We have chosen the structure of the dialogue to introduce the reader to the written pages containing our ideas so to keep the dynamism which has characterised our speeches. We hope we are going to give you the feeling of every single intervention and even the whole panorama of this dialogue.

Girelli

I would like to begin starting from Medicine, or better from the origins of our Medicine. Regarding this matter, the diagnosis has always been reached after having followed very precise procedures which had been defined starting from the origins of the Western Medicine, particularly with the beginning of the Hippocratic School of Cos (Vth century B.C.).

This School had taught that through a comprehensive vision of symptoms (synopsis) it is possible to learn the èidos , which is the form of the disease corresponding to a good part of the disease diagnosis itself.

Neri

The studies of Medicine have produced a strong imprinting. When I was a young doctor, the diagnosis usually coincided with a number of procedures you are talking about: the case-history, an objective examination on the patient with a scrupulous and detailed collection of his symptoms, a differential diagnosis. Therefore, on its side, the diagnosis was coinciding with the determination of the disease.

Girelli

The Hippocratic School was totally aware of the fact that the procedures which had been defined would have produced some doubts: the diagnosis correctness was somehow depending on a clinic evaluation.

However, in a passage of the Antica Medicina (Ancient Medicine) it is quite easy to understand that "exact measures" do not exist; therefore, if the qualified and honest doctor is not totally sure of his diagnosis, it is better to choose a science which is able to limit the human mistake on knowledge as far as it is possible in order to cancel any doubt.

Neri

When I was at the University, I had particularly appreciated a good and acquittal formula written in the Antica Medicina (Ancient Medicine): "I will praise so much the doctor who did a few mistakes". I had not understood as the warning of the beginning was such important, that is the one on the absence of some measure, number or weight which could be valid "from a point of view for an exact knowledge".

I believe it is quite evident that the uncertainty is a proper condition of the medical practice, widening its definition to the conception of Medicine itself.

Girelli

The history of medicine had demonstrated as during time there had been different attempts to consider the disease as a real entity, concrete before and logic after, anyway as something which could be a constitutive factor of the living world.

This conception of disease is the ontological one.

Neri

According to doctors, the disease has to be considered as something which really exists and not as the name which is given to something corresponding to a very strong and stubborn ambition.

Girelli

I agree. Above all, after the Scientific Revolution of the VIIth century and under the influence of Naturalism, some attempts to classify diseases had developed and these attempts were considered as real. They had never been completed, as it had happened for plants classification instead.

Neri

Of course. Diseases do not exist as sick, pathogenic germs ot phatological process.

Girelli

We could observe a consequence of this approach to the disease in the DSM (Diagnostic Statistical Manual). It determines and collects characters (symptoms) in nosographical pictures existing together and more frequently (clusters). Therefore, this approach is based on a nominalist and operational theory of the disease and not on an ontological conception.

Neri

I believe you can see the importance statistics have, right in the picture of DSM.

Girelli

Let's go step by step. During centuries, a second transformation about the manner of considering the disease in medicine had occurred, and this had meant to include it in a framework of complexity. I mean the opportunity of considering the disease from different points of view: the clinic and descriptive one (largely coming from the School of Cos ) the anatomic and patological one, the etiological one. As an example, the same disease had firstly been identified as phthisis on the basis of its clinical peculiarities and after, when the damage of the organ and tissue (lung and tubercule) had been determined, the disease had become a pneumonia with special features; the discovery of the Koch bacillus had later underlined the etiological dimension and so the same disease had been identified as tubercolosis.

Neri

Besides, the disease is different if it is observed by the doctor or seen and felt by the sick.

Could you explain it better?

Neri

The English language picks up better than the Italian the difference I am speaking about. English uses the term disease to define the disease when this one is considered as something objective, as a syndrome; other two words- sickness and illness- explain "the way" the disease is lived.

Someone who feels tired and a bit sick is reported to say: "I feel sick and tired" without using the word disease.

Girelli

Where do they usually meet the doctor and his patient?

Neri

They meet in the medical centre, in the ambulatory, at the hospital. Balint talks about the disease as a construction of the patient and the doctor together. He considers the disease as something which is progressively determined by the very first "offers" of the patient's symptoms and by the very first "answers" the doctor gives.

Girelli

The disease can even be considered as the relationship between the part and the whole. Every time a part of our body is sick and we suffer from it, we could ask if it is only that part which is making us suffering or if it is all of us who is suffering and this suffering has focused on a specific part of our body. These are two different points of view and both of them point out a need for care and listening, also if they could appear as a contradictory association.

Neri

The discovery of the immunity system and the determination of its connections with the affective condition have apparently evaluated the regulatory mechanisms between the parts and the whole of our organism.

Girelli

I would like to point out a last aspect of the School of Cos conception which I believe of a great value: the disease as a path which has its own evolution. I would like to read a small passage by Franco Voltaggio: " According to doctors from Cos , diseases appear as a process which (.) have an evolutive and systemic phenomenology all together. Somehow, they are systems in progress which are marked by a partial independence on the subject where they manifest (.) and by a sort of implicit finalism (.). In (this) perspective (.) , to recover does not mean to remove the disease, "to expel it", but to promote a spontaneous strategy performed by the organism itself. This means the therapy as it is properly defined (.) is conceived to support the canalization so to get the remission of the disease or avoid the deviation of it ".

Neri

Two passages had struck me. The first one is: " Diseases are systems in progress ".

Girelli

This sentence underlines it is fundamental we take into consideration the autonomy the disease has acquired after having been constituted as a system. The disease "as a system" follows its rules and dynamics. I mean that once the disease is formed as it is (I mean once a number of facts have developed: the attack by a bacillus, people immunity reactions, the assumption of the medicine) it is relatively independent from the person himself , meaning that the disease has its history and evolution.

Neri

The second one is: " Diseases are equipped by an implicit finalism ".

Girelli

We are talking about the prognosis practice, meant not only as a forecast on the disease positive or negative results, but also as an evaluation of the direction it could take, just considering all the factors which are involved into the field of the disease, whether if they are positive or not.

Neri

Freud and Psychoanalysis have discovered a particular type of the double of the disease and they have also offered an interpretation of it when the relationship between patient-doctor occurs during the discovery of the transfert and its neurosis.

Girelli

I am thinking about two other contributions of psychoanalysis to the idea of the disease: Winnicott and Erikson. Both of them have pointed out the relation feature of psychopathology and have opened a debate on the constitutive role of the environment for the human being development (and his psychopathology) which is central for the idea of the disease in the small analytic group. Winnicott accent is put on the affective environment, Erikson's one is on the social and cultural environment. About Erikson's idea, it is important to underline that identity is based on three components which are interacting one another: the personal one, the social one or that one of the group, the cultural and ideological components. Erikson wanted to point out that any of us acquires a feeling of identity which is not merely personal (intrapsychic) but is constituted by the recognition of ourselves inside a group of peers and by the recognition of which world of values and beliefs we belong to.

Neri

According to this perspective, how could we think about the disease in the group?

Girelli

I am thinking about a suggestive description of the social disease, written by Boccaccio in the Decamerone (Decameron) when he describes the plague in Florence in 1348, which I would like to read to you: " Nacquero diverse paure et immaginazioni (.) , e tutti quasi ad un fine tiravano assai crudele, ciò era di schifare e di fuggire gl'infermi (.) . L'uno cittadino l'altro (schifava), e quasi niuno vicino (aveva) dell'altro cura, et i parenti insieme rade volte, o non , si (visitavano), e di lontano, era con sì fatto spavento questa tribolazione entrata ne' petti degli uomini e delle donne, che l'un fratello l'altro abbandonava, et il zio il nipote, e la sorella il fratello, e spesse volte la donna il suo marito; e (che maggior cosa quasi non credibile) li padri e le madri i figliuoli (.) schifavano (.) . In tanta afflizione e miseria della nostra città era la reveranda autorità delle leggi, così divine come umane, quasi caduta e dissoluta tutta ".

"Different fears and imaginations were born (.) and quite everyone tried to reach such a crude target which was to disgust and keep away from the sick (.) . The citizen (disgusted) the other one and quite anybody (had) care of the other one and families were rarely or never (visiting) one another and so far this trouble had troubled men and women souls that a brother could leave his brother and the uncle could leave his nephew, and the sister could leave his brother and often the lady could leave her husband; and (something mostly incredible) was that fathers and mothers could even leave their sons (.) disgusting (.) . In our town so much misery and pain had become the ruling authority of laws, both divine and civil ones, and the town was quite fallen and dissolute ". 2

This description makes us clearly understand how the social disease damages the basis of the civil living; It means that anybody can non longer recognise himself in the values we had talked before. These values lose their function.

Neri

"The social disease" is at an interesting level of debate, but it is not exactly what I would talk about. I would try to consider the issue of the "disease in the pattern of the Group" according to another point of view. Anthropological studies have demonstrated as the individual disease is always involved in a series of meanings and interpretations.

Girelli

Could you make an example?

Neri

The disease " pisa " is very well described by Marc Augé who had carried on some research on the Alladian along the Costa d'Avorio (the Ivory Coast ). " Pisa " is the disease of the man spitting blood and losing his energy; the origin of this last one is usually attributed to the adultery acted by the wife.

Girelli

How is it possible to attribute the symptom of spitting blood to the wife's adultery?

Neri

We have to deepen our debate. The system of homologies and the logic used by Alladian to build and give a meaning to the idea of " pisa " are the same which support a particular prohibition: the prohibition to have a copulation on the Savannah ground.

Girelli

In which way could we connect the disease with this strange taboo?

Neri

The basis of the disease and the prohibition is formed through the equivalence of the blood and the sperm (blood=sperm). Other factors of the same symbolic system are the hot character of the "blood-sperm" and the principle of the incompability of the hot with hot itself. If we use this equivalence, we could explain as the man sperm betrayed by his wife cannot mix in her body or add to the sperm of the other sexual partner. As a consequence, the sperm "reflows" in the man under the form of blood and it is vomited or spitted. Since the Earth is hot and the copulation ( copula) is hot too, to have a copulation on the Savannah ground makes Earth's heat increase. Risks of sterility and dryness are run.

Girelli

It is a system of analogies really complex.

Neri

The system of equivalence used by Alladian to give a sense to pisa is very difficult and fine, in fact. It is developed into: the somatic symptomatology of the disease (spitting or vomiting blood) and his psychological expression: jealousy, rage, a feeling of being abandoned; (anyway, this last one is not directly expressed but it indirectly involves the condition of the man betrayed by his wife); the compatibility (crasis) and/or incompatibility (dyscrasia) of people (the husband, the wife, another man) and of fluids (blood, sperm, vomit); the order of the community and rules infraction (relationship and marriage obligation); interpersonal and somatic transitions and their possible inversion (the loss of control, the inversion of the flow, spitting).

Girelli

The idea that man disease refers to his belonging Group has been expressed by Foulkes trough the expression "localization of the disease". Symptoms of a single person are an aspect of something much difficult which deals with the network of his significative relationships.

Neri

What are you saying on localization is really interesting, but I think it partially considers the debate on the disease " pisa ".

Girelli

Robi Friedman believes the research on nosographic and interpersonal categories should be deepened. According to this research, the responsibility for the trouble is free from the person suffering from it and Friedman focuses his attention on how all the environment should face a transformation, becoming something different and not only for the single person who is sick according to everybody.

Neri

This is a further step: the feeling and possibility of the disease transformation and treatment participate into the creation of a system of meanings which is common to the Group members.

Girelli

Explain to me why you have referred to a disease and a culture such different from ours.

Neri

I have carried on this example for two reasons. Above all, I believe it is important the connection between the disease (any disease) with more general vital forces. As far as the disease " pisa " is concerned, the connection is with "fertility", sterility of the Earth. Besides, I believe it is interesting that the conception of "disease" involves some factors linked to the laws and taboos of the community or the group. It is what we see in the small analytic groups. I have tried to consider it by the introduction of the conceptions " commuting " and " nomos " and "Group affective patrimony" in my book Group.

Girelli

Now I understand it better: the disease finds its place in the Alladian system of the community rules through a logic connection which does not belong to what is a properly aristotelic logic. Does the small analytic group use its oneiric and mythical logic?

Neri

Yes, it does. However, sometimes it is necessary to produce an instrument which could make its performing easier. To reach this target, just to make an example, during my sessions interventions, I usually use passages of myths, movies, stories. I never use them totally and I do it just to open a chain of group associations. They are "fragments" which are producing a new history or myth, particularly important for that specific small analytic group.

Reference's note

In order to have a more fluent reading of this text, we did not write any bibliography. We do it now. In the very first introduction to our dialogue, we had referred to Bateson (1972), p.3. Concerning the first part of the text which is focused on the conception of disease in medicine, we point out that: the first two interventions Girelli did, had found their origin in Voltaggio (1992), pp.329 and 322; a part of the historical news which had been reported on the Hippocratic School had been found in the text by Angeletti, Gazzaniga (2002) and the article by Arecco (1999); the following three interventions which were devoted to a synthesis of the historical development of the conception of disease in Medicine are based on the information given by Grmek (1998), pp.17-19. Neri refers to Grmek (1998), p.23 when he talks about the disease status, as well. We had also observed the same critical position towards the ontological status of Landoni disease (2004) even if his debate was precisely making reference to the disease as a result of the diagnostic process since this last issue represents his work's focus. We have observed in the DSM that the nominalist approach is also underlined by Tucci (2004) as a peculiarity of the diagnosis ideas which had been described in the Manuale Diagnostico e Statistico . When Neri talks about Balint and his relationship doctor-patient, he is making reference to the time he had worked with bibliography and also the text by Tomassoni and Solano (2003), p.60. Making a reference to the diagnostic process, the same observation about the personal meeting between the patient and his doctor is present in Panzera (2004). The thought to which our colleague Panzera is clearly making reference is Gadamer (not Balint).

During the debate of the conception of disease in Psychoanalysis, Girelli had cited Winnicott and Erikson and she was thinking about the two texts the reader finds in the biblography. Even when she had spoken about the localization of the disease (Foulkes) and of interpersonal nosographic categories (Friedman) the sources are those written in the bibliography. The connection Neri did between the anthropological reading of the disease and the idea of the disease in the small analytic group was possible on the basis of what Augé had pointed out in his studies on the Alladian of the Ivory Coast , and the reader can find it in the text listed in the bibliography.

Notes

1 Already published in Rivista Italiana di Gruppoanalisi , 2004, XVIII, 2, [41-49].

2 This translated passage of Decamerone by Boccaccio has to be considered as a free interpretation of the translator.

References

Angeletti L.R. e Gazzaniga V. (2002). Storia, filosofia ed etica generale della medicina . Masson, Milano.

Arecco D. (1999). La medicina secondo Ippocrate. Anthropos & Iatria , III, 1 (http://www.medicinealtre.it/1999/arecco-1-99.htm, consultation date: january 18 th , 2004.

Augé M. (1984). Ordre biologique et ordre social: la malarie, forme élémentaire de l'événement. In Augé M. e Herzlich C. (eds.) Le sens du mal. Antropologie, histoire et sociologie de la maladie . Éditions des Archives contemporaines, Paris.

Balint M. (1930). The crisis of medical practi ce. The American Journal of Psychoanalysis , 2002 , LXI, 1, [7-15].

Balint M. (1957). The doctor his patient and the illness . Pitman Medical Publishing, London .

Bateson G. (1972). Steps to an Ecology of Mind. Chandler Publishing Company, San Francisco .

Boccaccio G. (1349-1351). Il dec amerone . Hoepli, Milano 1972.

Erikson E.H. (1968). Identity: Youth and Crisis . Norton , New York .

Foulkes S.H. (1948). Introduction to Group-Analytic Psychotherapy: Studies in the Social Integration of Individuals and Groups . Heinemann, London .

Friedman R. (2003). Who contains the group and who is the leader? A social - pathological perspective . Unpublished work.

Grmek M.D. (1998). La vita, le malattie e la storia . Di Renzo editore, Roma.

Landoni G. (2004). Divagazioni sulla diagnosi. Rivista Italiana di Gruppoanalisi , XVIII, 1.

Neri C. (1998). Group . Jessica Kingsley Publishers, London and Philadelphia .

Panzera G. (2004). Considerazioni sul concetto di diagnosi. Rivista Italiana di Gruppoanalisi , XVIII, 1.

Tomassoni M., Solano L. (2003). Una base più sicura. Esperienze di collaborazione diretta tra medici e psicologi . Franco Angeli, Milano.

Tucci P. (2004). L'interesse dello psicoanalista va oltre la diagnosi. Rivista Italiana di Gruppoanalisi , XVIII, 1.

Voltaggio F. (1992). L'arte della guarigione nelle culture umane . Bollati-Boringhieri, Torino.

Winnicott D.W. (1965). Maturational Processes and the Facilitating Environment . International Universities Press, New York.

Raffaella Girelli Clinical Psychologist, Psychotherapist, scientific co-worker at the chair of "Basis of group dynamics" (University of Rome "La Sapienza").

laudio Neri is Professor of "Basis of group dynamics" ( University of Rome "La Sapienza). He is training and supervising analyst for the Italian Psychoanalytic Society and the International Psychoanalytic Association. Full member of the London Institute of Group-Analysis.

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