to medical semiotics could well “lead to therapeutic interventions that specifically target the reflex and potentially treat the underlying cause” (2021, p. 176), in other words, to a medicine that is at one and the same time more individualized and more holistic.

Fig. 3

Adapted from Uexküll (2010) and Nowlin (2021, p. 172). © Schiller 2022

This Uexküllian Function Circle Model represents the pathological conditioning of aberrant defense.  With pathological conditioning, the stimulus or sign is received by the perceptual organs at the same time other inputs are received, thereby creating a learned association of the stimulus for the subject, that alters the meaning and the valuation by the effector organs. In this case, the conditioned stimulus of the psychological misdiagnosis and the psychopharmacological misprescription (represented by the icon of a pill), the aberrant defense of the serotonin syndrome and its seizures (represented by the icon of electricity in the brain) that serves as an unconditioned stimulus to this conditioned stimulus during further exposures, and the drive state response (represented by the icon of gears in the brain) that negatively-aversively valuates this medical child abuse, link together via associative learning, subsequently triggering this aberrant defense for traumatic stimuli – here, the very signs of medicine itself (represented by the icon of electricity in the brain overlapping the icon of a pill).

Taken as a whole, Hendlin and Hope’s Food and Medicine: A Biosemiotic Perspective, as exemplified by Stano and Nora’s chapters in the volume, critically explicates with high excellence the ways in which our health as humans is importantly connected to and inextricably dependent on the environments in which we live. Over the past fifty years, historical progenitors of this biosemiotic perspective have been variously termed “medical semiology” (Barthes, 1972), “clinical semiotics” (Shands & Meltzer, 1975; see also Shands 1970), “diagnostic semiotics” (Kahn, 1978; see also Kahn, 1983), and, within the very biosemiotic tradition itself, “medical semiotics” (Uexküll, 1982). However, I propose the use of the term health semiotics rather than medical semiotics. In terms of taxonomy: The semiotic discipline includes several subdisciplines (e.g., biosemiotics, cognitive semiotics, cultural semiotics, cybersemiotics, literary semiotics, social semiotics, etc.). The biosemiotic subdiscipline includes several branches (e.g., anthroposemiotics, ecosemiotics, phytosemiotics, zoosemiotics, etc.). From these, either individually or jointly, a study in health semiotics and its subfields (e.g., medical semiotics, nutritional semiotics, etc.) may be undertaken. Health semiotics could encompass not only food and medicine, but also lifestyle and wellbeing, as well as the subjective, qualitative perspectivism that makes biosemiotics frontier research. Health semiotics would also be consistent with the thematic as well as the terminological turn from medical humanities to health humanities over the last decade. After medical historian George Sarton introduced the term “medical humanities” in the mid-twentieth century (1948, p. 127), this field of study has at last begun its “maturation” through “an ongoing debate about the scope and the goals” (Ahlzén, 2007, p. 385). The shift in paradigm from medical to health suggests what Craig M. Klugman and Therese Jones portray as “a decentering of medicine” (2022, p. 6). That is, health humanities embraces inclusivity and engages interdisciplinarity (Jones et al., 2014, p. 7), thereby encompassing different health practices and diverse health processes between professionals, caregivers, patients, and communities. After all, Paul Crawford argues, there are manifold contributions to health and wellbeing that “fall outside [of] medicine per se” (Crawford et al., 2015, p. 2). As framed by Crawford, the central question that conceptually qualifies not only the health humanities but also the medical sciences is “the notion of meaning” (Crawford et al., 2015, p. 4). Taking meaning into consideration is both needed and necessary, Crawford asserts, to “understand the individual’s life-world” (Crawford et al., 2015, p. 4), or what is termed the Lebenswelt in Husserlian phenomenology, which is to say, the individual as well as the social contexts or codes that ground the interpretation of disease, environment, food, and medicine. Certainly, medical humanities have done important work in regard to meaning by critiquing, challenging, and contextualizing dominant medical ideologies. But medical humanities, as Sarah Atkinson specifies, “seldom if ever ventures beyond a neoliberal, humanist notion of the individual body-subject and associated conceptualizations of responsibility, rights, and risk management to really explore alternative ‘collective’ and ‘relational’ approaches to ‘flourishing’” (Atkinson et al., 2015, p. 77). This is where the Umwelttentheorie in biosemiotics comes into play. The specific contribution of health semiotics, which takes as its subject the Innenwelten, the Umwelten, and the Welten in between, is most pronounced when the question comes down to relationality.

The issue of relationality for the interpretability of signs can be traced back to the historical progenitors of health semiotics. From the perspective of many, if not most, oftoday’s medical practices, Genevieve Miller points out, Airs, Waters, and Places can be seen to have been based on “philosophical presuppositions” that force “observational data into a preconceived pattern” with a significant “lack of proof” (1962, p. 130). Yet in every age, this classical treatise from the Hippocratic Corpus has been appropriated, or rather misappropriated, for arguments from authority (argumentum ab auctoritate) to support not only novel medical theory but also trending medicalized ideology. “Like a religious document,” Miller laments, the text has been “made to fit every time and place” (1962, p. 140). Given such intertextuality, Hippocrates’ Airs, Waters, and Places, with its many iterations, and its many interpretations exemplifies the progenitors to Hendlin and Hope’s Food and Medicine: A Biosemiotic Perspective. And the comparison between Airs, Waters, and Places and Food and Medicine demonstrates the extent to which contemporary biological semiotics evolved out of classical medical semiotics. However, as medical historians Alison Bashford and Sarah W. Tracy establish, the “symbiotic relationship” between we humans and our environments “was seen as one of dependence” in the classical medicine of the Hippocratic Corpus but “is seen as interdependent” in the contemporary medicine of occidental culture (2012, p. 496). Nevertheless, Bashford and Tracy clarify, in contemporary medicine as well as in the Hippocratic Corpus, the environment is understood “to predispose to disease, to be a proximate cause of disease, and to cure disease” (2012, p. 513). By taking a biosemiotic perspective, Hendlin, Hope, and the nine contributions in their edited volume boldly seek to bridge the segregation between nature and culture in the medical sciences as well as in the medical humanities. To a large extent, they achieve this aim by explicating (1) the sign relations in food and medicine, (2) the sign relations of medical theory and practice, and (3) the sign relations between the biology in medicine and medicine of society. What is more, Hendlin and Hope claim the principal responsibility of medical practice is not only to protect health and wellbeing but also to promote “semiotic fitness,” in other words, “to help organisms make decisions in their environment so that they can sustain their bodies in a state that enables them to continue making good decisions” (2021, p. 3). Indeed, the program for semiotics that is put forward in Hendlin and Hope’s edited volume constitutes not only a health semiotics but also a biosemioethics. To extend semiotics from logic theory to medical practice, Petrilli concludes, explicitly requires an ethical responsibility because semiotics in, of, and between medicine “concerns the health of life” (2003, p. 98). In this way, the applied and theoretical futures of health semiotics, as exempified by Hendlin, Hope, and the contributors to Food and Medicine: A Biosemiotic Perspective, should address the health of humans, the health of the environment, and the flesh in between through which these signs are interpreted.