The Discursive Formation of The Body

THE DISCURSIVE FORMATION OF THE BODY
IN THE HISTORY OF MEDICINE
ABSTRACT. The principal argument of the present paper is that the human body
is as much a reflective formation of multiple discourses as it is an effect of natural
and environmental processes. This paper examines the implications of this
argument, and suggests that recognizing the body in this light can be illuminating, not only for our conception of the body, but also for our understanding of
medicine. Since medicine is itself a discursive formation, a science with both a
history, and a future, it is argued that much can be learned by reflecting on the
progression of models, or "paradigm-shifts,", in terms of which modern
medicine has articulated the human body that figures at the heart of its discourse. Four historical periods of medicine will be considered, each one
governed by its own distinctive paradigm. It is argued, finally, that, with the
emergence of behavioural medicine, and, more particularly, psychoneuroimmunology, a new discursive formation in medicine, one can see a new
conceptualization of the human body beginning to take shape; and that this new
figure of the body makes it possible for the very first time to conceive the
construction of testable hypotheses regarding correlations between the objective
body of science and the phenomenological body of experienced meaning.
Key Words: body of experienced meaning, discursive formation, immunocompetence, objective body, psychoneuro-immunology
Read in the light of Adoph Portmann's work, the present paper

may be thought of as a contribution to the great unfinished project
of his lifetime. While urging recognition of the diversity and
complexity of the objects of concern to the biological sciences, and
strongly encouraging interdisciplinary work that would transgress obsolete traditional boundaries, Portmann argued for a new
theoretical paradigm, a coherent science of life capable of integrating the different realms of knowledge into a comprehensive
understanding of the organism as a unified system and a center of
activity inhabiting larger systematic environments.
David Michael Levin, Ph.D. Professor of Philosophy at Northwestern University, 633
Clark Street, Evanston, Illinois 60201, U.S.A.
George Freeman Solomon, M.D., Sepulveda Veterans Administration Medical Center,
San Fernando, California 91343, U.S.A.
The Journal of Medicine and Philosophy 15:515-537,1990.
1990 Kluwer Academic Publishers. Printed in the Netherlands.
Downloaded from http://jmp.oxfordjournals.org/ at University of North Carolina at Chapel Hill - Health Sciences Library on September 25, 2016
DAVID MICHAEL LEVIN AND GEORGE F. SOLOMON
David Michael Levin and George F. Solomon
Although Portmann was committed to a vision of the unity of

the sciences, he was never blinded by a false, and nowadays
increasingly discredited ideal of objectivity, and he never lost
sight of the 'mode of being7 which distinguishes all living organisms - what he was wont to call their 'inwardness', and what
von Uexkull described as their 'capacity to be a center of activity'.
Other research programs have also advocated the unity of the
sciences, but they all attempted to achieve that unity by imposing
some form of reductionism, invariably reducing processes of
meaning ('inwardness') to processes that could be objectively
studied and explained in the vocabulary of a purely mechanistic,
quantifiable discourse. By contrast, Portmann's program attempted to achieve the ideal of unity by discovering new concepts
and methods, so that the study of processes of meaning - the
different ways that organisms generate, carry, and perform
meaning - may be included, rather than excluded and denied.
The human body is, of course, an evolutionary biological entity,
but not merely so. It is also an ongoing achievement of socialization and acculturation, processes which communicatively interact
with its biological nature, and not only develop this nature, but
permanently shape and transform it. Moreover, since human
beings are sociable from the very beginning - since, that is to say,
human bodies are biologically organized and ordered for communicative interaction from their very beginning, it is not possible
to draw the boundary between the body of nature and the body of
culture with any precision, certainty, and finality. The boundary
has, in fact, been continually redrawn, especially in this century,
as the science of medicine accumulates knowledge that incorporates the body into ever more subtle and more intricate
programs of analysis.
The human body is, therefore, a complex discursive formation:
an evolutionary historical 'construct7, so to speak, of reading and
writing, programs of theoretical research and clinical practices.1
(The word 'construct7 could be misleading. It is meant to contest a
naive biologism; but it does not imply the truth of the opposite
extreme, viz., that the body is totally fabricated by the material
and social conditions of historical life.) More specifically, the
human body is a discursive formation within the context of the
history of medicine, which is itself a discursive formation. The
history of medicine is inseparable from the fact that there have
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been, and still are, many different, often conflicting representations

of the human body. The advancement of medicine as science and
clinical practice depends, perhaps now more than ever, on a
recognition that 'the body7 which figures in medicine is always a
discursive historical formation, a matter of selective representation; there is, in short, no totally 'natural' human body. To understand this point is to be released from captivity to one's representations - especially schemata which no longer work.
In his major book on Nietzsche, the first philosopher of modernity to argue for the wisdom and virtue of the body, Heidegger
(1889-1976) asserted that "most of what we know from the natural
sciences about the body and the way it embodies are specifications
based on the established misinterpretation of the body as a mere
natural body" (Heidegger, 1979, pp. 99-100)2. "This bodily nature," he observed, "hides a whole problematic of its own,"
(Heidegger, 1962, p. 143).3 Almost five decades later, though, he
still had made no breakthrough, and he conceded that understanding the body is one of "the most difficult problems" (Heidegger
and Fink, 1970, p. 146). Despite these difficulties, Merleau-Ponty
(1908-1961) worked for many years to articulate a philosophical
critique of the conceptualizations of the body that he found in the
discourses of the sciences. Eventually contributing a deep
phenomenology of embodiment, he argued that "we must learn to
distinguish it [the body which I live and experience, just as I live
and experience it] from the objective body as set forth in works on
physiology. This is not the body which is capable of being inhabited by a consciousness ... It is simply a question of recognizing that the body, as a chemical structure or an agglomeration of
tissues, is formed by a process of reduction, from the primordial
phenomenon of the body-for-us, the body of human experience,
or the perceived body," (Merleau-Ponty, 1962, p. 85).4 Insisting on
the need to acknowledge the body of experience, Merleau-Ponty
declared that "my body is made of the same flesh as the world,"
meaning by this that the meaningfulness of the body, its life and
death, diseases and afflictions, cannot be recognized and understood so long as the body is regarded as nothing but a self-contained material object, reductively conceptualized in terms of a
physics of mechanisms, and studied, as if it were just an object, in
isolation from its inhabited world.
In The Birth of the Clinic, M. Foucault proposed a new systematic
framework for understanding the historical emergence of clinics
The Discursive Formation of the Body
and hospitals in seventeenth and eighteenth century France

(Foucault, 1973).5 Using this framework, he related the history of
these institutions to the advancement of medicine as an empirical
science. In particular, he demonstrated the influences connecting
the functions of these institutions to a sequence of profound
changes in the clinical practices of medicine: changes which made
the traditional modes of perception obsolete, and even presented
problems for the prevailing epistemology. Foucaulfs work
suggests that it would be useful to study how the history of
medicine is related to a succession of different interpretations of
the human body, and that we could make the history of medicine
more intelligible by following the logic of its various conceptualizations of the body. Since a concern for the nature of the body
is at the very heart of medicine, the history of medicine calls for an
interpretation that sheds light on the history of the body, bringing
out essential correspondences between evolving conceptions of
the body and progressive conceptions of disease and healing. The
following interpretation employs Foucaulfs framework, but it
goes beyond the subject matter taken up by his account, following
the conceptualization of the body as it leads to the discourse and
practices of the present.
Here we shall consider six parameters for interpreting the history
of the body as it figured in the history of medical research. The
primary focus will be on the body of research, not the body that
figures in the healing relationship between patients and physician.
When one examines the clinical and discursive practices of
research, what kind of body does one find assumed? We shall
concentrate on the advances that distinguish the medicine of the
'classical' age from the medicine which began, broadly speaking,
in the seventeenth century, and which we shall call 'early
modern'. But as we reflect on the limitations of late modern
medicine, we will also touch on some very recent advances - new
ways of thinking that begin to define what we might call a
'postmodern' medicine.
(1) From abstraction to concreteness. The body recognized by
medicine in the Middle Ages and early Renaissance was an

abstract nomenclatural construct, an idealized projection of
speculative reason, an entity the nature of which was reduced to
the logic of an intelligible form. During this period 'classical
medicine' did not directly look at, nor did it really see, concrete,
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individual bodies. What in fact it saw were confirmations or

deviations from the nosology of its authoritative texts. It is as if
medicine looked at bodies 'sideways', making only occasional
glances that turned away from the established texts. However, in
the seventeenth century, at the beginning of the modern age,
medicine began to think of itself as an empirical science, and it
began to insist on the need to understand disease concretely by
examining individual bodies. But in the final analysis, what we
take to be 'concreteness' is only a product of interpretation.
Today, as we near the end of the twentieth century (late modernity), medicine is beginning to realize that the 'concreteness' of its
mechanistic paradigm is not an ultimate truth and that, just as
classical medicine projected an interpretive abstraction onto the
concrete body, so, analogously, mutatis mutandis, has late modern
medicine. Postmodern medicine sees this paradigm as unwittingly
imposing yet another conceptual abstraction on the body, and
it is consequently groping towards a new, more adequate concreteness - the concreteness of a paradigm more consistent with
the fact that the patient's body is always the site of meaningful experience.
(2) From exteriority to interiority. The body of classical medicine
was a very subtle body of humours and dispositions; but the
perception of its 'nature' conformed more to a pre-established
classificatory aesthetic than to the truth of its observable condition. By contrast, when, in the early modern period, physicians
started really to look at the body, what at first they saw was a gross
mechanical body, dense and opaque. The body of early modern
medicine was seen as an extremely intricate machine, and it was
examined, for the most part, from a very detached, external
standpoint. The opening up of cadavers for research and learning
was therefore emblematic of a revolutionary change in the way
medicine began to look at the body. The once sacred body, surrounded by cultural taboos, suddenly became a worldly machine,
a matter of interiority, a profane flesh to be seen into and seen
through, a presence conceived as if its mechanisms would eventually be transparent for technological knowledge. However, late
modern medicine has penetrated so deeply into the invisible
interiority of the flesh that it has begun to see how ultimately
necessary it is to abolish the boundary articulating the body in
terms of an exterior and interior reality. Body and environment
are not only inseparable; they are in continuous interaction, and in

continuous interdependence. Current research into the logic of the
body's immune processes has already signalled the beginning of a
postmodern discourse in which medicine will be working far
beyond this old schematism.
(3) From qualities to causalities. Classical medicine thought of the
body as an association of qualities, a substance tunelessly
qualified by its various states and conditions. Anatomical pathology initially promised the possibility of penetrating the density of
the flesh and finding 'first causes' for all diseases. However, as
late modern medicine has strictly followed out the logic of its
explanatory conceptualizations, it has increasingly found them
inadequate. The very precision of its principle of causal agency,
the very power of its explanatory work - and, subsequently, the
very successes it celebrated in understanding and controlling
diseases caused by bacterial infections - has enabled it to continue
revising the simple concept of agency, which seemed at first to
promise so much, and then, subsequently, despite its increasingly
apparent shortcomings, to be so irreplaceable. Now, this principle
can be relinquished. Medical knowledge has advanced far enough
to conceive a post-modern alternative. This story is developing
very much like the history of the constancy hypothesis - the
model of simple, one-to-one stimulus-response correlations in
experimental psychology. Better models were eventually found.
In responding to virus epidemiology, late modern medicine has
finally been able to reconceptualize the principle of simple agency
in the language of host environments, communicative systems,
interactive fields, local economies, and planetary ecologies.6
Ultimately, the infectious cultures of biology and epidemiology
cannot be isolated from their larger social and political cultures,
and so causal explanations cannot be confined to the activities of
isolated agents. For modern medicine, the body exists in time and
space, a continuous succession of physical states, conditions
medicine has long attempted to explain by a causality of spatiotemporal proximities. But late modern medicine is increasingly
finding itself compelled to abandon its model of simple causes
and work out a new model of multifactoral influence: a model for
which the network, rather than the straight arrow, might be an
appropriate heuristic symbol. In the age of postmodern medicine,
research into epidemiology and the logic of immunocompetence
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will need to produce a new discourse in etiology and

pathogenesis.
(GFS) Beginning in 1960, the visionary internist-psychiatrist
George Engel began to call for a bio-psychosocial unified (vs.
biomedical or "unit cause") concept of health and disease. He
differentiated necessary from sufficient conditions in etiology and
cited patterns of response to stressfully experienced events as
among the relevant conditions. He pointed out that general
systems theory, by treating sets of related events as collectively
manifesting functions and properties on specific levels of the
whole, makes possible recognition of isomorphies across different
levels of organization - molecules, cells, organs, the organism, the
person, the family, the society and the biosphere.7
(4) From states to processes. Early modern medicine abolished the
old Aristotelian logic of qualities and set out to understand how
the body it was looking at actually works. In its earliest phase, it
saw structures, and submitted the body to structural differentiation, concentrating on the articulation of its structural complexity
(e.g., the layout of the organs). This structuralism prepared for its
later phases, which may be characterized by saying that late
modern medicine increasingly attended to the body's functional
complexity, establishing this complexity in terms of functional
differentiation. By pushing this mechanistic research program to
its limits, however, late modern medicine could encounter the
inadequacies of traditional (early modern) functional thinking,
and has recently begun to move beyond the early and late modern
discourse of structural and functional states to a postmodern
discourse which can recognize both states and systemic processes.
Even so, it should be noted that such a discourse has not yet
abandoned an essentially mechanistic way of thinking - and that,
in point of fact, very little systems-theoretical thinking in medicine
has as yet been driven by the logic of its research to give up the
powerful resources of mechanism.
Kenneth Pelletier, for example, applauds the shift to systemstheoretical and information-processing categories (Pelletier,
1984).8 He is right to do so; this shift is indeed an important new
development. But he fails to understand that this shift, far from
being a major paradigm-shift, a major break with the mechanistic
thinking of the modern paradigm of knowledge, truth and reality,
only attempts to adapt the old paradigm of mechanisms - objec-
tivist thinking - to the new complexities. We are not proposing,

here, the total abandonment of mechanistic thinking. Such thinking was crucial to William Harvey's insight into the nature of the
heart: it was an important breakthrough to see the heart as a
pump. Even today, this mode of thinking can be useful and
constructive. But (a) we must take care not to blur the essential
distinction between mechanistic and non-mechanistic models, and
(b) we must acknowledge that almost all systems-theory discourse
today is still operating within the mechanistic paradigm that has
prevailed since the beginning of modernity in the seventeenth
century. Moreover, (c) we should continue to work with this
paradigm, pushing it to its limits and seeing how far we can
proceed by its light. This is the only way we have to get beyond it.
However, (d) we should also at the same time hold ourselves
open to alternative possibilities, exploring, in particular, the
possibility of systems-models which are not based on mechanistic
principles.
(5) From analysis to holism. Whereas classical medicine conceptualized the body as an organic whole, but only abstractly, and only in
terms of a pre-established system of categories, modern medicine
(in both its early and its late phases) has conceptualized the body
more concretely and empirically, but also more mechanistically
and more analytically, as a totality of discretely functioning parts.
However, finally able to take up the organicism circulating in
cultural discourse since the late nineteenth century, recent
medicine has been labouring to use its analytic knowledge as a
basis for understanding the body, once again, in more systemic
terms, and as an organic whole. The age of postmodern medicine
may be said to begin with a theoretical and clinical commitment to
the process-holism of systemic understanding.
(GFS) New discoveries in one realm of science or technology
influence models and theories in others. Not only Harvey's actual
discovery of the closed loop of the circulation of blood and the
role of the heart as a pump, but also the development of mechanical technology, particularly the harnessing of steam energy,
played a role in the modern conception of the body as a machine.
Later discoveries of self-regulating mechanisms to maintain
needed blood flow in the face of varying demands, peripheral
resistance, and even blood volume, were elaborations on, rather
than revisions of, old models based on the addition of automated
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'servo-mechanisms'. (It is only because of the very recent discovery that the heart is also an endocrine organ producing peptide
hormones, which influence cardiovascular and other physiological
functions, that the heart has been accepted as 'communicator^ as

well as a pump.) Even in psychiatry, Freud drew upon
nineteenth-century physics in his model of libido as drive (Trieb)
countered by the forces of repression, a 'mechanism' which could
'fail', or around which 'leaks' could occur. His was an essentially
mechanical model of the psyche, a machine, albeit a dynamic one.
The development of histology by R. Virchow and others,
through the application of the microscope and the development of
staining techniques, not only carried the mechanical model to the
cellular level, but also provided a basis for subsequent physiological models based on chemistry and electricity. The therapeutic use
of 'magnetism' (Mesmer) and galvanic electricity implied an
electromagnetic model of inner body processes. Oxidation,
understood in inorganic chemistry since A. L. Lavoisier, was
carried to the bio-chemical level, and circulation became a
chemical pipeline to ventilation and waste disposal machinery.
The telephone exchange became a model for seeing the central
nervous system as a switchboard. The borderline between electrical and chemical processes began to get blurred with the discovery of the first neuro-transmitter (acetyl choline) in the 1930s
(Otto Loewi), by which electrical impulses are transduced and
transmitted chemically. Analogies relating bodily processes,
particularly the most baffling, namely, the workings of the brain,
to machines continue to the present. The large digital computer
can 'crunch' information more prodigiously than the brain, but it
cannot do what the brain does. Even the analog computer is not
up to the job. What about parallel processing, a recent development in computer science? Some feel that the 'correct7 analogy has
arrived. Karl Pribram, taking a different approach, has likened the
brain to a hologram, in which a part can reproduce the whole albeit with less detail. Yet, all these biomechanical, biochemical,
bioelectric, and photoelectric models lie within the body, where L.
da Vinci and A. Vesalius began to dissect.
(6) From mechanical isolation to systemic integration. Whereas classi-
cal medicine thought of the body as an instance of the sacred

whole, a register of the cosmological order, early modern
medicine could only begin to understand the body empirically
and concretely by making it totally profane - reducing it to a

mechanism isolated from the surrounding world: something
essentially, or virtually, self-contained and self-sufficient.
Recently, however, late modern medicine has begun to restore the
body to the larger world-order. With increasing success, it has
tried to see the body as a self-regulatory system whose
functioning is dependent on, and inseparable from, the larger
world, and which consequently can exist only in continuous,
psychologically mediated interaction with a complex field of
social, cultural, historical, and environmental conditions. Working
with this model of the body, late modern medicine has increasingly recognized diseases as meaningful epidemiological
processes belonging to distinctive life-world 'economies'. Thus,
research programs in epidemiology are now coming together with
research programs in the logic of endocrine and immune
processes to establish the need for a postmodern medicine capable
of understanding the body in all the dimensions of its systemic
integration.
(GFS) An understanding of the dynamics of the endocrine
system set the stage for the blurring of the distinction between the
inner [homeostasis (Cannon)] and the outer [adaptation (H.
Selye)]. Secretions of the endocrine glands - thyroid, adrenal
cortex and medulla, gonads, pituitary - were found to change
with 'external' influences via central nervous system mediation.
The pituitary 'master gland' not only controls other glands, such
as the thyroid, via thyroid-stimulating hormones (TSH), and the
adrenal, via adrenal corticotropic hormones (ACTH), but the
pituitary, in turn, proved to be under the influence of hormones
released by the brain (hypothalamus) and delivered by venous
blood-substances such as the corticotropin releasing factor (CRF).
Hormones, unlike 'transmitters' (such as acetyl choline), work at a
distance, not just across a gap of synapses. Their control by the
brain makes experientially-influenced peripheral bodily effects
understandable, at least to a degree. (As will be discussed further,
the subsequent discovery of neuropeptides has greatly advanced
this understanding.) Enter Selye's 'general adaptation syndrome'.
'Stress' became non-specific, and the physical consequences of
stress were interpreted as the result of heightened (or 'exhausted')
adrenal cortical activity via the hypothalamo-pituitary-adrenal
axis (CRF>ACTHcortisol). However, many hormones other
than cortisol (thyroid, growth, gonadal, etc.) turn out to be 'stress-
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responsive'. As research progressed, it was realized that

physiological responses to a stressor vary according to its nature,
duration, intensity, timing, controllability, and other variables and
are subject (especially in humans) to 'modifiers' (such as social
support). To complicate matters further, the organism's personal
history, e.g., early life experiences (whether in experimental
animals or humans) and 'personality7 (e.g., fighting behavior or
dominance in rodents and assertiveness in humans) appear to
affect endocrine responses to stress. Behavioral interventions, such
as regular exercise or relaxation training, can 'buffer' physiological effects of stress.
To understand the significance of these findings and see in what
direction they are pointing, we need to conceptualize the history
of modern medicine and conjecture its future in terms of (at least)
seven distinct bodies. This history demonstrates the indisputable
power of mechanistic and analytic thinking. But the evolutionary
implications of this logic have now been followed out to a point
where its inherent limitations and antinomies are finally becoming
apparent. Present research suggests that the future of medicine
lies in a different logic: a thinking which is more organic and
integrative.
The historical progression which the different 'bodies' mark is a
progression in research whereby medical knowledge (a)
penetrates ever more deeply into the inferiority of the body, and
(b) articulates the body with increasing analytic differentiation.
However, the progression also points in the direction of a fundamental paradigm-shift. The shift from structural accounts to
functional explanations was an important development; but these
functional explanations are still conceived in mechanistic terms;
they do not call the mechanistic paradigm into question. In this
sense, structural and functional approaches are not as different as
they have commonly been thought to be. Although even research
programs formulated in terms of processes, systems, and energy
can be - and indeed have been - conceived in such a way that
they, too, continue the mechanistic paradigm, some current
research seems to indicate the need for a genuinely new
paradigm, formulated in terms of systems and processes that
would be understood non-mechanistically : as Ilya Prigogine has
argued, drawing on recent developments in physics, there are
complex, open-ended systems the elements of which are so
organized, so interrelated, that the conditions of the system are
not predictable on the basis of the elements themselves (Prigogine

and Stengers, 1984).
(GFS) Recent developments in biochemistry, namely, the
peptide chemistry of small 'messenger' or 'communication'
proteins and their receptor sites on cell surfaces, have set the stage
for a qualitative shift not only in neuroscience (because there are,
within the CNS, modulations of function at a distance, caused by
neurally-produced molecules, as well as processes of transmission
at the synapses), but also in physiological models of the body,
since neuropeptides act peripherally as well as within the CNS.
Neuropeptides, the recognized number of which approximates
fifty, were originally studied in other contexts as 'gut peptides'
(such as vaso-active intestinal peptides or VIP), hormones (such as
somatostatin) and growth factors (such as the nerve growth
factor). Candace Pert and co-workers refer to neuropeptides and
their receptors as a 'psychosomatic network' (Pert et al., 1985, pp.
820-826). Not only are there receptor sites for neuropeptides in
the brain, especially in emotion-mediating areas, but such receptors occur at various sites in the body that are sensitive to emotional reactions, including the gut and the glands, and, especially,
on mobile cells of the immune system, which is responsible for
resistance to viral and bacterial infections and for the killing of
cells with abnormal surface markers, such as cancer cells. John
Morley, G.F. Solomon, and colleagues refer to neuro-peptides as
'Conductors of the Immune Orchestra' (Morley et al., 1987, pp.
527-544). Neuropeptides may play an increasingly important role
in the conceptualization of a new model of the body. In terms of
our parameters, neuropeptides require that models based on the
mechanical isolation of the body give way to models recognizing
the body's systematic integration.
It was suggested that the history of medicine may usefully be
conceptualized by reference to a succession of 'bodies'. If it is
possible to speak of an evolutionary logic, a history marked along
the way by paradigm-shifts in models of the body, perhaps the
seven models proposed in the remainder of this essay will contribute to our understanding of the history of modern and contemporary medicine.
(i) The rational body. The body we find represented in the discourse
of classical medicine was essentially a rational body, a body
pictured in conformity to an aesthetic of rational intelligibility,
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a sacred and universal body replicating the larger cosmology.

(ii) The anatomical body. By contrast, the body which emerged in
the clinical and discursive practices of early modern medicine was
essentially an anatomical body, a body understood in purely
structural terms, a body of organs, displaying the sites for the
ancient theory of humours.
(iii) The physiological body. Increasingly, though, as knowledge
dared to penetrate the veil of the skin and explore the interior it
conceals, the body which figured in medical discourse was a
physiological body, a body-machine whose structures were seen
as mechanisms, and required mechanical explanations of their
functions.
(iv) The biochemical body of cells and molecules. Making use of old
and new technology, analytic medicine began to invade the

invisible nature of the flesh, looking with a microscopic eye into
the most minute structures of the skin, the musculature, and the
organs, and accordingly representing the body as an intricate
network of tissues. Yielding to even deeper, and even more
analytic, more atomic methods of probing, the body of tissues
disclosed itself to be a differentiated cellular body, ultimately
analyzable into molecular interactions. Because late modern
medicine has faithfully and relentlessly followed out the logic of
its analytic, atomic method, and new techniques of research have
made possible even more subtle forms of analysis, the body of
cells was in its turn disclosed as a gross body, concealing a body of
much more subtle nature: a body of biochemical processes. The
breakthrough to this dimension brings us into the present. It
represents a great achievement - and discloses the latest implications - of analytical medicine, the research program whose
mechanistic logic has governed medicine ever since the seventeenth century.
(v) The psychosomatic body. In the early years of this century,
however, psychosomatic medicine, encouraged by the contributions of psychoanalysis to our understanding of hysterical conversions, introduced a representation of the body which, for the first
time, attempted - albeit with only limited conceptual resources to break away from the analytic methodology, to break out of
mechanism, to break through the ontology of distinct minds and

bodies, and to think the body of medicine in a radically new way.
However, psychosomatic medicine was compelled to restrict its
claim to a post-cartesian conceptualization of mind-body identity,
applying it only to a very limited zone of problems: the zone in
between the material body (too dense and opaque) and the
volitional body (transparently psychological). It could suggest
new interpretations of asthma, skin allergies, migraines, ulcers,
colitis, rheumatoid arthritis, and hypertension. But, according to
the logic of its concepts, most pathologies could not be classified
as 'psychosomatic7: tumors and cancers; infectious diseases;
neurological disorders such as multiple sclerosis, Parkinson's
disease and Tourette's syndrome; Alzheimer's disease; and AIDS.
One limitation that has hobbled psychosomatic discourse comes
from the fact that while advocating the unity of mind and body, it
has failed to overcome the dualism which isolated this unity from
its environments - nature, society, and culture. There is, however,
a second, and more fundamental limitation, which comes from the
fact that it has not sustained the courage of its original intuitive
conviction: it talks boldly about a psycho-somatic whole, but it
limits the conceptual reference of 'psychosomatic' to a very small
range of cases and instances. If what we have been calling 'mind'
and 'body7 are really one, then all diseases, without exception, are
and must be 'psychosomatic'. But the discourse of psychosomatic
medicine has never been prepared to support such a radical and
consequential thesis. It has required a new generation, and a new
discursive formation, i.e., behavioral medicine, to conceptualize
and demonstrate this point. Only now, with the development of
psychoneuroimmunology, can the science of medicine begin to
represent the body as a psychosomatic unity integrated into its
environments, and begin to articulate the networks of causal
correlations implied by this representation. There is also a third
limitation inherent in psychosomatic medicine - a limitation that
the catalogue of afflictions (noted above) to which it has successfully applied itself at once betrays: for psychosomatic medicine,
the body carrying any one of the diseases not classified as
'psychosomatic' remains a body alien to experiential meaning - a
body the diseases of which could never be essentially identified
with, or identified as, processes of embodied meanings.
Psychosomatic medicine was prepared to see embodied meanings
in asthma, ulcers, and arthritis; but it could not even begin to
528
529
represent cancers, multiple sclerosis, and AIDS in terms of embodied meanings. Because of its inherent contradictions,
psychosomatic medicine has failed to provide a new paradigm.
But its bold vision lives on, incorporated into the work of behavioural medicine.
(GFS) Biogenic and psychogenic factors complexly interact in
physical as well as mental illnesses. 'Psychosomatic' diseases,
such as peptic ulcer and rheumatoid arthritis, have both genetic
and personality-pattern predisposing factors and stress-related
precipitating factors. Peptic ulcer is a 'resultanf of varying proportions of high pepsinogen levels (genetically influenced), a dependent personality pattern, and current stress (Arthur Mirsky). Since
similar interactions are relevant to 'mental illnesses', they, too,
might be considered 'psychosomatic'. There are family history
patterns suggestive of complex genetic influences in schizophrenia and affective disorders (major depression, bipolar illness).
Schizoid, schizotypal, borderline, and paranoid personality
patterns may antecede schizophrenic illness, and 'cyclothymic7
patterns may antecede affective illness. Loss may precipitate
depression. The loss of a parent during childhood may predispose
an adult to develop depressive illness. Schizophrenia and affective
disorders may be related to abnormal levels of, or receptor sensitivity to, certain neurotransmitters (dopamine and norepinephrine/serotonin, respectively). It is impossible to delineate the 'end'
of psychology and the 'beginning' of biology. Does it not follow that
the boundary between body and environment is also indistinct?

Psychosomatic medicine, which began with symbolic interpretations of symptoms and with personality typologies of patients
with specific diseases, made the leap from mind to body and went
beyond 'either/or' thinking, but limited itself to a narrow range of
conditions and restricted consideration of mediating mechanisms.
(For example, the ulcer patient's longing for emotional
'nurturance' was interpreted as leading to hypersecretion of
gastric juices that are normally released in preparation for nutrition.) It took a new generation of practitioners and behavioral
medicine to realize that mind and body interact as one and that all
diseases are 'psychosomatic'. It
took
the
development
of
psychoneuroendocrinology and psychoneuroimmunology to

elucidate mechanisms underlying this monism. It will take new
models to go yet further and truly integrate the experiental with
the mechanistic.
(vi) The body of psychoneuroimmunology. Now, as we approach the
beginning of a new century, revolutionary research into the logic

of immunocompetence is realizing the vision inaugurated by
psychosomatic medicine, making visible a body of extraordinarily
subtle functions and processes. This dynamic, synergic body is
seen as a system functioning in a larger system, a multifactoral
network of causes and effects, in which effects can also become
causes. This body cannot be represented as a 'substance'. It has
become necessary to represent it, rather, as a system of intercommunicatively organized processes, functioning at different levels
of differentiation and integration. It represents a growing body of
evidence supporting a new concept of disease and a much
broadened understanding of epidemiology, according to which
diseases do not take place in an environment conditioned only by
the forces of nature, but occur, rather, in a communicative field, a
world, of social, cultural and historical influences: influences
which the proprioceptive body processes as meanings. Thus,
epidemiology and immunology are beginning to understand the
fact that the individual body is also a social body, and is therefore
inseparable from the social and cultural life of populations.
(GFS) Psychoneuroimmunology ('behavioral immunology7,
'neuro-immunomodulation') is now a rapidly expanding field
concerned with complex bidirectional interactions between the
central nervous system (CNS) and the immune system, and also
with their clinical and bioregulatory implications (Solomon, 1987,
pp. 1-9).9 The field arose originally out of observations focused on
personality, stress, and emotional distress factors in the onset and
course of autoimmune diseases (in which the body's immune
system 'turns againsf the self), conditions then being found to be
associated with 'relative immunologic incompetence'. This
combination, plus growing evidence that distress is associated
with the elevation of adrenal cortical hormones (which can be
immunosuppressive), led to the hypothesis that 'stress can be
immunosuppressive'. In the late 1960s, my (GFS) thenprovocatively named 'Psycho-immunology Laboratory7 at Stanford University went on to demonstrate experimentally, in rodents, the effects of both stress (suppressive) and early experience
(enhancing) on humoral immunity (antibodies). Going against the
prevailing orthodoxy of the 'autonomy7 of the immune system as
responding only to antigenic challenge, these early observations
had little impact. It was not until Robert Ader's elegant immuno-
530
531
pharmacologic conditioning of immunosuppression in the 1970s

that the field began to be accepted. Ader paired an immunosuppressive drug (cyclophosphamide) with saccharin and showed
that, subsequently, saccharin alone could suppress immunity.
Such 'classical' conditioning can be mediated only by the CNS.
This work (which also has many implications regarding theories
of the placebo) rediscovered (with more elegant methodology)
observations on the conditioning of immunity made at the Pasteur
Institute in the mid-1920s (Metal'nikov and Chorine), but the
evidence was essentially ignored because it seemed too implausible.
A particularly exciting contemporary aspect of psycho-neuroimmunology relevant to this discussion is that aspect concerned with
the effects of CNS peptides on the immune system (already
mentioned) and, conversely, the effects of peptide messengers of
the immune system (cytokines, lymphokines) on the CNS. Some
illustrations follow. Beta-endorphin (an opioid neuropeptide)
enhances the activity of natural killer (NK) cells, the 'first line of
defense' against cancer cells and virus-infected cells. (NK cells are
stress-responsive.) Lymphocytes produce ACTH (a peptide
neurohormone) and gamma-endorphin. CNS cells can produce
the "immune" cytokine interleukin-1 (IL-1). IL-1 enhances ACTH
and growth hormone production via CNS mechanisms. Thymosin
beta (an immune regulatory hormone of the thymus gland) elicits
secretions of LHRH (a peptide neurohormone). IL-1 increases
during a slow wave sleep, which, in turn, is enhanced by interferon (an immunoregulatory cytokine that also has anti-viral and
anti-tumor effects). Neural growth factors affect immune cells.
Therapeutic interferon administration can result in psychiatric
morbidity (necessarily mediated by the CNS). Examination stress
alters the expression of IL-2 receptors on lymphocytes. Substances
P and K (neuropeptides) induce the release of IL-1 and IL-6. The
bidirectionality and multidimensionality of the CNS-immune
system is apparent. The need for a systems-theory approach to
understanding the workings of the body seems obvious. The body
must be understood in context. Brain cells, neuropeptides, immune cells, and immune cytokines are all influenced by experience.
System theory, to be most useful, should be carried as far as
possible. The impact of what is 'added' to the system, and not
only the nature of the interactions that are 'within' the system,
must be understood. The interacting systems of the body are

related to systems beyond the body. Even though systems theory
today is still mechanistic, its application to the body should ultimately
lead to a systems model that is pushed beyond the limitations of
mechanism.
The unraveling of physiological links between immune system

and CNS makes correlations between the two systems seem much
less far-fetched than they did twenty-five years ago. Philosophical
considerations in science, such as 'why7 the CNS and immune
systems 'oughf to be linked, may indeed have heuristic value.
Both the CNS and the immune system relate the organism to the
outside world and serve functions of surveillance, defense, and
adaptation. (J. Edwin Blalock has called the immune system a
'sensory organ', since it responds to signals in the environment to
which the five senses cannot react; Walter Pierpaoli has referred to
the bone marrow, which 'gives birth' to immune cells, as a
'morphostatic brain'.) Both systems have memory and learn by
experience. Defenses that have gone awry or are inappropriate
can produce disease in both systems. An inappropriate fear is
called a phobia, and an inappropriate immune response is called
an allergy. Aggression turned against the self ('retroflexed') leads
to depression on the one hand (Freud) and to autoimmunity on
the other. Either depression (suicide) or autoimmunity can lead to
death. Inadequacy of defense in either system leads, respectively,
to emotional or to physical (as in AIDS) vulnerability. Early life
experiences can either inhibit or enhance adult psychological
vulnerability and/or resistance to physical disease. Prior experience can lead to 'sensitization' or to 'tolerance' in either
system. (Prior mastered challenges enhance 'ego strength', while
defeats lead to psychic vulnerability. Very low dose antigenic
stimulation can produce immune tolerance while higher dose
challenges can produce sensitization/immunity. Gentle handling
in infancy enhances and premature weaning suppresses adult
immune responsivity in the rat.) Just as 'philosophical'
considerations can lead to a greater understanding of
mechanisms, thinking in non-mechanistic terms, in turn, may
bring us to newer models that go beyond the limitations of the
mechanistic paradigm.
(vii) The body of experienced meaning. The body of psychoneuro-
immunological research represents a growing body of evidence
532
533
pointing to the day when medicine will be able to understand

how the diseases afflicting us, as well as the body's processes of
healing, are sensitive to the effects of proprioceptively experienced meaning, and how, more generally, processes of disease
and healing are correlated with experienced meanings. The body
which would correspond to this achievement is the body of
psychoneuro-endocrinology, the body now being brought to light
by neurological, immunological and epidemiological research: the
first medical body subtle enough to promise the possibility of
testable correlations with the phenomenological body of experienced meanings. Within a discourse dominated by Cartesian
dualism, psychosomatic medicine struggled to articulate this
body; but its inherent conceptual limitations and contradictions
denied it the success which behavioural medicine is now beginning to enjoy. By contrast, the body of psychoneuroimmunology
represents a much more differentiated, more finely tuned
articulation of disease and healing processes, increasingly dissolving the three long-standing dualisms of mind and body, body and
environment, individual and population. For the first time,
medicine is equipped with a discourse capable of formulating very
specific correlations between (a) the patient's bodily experienced
meanings and (b) conditions or states of the medical body, the
body which figures in the research and clinical practices of
medicine.
However, it must be noted that medicine's success in making
such correlations does not depend only on advances in medical
knowledge. It also depends on the ability of patients to fine-tune
their embodied awareness, their sensitivity to processes of bodily
experiencing, and their skillfulness in carrying those processes
forward into more articulate, more discriminating meanings. For
many centuries, Western culture has denied recognition to this
ability and consequently made it very difficult for people to enjoy
contacting and working with their body's felt meanings - the
intricate meanings carried by their bodies in co-responsiveness to
particular situations and circumstances. At long last, however, our
culture has begun to recognize, to legitimate, and to facilitate this
natural skill. As experienced-meaning processes become more
subtle, more intricate, more discerning, it is reasonable to expect
that there will be an increasing convergence between the body of
medicine and the body of lived experience, due as much to the learning
of this skillfulness in articulating bodily-felt meanings as to the
achievements of systemic, post-modern medicine.

The convergence between the body of medicine and the body of
experience will be greatly facilitated by a recognition that the
human body is more than a biological organism, more than a physical
substance - that it is also, in short, a discursive formation. Insofar as
the science of medicine works with this understanding, recognizing the body as (1) an evolving historical formation and (2)
discursive, i.e., inherently organized in terms of communicative
and intercommunicating processes, the overwhelming hegemony
of counterproductive representations and paradigms will be
easier to question and overcome. For medicine, the recognition of
the body as a 'discursive formation' means (a) that it relinquishes
the epistemological assumption of naive realism (the assumption
that its concepts are observer-neutral and correspond to a totally
independent, objective reality), (b) that it comes to terms with its
status as an interpretive, or hermeneutical science, and (c) that its
relation to the entity it calls 'the body7 is mediated by a network of
historical assumptions and representations which are never more
than provisional and tentative, and remain always open to reassessment. But, by the same token, insofar as patients themselves
begin to understand their bodies in this new way, i.e., as a formation of, and the center for, discursive processes, they too will be
freed from counterproductive conceptions of the body and may
begin to realize the extent to which the body that they present to
medicine for diagnosis and treatment is a body of meaningful
experience, a body of significant intelligence, inherently informed
about itself; a body the very nature of which can be profoundly
changed by virtue of each patient's sensitivity and embodied
awareness, and his/her own skillfulness in articulating the body's
carried meanings. For each patient, then, recognizing the body as
a 'discursive formation' means learning to draw sustenance from
the fact that the conditions of his/her body of concern to medicine
- the body's diseases and health - are also conditions of meaning
borne by each patient, and that so-called 'physical states' are
inseparable from the patient's ability to 'embody7 the meanings of
life, to experience and articulate these experiental meanings in, as,
with, and from the dimensions of the lived body, the body each
patient is.10
534
535
NOTES
1
The term 'discursive formation' was first introduced by Michel Foucault. See,
The Order of Things: An Archaeology of the Human Sciences (New York: Pantheon,
1971) and The Archaeology of Knowledge (New York: Harper & Row, 1976).
2
Also see Nietzsche's own notes on the body in The Will to Power (New York:
Random House, 1967).
3
For further discussion of this problematic, see David M. Levin, The Body's
Recollection of Being (Boston and London: Routledge & Kegan Paul, 1985).
4
Also see Medard Boss, Existential Foundations of Medicine and Psychology (New
York: Jason Aronson, 1979).
5
Foucault succumbed to AIDS in 1984. At the time of his death, he occupied a
chair in the History of Systems of Thought at the prestigious College de France.
6
See Roger Levin, 'Cancer and the self: How illness constellates meaning', in
David M. Levin (ed.), Pathologies of the Modern Self: Postmodern Studies on
Narcissism, Schizophrenia and Depression (New York: New York University Press,
1987). I want to acknowledge Roger Levin's crucial collaboration in the preparation of my part of the present paper, and thank my friend Wayne Herring, M.D.,
now doing research in the neurology of motor disorders at the Veterans Administration Hospital in Lyons, New Jersey, for his very helpful comments. I also
want to give thanks to Don Johnson, Director of the Somatic Psychology
Program at the New College of California, San Francisco, and of the Somatic
Research and Education Programs at Esalen Institute, Big Sur. (DML) The
collaboration on this paper began in June, 1988, thanks to a seminar which Don
Johnson organized at the Esalen Institute. Both authors (DML and GFS) are
grateful for the special opportunities this seminar provided.
7
See George L. Engel, 'A unified concept of health and disease' Perspectives in
Medicine and Biology, 3:459-458, and 'The need for a new medical model: A
challenge for biomedicine', Science, 196:129-136,1977.
8
Also see Pelletier, K., A New Age: Problems and Potentials (Novato, California:
Robb Briggs, 1985).
9
Also see Robert Ader (Editor), Psychoneuroimmunology, Academic Press, New
York, 1981. A new two volume text, Psychoneuro-immunology II, is in preparation
with more than double the number of chapters of the 1981 version, and George
Solomon has already added 39 additional 'postulates' concerning specific aspects
of CNS-immune interaction to the 1987 list of 351.
10
For a more specific, more concrete formulation of what I (DML) mean when I
call for self-developing practices and learning processes that work with the body
as a 'discursive formation', see Eugene Gendlin, Focusing (New York: Bantam,
1981); 'A philosophical critique of the concept of narcissism', in David M. Levin
(ed.). Pathologies of the Modern Self (New York: New York University Press, 1987;
'Experiential psychotherapy*, in Raymond Corsini (ed.), Current Psychotherapies
(Itasca, Illinois: F.E. Peacock, 1973), 1st ed. only; and 'Experiential Phenomenology', in Maurice Natanson (ed.), Phenomenology and the Social Sciences (Evanston:
Northwestern University Press, 1973).

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Boss, M.: 1979, Existential Foundations of Medicine and Psychology, Jason Aronson,
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Engel, G.: 1977, 'The need for a new medical model: A challenge for
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journal of Immunology 135,820-826.
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THE DISCURSIVE FORMATION OF THE BODY

IN THE HISTORY OF MEDICINE

Read in the light of Adoph Portmann's work, the present paper

DAVID MICHAEL LEVIN AND GEORGE F. SOLOMON

David Michael Levin and George F. Solomon

Although Portmann was committed to a vision of the unity of

been, and still are, many different, often conflicting representations