364                               JOHN NESSA                                    Sign             Interpretation           ...
SEMIOTICS AND CLINICAL MEDICINE                      365pain" for the surgeon becomes "a suspected appendicitis". But its ...
366                              JOHN NESSAsignifies anything is like having a coin with one side only. The meaningof a si...
SEMIOTICS AND CLINICAL MEDICINE                     367    This definition has three elements: The primary sign, the inter...
368                      JOHN NESSA      Person A                                 Matter C                                ...
SEMIOTICS AND CLINICAL MEDICINE                    369             Sign 1                      Object 1                  /...
370                               JOHNNZSSAdoes psychoanalytic theory. 20-23 In everyday medicine, history taking isprimar...
SEMIOTICS AND CLINICAL MEDICINE                       371          6. APPLYING SEMIOTICS TO A CLINICAL CASEThe clinical vi...
372                              JOHN NESSA    First, I have to repeat that the diagnoses are not primarily facts belongin...
SEMIOTICS AND CLINICAL MEDICINE                      373and interaction with the patient. 38 In the case of clinical medic...
374                              JOHN NESSA                              8. DISCUSSIONAll clinicians are familiar with his...
SEMIOTICS AND CLINICAL MEDICINE                        375                                  I   IIIII   .              %__...
376                                  JOHN NESSA4 Mayou R. Medically unexplained physical symptoms. Do not overinvestigate....
SEMIOTICS AND CLINICALMEDICINE                             37741 Bumum JE Medical diagnosis through semiotics. Giving mean...
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john nessa - semiology

  1. 1. JOHN NESSAA B O U T SIGNS A N D S Y M P T O M S : C A N S E M I O T I C S E X P A N D T H E VIEW OF CLINICAL MEDICINE?ABSTRACT. Semiotics, the theory of sign and meaning, may help physicians complementthe project of interpreting signs and symptoms into diagnoses. A sign stands for something.We communicate indirectly through signs, and make sense of our world by interpretingsigns into meaning. Thus, through association and inference, we transform flowers into love,Othello into jealousy, and chest pain into heart attack. Medical semiotics is part of generalsemiotics, which means the study of life of signs within society. With special referenceto a case story, elements from general semiotics, together with two theoreticians of equalimportance, the Swiss linguist Ferdinand de Saussure and the American logician CharlesSanders Peirce, are presented. Two different modes of understanding clinical medicine arecontrasted to illustrate tile external link between what we believe or suggest, on the onehand, and the external reality on the other hand.KEY WORDS: The theory of signs, symptoms and signs, diagnostic interpretation,structural linguistics, Ferdinand de Saussure, Charles Sanders Peirce, medical semiotics,scientific mode of understanding, henneneutic mode of understanding 1. I N T R O D U C T I O NEven though the expression "signs and s y m p t o m s " tends to c o m e out in asingle breath, as a unit, the two concepts are often discussed seperately inthe medical literature. According to Lester King,1 s y m p t o m s are subjective,or intersubjective, verbally expressed sensations, presented in the medicalconsultation. A sign is more objective. It unravels a disease when perceivedand interpreted by a skilled clinician. A clinical symptom is, unlike a sign,transient and volatile, without substantial information. T h e distinction between signs and symptoms is one o f the consequenceso f biomedicine having b e c o m e part o f the natural sciences during the lastcentury. In the Hippocratic tradition, a symptom had its own status, givinginformation for medical observations. A s y m p t o m was three-dimentional,in the sense o f pointing to the past (anamnesis), present (diagnosis) andfuture (prognosis). 2 The Galenic tradition, which was the only authoritativemedicine o f the Middle Ages, embodied theoretical medical knowledge intexts called Institutes o f Medicine. 3 S e m i o l o g y (from G r e e k s e m a - s i g n )was one o f the five segments o f these texts.Theoretical Medicine 17: 363-377, 1996.(~) 1996 Ktuwer Academic Publishers. Printed in the Netherlands.
  2. 2. 364 JOHN NESSA Sign Interpretation Reference (into meaning) (to an object) Figure 1. Different aspects of the message. A medical consultation often starts with the patient presenting a symp-tom, a bodily sensation of some kind. The common assumption is that thesymptom may express bodily or emotional pathology. A healthy person hasno symptom. The problem is, however, that even in patients presenting withone or more symptoms we often cannot identify any significant pathology;we have no physical findings, all tests are normal .4 The patient neverthelessusually wants an explanation for his or her sufferings, which biomedicinein many cases cannot give. And traditional explanations, such as somati-zation, hypochondriacal symptoms or functional overlay, are insufficient,pejorative and theoretically inadequate for both doctor and patient. 5 2. SEMIOTICSThe word "semeion" stems from the Greek noun "sema", which means"sign, signal, mark, token". The term "semiotics" is understood as thetheory of sign and meaning, and has been given various definitions. Iuse the Saussurian term "the study of life of signs within society". 6 Thesubject matter of semiotics is messages, any messages whatsoever, andtheir relation to interpretation, meaning and reference (Figure 1). Meaningand reference are not identical terms. The meaning of a message is givenby what the receiver understands by the message, literally how the messageis interpreted. The reference of a message concerns the relation betweenthe message and the object in the world the message is referring to. Thedifference between the terms may be illustrated by a clinical example:A patient complains of abdominal pain. The surgeon, interpreting it asappendicitis, decides on an operation. The peroperative finding is a paleappendix and enlarged nodes. Hence, the meaning of the sign "abdominal
  3. 3. SEMIOTICS AND CLINICAL MEDICINE 365pain" for the surgeon becomes "a suspected appendicitis". But its reference,namely the source, the object of the pain, is unknown, or perhaps, a viralinfection giving enlarged lymph nodes and abdominal pain. Semiotics contains theories and models about linguistic signs (words)as well as gestures and other signals which are perceived and interpretedas part of the interaction between man and the world around him. In this article, my aim is to show if and how the theory of semioticscan be used to expand the view of clinical medicine. Theories of signswill be used as key concepts for understanding medical symptoms andtheir pragmatic and clinical function. Special emphasis will be put on theSwiss linguist Ferdinand de Saussure and the American logician CharlesSanders Peirce, two theoreticans of equal importance to the developmentof modern semiotics. A clinical vignette will be used as a heuristic device,to illustrate the relevance of semiotics to clinical medicine. 3. CASE HISTORYA case history presented by Cecil G. Helman may be well known to manyphysicians: A man in his forties consulted his general practitioner duringa busy practice day for two episodes of pain on the left side of his chest. 7He was afraid that the pain had "something to do with my heart". Hewas a busy man, and admitted to his doctor that he had been "under a lotof stress recently". He was briefly examined by the general practitioner,who found no physical abnormality, concluding "its just due to strain, butwed better be sure and run a few tests". He was sent to a hospital, toldby a doctor there that he had had a small heart attack, "probably anginalin origin". The patient asked for a second opinion by a cardiologist, whofound no abnormalities whatsoever, and told the patient that his "tension"in his daily life was responsible for his "hyperventilation". 4. LANGUAGE AS SEMIOTICS: FERDINAND DE SAUSSUREFerdinand de Saussure (1857-1913) was a Swiss professor in linguistics.His theories, also called structural linguistics and semiology, in addition tothe widely accepted term semiotics, is primarily a theory about language.Essential in his theory is the term linguistic sign. A sign is, according toSaussure, a dual entity. 8 It consists of both a noise and an idea, a soundthat signifies (= signifier) and a concept that corresponds to it (= signified)."Signifier" and "thing signified" are inseparable, as are the two sides ofa coin or the inside and the outside of a circle. To have a sign that not
  4. 4. 366 JOHN NESSAsignifies anything is like having a coin with one side only. The meaningof a sign is a concept to be interpreted according to an idea, not a thingidentified as an object (Figure 1).9 The relation between "signifier" and"thing signified" is arbitrary and conventional. Therefore the same ideacan be called "stomach" in English and "Magen" in German.~° Both medical symptoms and medical diagnoses are conceptualizationsof ideas, and hence linguistic signs. And so are the words "strain", "angina"and "hyperventilation", the three different labelling diagnoses taken fromthe case story. These words, as noise or as written signs, are in themselveswithout meaning. They get their meaning in relation to an idea, a conceptabout diseases. Hence, they convey a message about everyday life (strain),cardiology (angina) and psychodynamics (hyperventilation), respectively.The signs also refer to a physical object outside language, to the physicalworld which the patient is part of. Maybe we could find later on, byan angiographic examination, abnormalities (partly or fully) responsiblefor his pain. Then we would find that the sign "chest pain" refers toan identifiable extra-mental physical entity, an object in the world. Butthe meaning of the sign, the "thing signified," is, according to Saussure,independent of this. He regards language as a system independent of thephysical, extra-linguistic reality. 11 Language is not primarily a naming-process of objects in the world. This does not mean that Saussure deniesthe possibility of a connection between language and reality. But accordingto his notion of a sign as a pure linguistic entity, he prefers to emphasizethe social and intersubjective character of all discourse. ~2 Language is"a system of interdependent terms in which the value of each term resultssolely from the simultaneous presence of the others". 13Words and conceptsare constituted as signs by their simultaneous differences from other signs.A sign both tells what a concept is and what it isnt. By saying "strain","angina" or any other medical diagnosis, the words act as signs by theirsimultaneous differences from other signs: It is "strain" that is implied,"not angina". 5. LOGIC AS SEMIOTICS: CHARLES SANDERS PEIRCEIn addition to structural linguistics, semantic theory was developed mainlyby Charles Sanders Peirce (1839-1914). Peirce defined a sign as "somethingwhich stands to somebody for something in some respect or capacity. Itadresses somebody, that is creates in the mind of that person an equvivalentsign, or perhaps a more developed sign. That sign which it creates I call theinterpretant of the first sign. The sign stands for something, its object".14,15
  5. 5. SEMIOTICS AND CLINICAL MEDICINE 367 This definition has three elements: The primary sign, the interpretantand the object. The interpretant is a more developed sign giving the pri-mary sign its meaning. According to Umberto Eco, the interpretant can beconceived as the definition of the sign, and it is something that guaranteesthe validity of the sign. 16,17 The object is what both the sign and the inter-pretant are referring to. This is a three-dimensional definition of a sign,the triadic relation of sign-object-interpretant is the irreducible characterof any sign that signifies. This may be highly theoretical and difficult to grasp. But since thehuman mind cannot function without signs, let us for a moment simplyreplace sign, interpretant and object with the pronouns I, you and it: I speakto you about something. I am the sign, you are the interpretant, and wespeak together about an object. To grasp the Peircian way of thinking in a clinical context, we have tostart with the following situation: A doctor (A) is talking to another doctor(B) about a third matter (C). Let us further suggest that A is a generalpractitioner talking to a cardiologist B about what may be the patientssufferings, his "real disease" C. As in the case story, by presenting theepisodes as chest pain the doctor is producing a sign which the cardiolo-gist may interpret as angina pectoris. For the cardiologist, theories aboutischaemic heart disease give the sign its meaning as angina pectoris. Ahas produced one sign, B has produced an equivalent; but yet another signcorresponding to the first one. But what they really are talking about, whatthe signs "chest pain" and "angina pectoris" are referring to in the physicalworld, may be quite different. Let us again imagine that the patient had anunrecognized tumor that caused his pain. Then this tumor is the object forthe sign - his pain - and hence its reference. Peirces triadic relation corresponds well with the clinical situationexemplified above (Figure 2). It has also its parallel in the triadic clinicalrelation symptom-diagnosis-disease. The patient "is" the symptom, the doctor interprets it as a diagnosis, and they both refer to an object which is a disease. Life is, according to Peirce, a process of continuous signification, semi- osis. Hence the interpretant of a sign in a sign-object-interpretant relation becomes a sign in a new triadic relation, and so on (Figure 3). Generally, the process of interpretation and signification has also to be called the coding process of the sign. A code is a system, a set of formally structured oppo- sites and differences, and hence a set of signs. 18 A system of cardiologicat concepts is a code category, as is a system of psychodynamics.
  6. 6. 368 JOHN NESSA Person A Matter C / Person B The clinical model: Symptom Disease / Diagnosis The semiotic structure: Sign Reference / Meaning The Peircian semiotic: Sign Object / Interpretant Figure 2. Four parallel triadic relations.
  7. 7. SEMIOTICS AND CLINICAL MEDICINE 369 Sign 1 Object 1 / Interpretant 1 Sign 2 Object 2 (= Interpretant i) (= Sign 2 object) "x/ Interpretant 2 I and so on, endlessly .... Figure 3. The process of continuoussignification.5.1. Symbolic, Indexical and Iconic SignsBoth sign, object and interpretant are complex entities. Peirce states thatphilosophy would do well "to provide itself with a vocabulary so out-landish that loose thinkers shall not be tempted to borrow its words", m(Maybe he has not succeeded since I am trying to apply his scemata andvocabulary to a medical setting.) Of special interest in medicine is the rela-tion between signs of disease and the disease itself, which is considered asthe object of the sign. Between the sign and its object, Peirce differenti-ates signs into three categories: symbolic signs, indexical signs and iconicsigns. Human language is a paradigmatic example of symbolic signs, asare the arab numbers 1,2, 3 etc. The connection between signs and objectsis artificial and conventional as one has to know the code and master thelanguage to interpret the signs. Communicative approaches to psychia-try and psychosomatics regard symptoms as arbitrary symbolic signs, as
  8. 8. 370 JOHNNZSSAdoes psychoanalytic theory. 20-23 In everyday medicine, history taking isprimarily a collection of symbolic signs. The indexical sign is causally related to its object. 24 It has some exis-tential relation to that object, and shows to its object by being a footprint,a track of what it m e a n s Y Smoke means fire, knocking on the door meansthat somebody is asking for the door to be opened. Bodily gestures, "bodylanguage" have strong indexical attitudes. Indexical medical signs areexplored mainly through the physical examination. An icon is a sign that has "some character in itself", showing what it is,like a line drawing, a sketch or a traffic sign. 26 X-rays or other technologicalvisualizations are medical examples of iconic signs. 27 The distinction between symbolic signs, indexical signs and iconicsigns is arbitrary and not exact. Hence Peirce himself states that it wouldbe difficult, if not impossible, to find an absolutely pure index, or tofind any sign absolutely devoid of the indexical quality. 28 In the realmof medical semiotics these difficulties are seen especially regarding thesymbolic and indexical sign pain. Even though the symptom of feeling- and expressing - pain has the same name for different diseases, it is asignificant clinical difference between a patient, in a relaxed atmosphere,telling about instances of abdominal pain or headache, respectively, anda patient showing his pain by rolling around on the floor screaming forhelp.5.2. Saussure and Peirce: Two Different ApproachesIndependent of, and unknown to each other, Saussure and Peirce developedtheir respective theories of signs. The differences between their approachesare obvious: Saussure defines the sign as a dual entity, Peirce as a triadicone. Saussure has a linguistic approach, his theory is about human lan-guage. Peirce, on the other hand, has a much wider approach. Language isonly a part of his semiotics, but he gives us ideas about the relation betweensigns and the physical reality. Saussure has a very profound knowledge andunderstanding of human language in general. But he lacks terms and vocab-ulary for an extensive use of his semiotics on extra-linguistic subjects.Peirce, on the other hand, has a more technical approach than Saussure.Both are essential to medical semiotics. King - without himself explicitlycommenting on it - uses a Saussurian concept when analyzing signs andsymptoms29 Marja-Liisa Honkasalo, who teaches medical semiotics in theDepartment of Public Health at the University of Helsinki, uses a Peircianperspective. 3°
  9. 9. SEMIOTICS AND CLINICAL MEDICINE 371 6. APPLYING SEMIOTICS TO A CLINICAL CASEThe clinical vignette may illustrate how we as clinicians structure ourthinking, and give meaning to patients symptoms. None of the applieddiagnoses depend on certain clinical signs. Rather, all physicians have bytheir respective interpretations produced different diagnoses. They are cre-ators of meaning when they conclude that the patients symptoms meansstrain, angina and hyperventilation, respectively. All the diagnoses are, inthe Peircian sense, different interpretions of the sign "chest pain". Thediagnoses may also illustrate the Saussurian sign: because the physiciansare proclaiming that the patient has muscular strain, angina and the hyper-ventilation syndrome, the patient, in a way, "has" these diseases. Thediagnoses depend heavily on the doctors interpretations, since diagnos-ing is naming, structuring of reality. None of the diagnoses are in essencefacts belonging to the external world, but linguistic and cognitive struc-turings of reality, ways of interpreting experiences and perceptions. Eventhough the patient might have ischaemic heart disease, angina as a diagno-sis explaining a specific episode of chest pain is in fact an interpretation,a "reflexive construct", a way of grouping experience into objects in theworld. 31 According to Thomas Kuhn, an essential part of scientific researchis regrouping of objects in the world. 32,33 It is to produce significant differ-ences creating knowledge. Both diagnoses can be regarded as regroupingsof knowledge different from other possible explanations. The presentedcase displays very clearly that more than one theoretical construction canbe utilized to explain a given collection of data. 34 7. MEDICAL SEMIOTICSA medical student didnt pass an examination because on studying a bloodsmear under the microscope he stated "I see only dots". What he shouldhave seen, after having studied haematology, was lymphocytes. It wasnot incorrect to see dots. It was, however, an insufficient and inadequatemedical interpretation of the smear. This example may illustrate the Kantian philosophical statement thatwe have no direct access to the world. In everyday life as well as inmedical settings, the only way to grasp reality is to perceive signs andinterpret them through inferences. To see something is always to see it a ssomething. Using the case story about the man with chest pain, I will nowtry to characterize the process of interpreting signs to understand what wedo when we attend to patients.
  10. 10. 372 JOHN NESSA First, I have to repeat that the diagnoses are not primarily facts belongingto the real world, but interpretations, ways of structuring reality, hypothesesand conjectures. This of course does not mean that a "real world" does notexist, or that we cannot speak about such a world. On the contrary, scientificmedicine is based on an assumption about objectivism, truth, reality andmethodology. There is supposed to be a physical reality behind the chestpain. And this reality is one and the same even though three differentdoctors make three different interpretations. This reality is what Peirce callsthe object of the sign. The problem arises: What is the relationship betweenthe interpretation of the sign, namely the diagnoses, on the one hand, andreality on the other hand. This is a problem about modes of understandingin clinical medicine, a notion which is discussed in a clarifying way byAllan B. Chinen. 357.1. Modes of UnderstandingAccording to Chinen, modes of understanding provide the external linkbetween thought or belief, on the hand, and reality, on the other. 36 Wecan define a mode of understanding in the Peircian semiotic term as therelationship between a sign, such as a proposition ("chest pain") and theobject the sign refers to, e.g. a situation in the real world. Different modesof understanding involve different kinds of relationships between the signand the referent.7.2. The Scientific Mode of UnderstandingThe diagnosis angina pectoris represents a scientific mode of understand-ing. Angina represents ischaemic heart disease, which is claimed to exist asan empirical, biological fact. The diagnosis is correct or incorrect, depend-ing on objective findings following a specific methodology to unravelcoronary heart disease. The scientific attitude constitutes a distinctive mode of understanding.In this mode subjective beliefs are distinguished from objective situations,and it is acknowledged that our beliefs can be wrong or incomplete. 37 Toapply a scientific attitude to the case story is to narrow the sign "chestpain" down to a question about somatic disease only.7.3. The Hermeneutic Mode of UnderstandingHowever, as physicians, we use other modes besides the scientific one.The reason is obvious. Human medicine is, unlike veterinarian medicine,an enterprise where the object is a an individual, a person, not a biologicalbeing only. To understand a man is to understand a being who under-stands himself. This acknowledgement requires empathic communication
  11. 11. SEMIOTICS AND CLINICAL MEDICINE 373and interaction with the patient. 38 In the case of clinical medicine, theseexchanges involve deeply personal values and meanings, on the part ofpatient and physician alike, whether explicitly discussed or not. The studyof meaning in philosophy is called hermeneutics, a term which coverssemiotics as well. The hermeneutic mode includes both personal and inter-personal dimensions of meaning - the patients or physicians own valuesand viewpoints on the one hand, and their communication with each otheron the other hand. 39 The main difference between the scientific mode of understanding andthe hermeneutic one is, according to Chinen, that in the hermeneutic mode,subjective experience and interpretations take precedence over objectivefacts. That is, the normal reference from subjective belief to objective sit-uation is temporarily suspended, and attention is focused on the subjectiveside. 4° This does not mean that no reference, no object exist. Above, I discussedthe diagnosis of strain. Strain is just as real as ischaemic heart disease. Butit is a reality on another level, not belonging to the physical, but the intra-(or inter-) personal mental world. The three diagnoses all represent different modes of understanding,different ways of interpreting the same sign and relating it to differentrealities. Different combinations of interpretations are possible, the patientmay or may not feel strain, may or may not have angina, may or may nothave hyperventilated. In what particular interpretation to rely on in a clini-cal situation depends on many factors. The everyday clinical interpretationdepends on previous experience and on bias of the individual physician aswell as on risk factors, the situation and its context, and is due to the art ofmedicine rather than science.7.4. Semiotics: Science or hermeneutics?The aim of medical semiotics is to narrow the gap of uncertainity and givea fuller understanding of the process of clinical work. 41 All symptomsand all clinical signs need an interpretation. Sometimes, this interpretationis due to routine practice. A bleeding wound in the forehead needs nohermeneutic interpretation for medical care. For a patient with a heartarrest, it is meaningless to ask what he could have meant by that. In termsof semiotics, sign and meaning coincide, and a scientific- biological way ofunderstanding takes precedence over a hermeneutic o n e . 42 But this is notthe rule. Rather, in clinical medicine, very often we cannot be quite sure.We seldom are immediately certain about a diagnostic problem. In suchcases, we have to reason and decide what information is most relevant tosolve a pragmatic clinical problem.
  12. 12. 374 JOHN NESSA 8. DISCUSSIONAll clinicians are familiar with history taking, listening to the patientssymptoms which lead us to physical findings and give us a diagnosis. Theensuing treatment follows routine standards. A number of physical symp-toms, however, such as abdominal pain, dyspepsia, headache, backache,joint pain, chest pain, palpitations and fatigue lack a satisfactory analyticalt e r m . 43 It makes no sense to say that these symptoms are not real. Theyare just as real as the patient is. To accept utterances at face value is a pre-requisite for all human communication. So also in medicine. But of courseit make sense to ask what kind of reality the symptoms reflect. The clinicalchallenge emerges when the symptom does not correlate with an identi-fiable pathology, probably because such a pathology often does not exist.The symptom is not always what Galenos learned, "the shadow behind thedisease". 44,45 The signs delivered by the patient may be regarded as a text,a story embedded in a body language. The patient is both telling and show-ing what is his or her sufferings and agenda. Hence, we perceive the sumtotal of the patients signs by both listening to, seeing, feeling, touchingand tasting the complex message from the patient. Symptoms experiencedand expressed can also be regarded as cultural and communicative acts,attempts to translate subjective sensations into signs that are understood inthe medical consultation. 46,47 The symptom is a verbal or physical sign experienced by the patient, the symptom presentation represents a "handing-over" of experience. Being ahuman being requires to organize life linguistically as well as expressingoneself to other human beings in a symbolic way. 48 Man is, according toErnst Cassirer, the symbolic animal. 49 This is also what Peirce is express-ing, insisting on the idea that man is the sum total of the words or signsthat man use. 5° The patient with chest pain got three different diagnoses. None ofthe diagnoses are in themselves objective physical findings, rather they are interpretations of symptoms and signs. The three different physicians recognize three different things, just as two observers may see two dif-ferent animals in the well-known duck-and-rabbit example, often used inpsychology textbooks (Figure 4). To interpret a symptom expressed as a diagnosis necessitates a cognitive structure, a code-set. The general prac- titioner chooses an everyday code, the hospital doctor a somatic code and the cardiologist a psychodynamic one. All the codes are meaningful, but none of them are expressing the whole truth. Understood as a semiotic sign production, the shift from the symptomatic attacks to the three different diagnoses is a shift from one sign to three different signs. The doctors are
  13. 13. SEMIOTICS AND CLINICAL MEDICINE 375 I IIIII . %__ C__ II I Figure 4. The duck-and-rabbitfigure(From Jastrow: Fact and Fable in Psychology).thus creators of meaning, and the diagnoses get their value as signs ofmeaning in the interaction between doctor and patient. 51 To interpret medical symptoms is normally to interpret verbal expres-sions. 52,53 Hence this procedure might be comprehended by means oflinguistics. 54 Semiotic interpretations put scientific medicine in a widercontext. Semiotics analyzes and interprets what happens with man as asocial being, interacting with other persons in an intersubjective way.The interpreting process is endless. The diagnosing is, as a linguistic andpragmatic activity, part of this process. This process is also an integral partof being a doctor, regardless of the physical findings we make. ACKNOWLEDGEMENTSI am grateful to Kirsti Malterud of the University of Bergen for her combi-nation of radical critisism and encouragement during many earlier drafts ofthis paper, to Anders Seim, 1464 Fagerstrand, and to Rolf Wynn, Univer-sity of Troms0, who both have corrected and commented on my differentversions. NOTESI King L. Medical Thinking. A ttistorical Preface. New Jersey: Princetown UniversityPress, 1982.2 HonkasaloM. Medicalsymptoms:A challengefor semiotic research. Semiotica, t991;87:251-268.3 King: 77.
  14. 14. 376 JOHN NESSA4 Mayou R. Medically unexplained physical symptoms. Do not overinvestigate. Brit MedJ, 1991; 302: 534-535.5 Ibid: 534.6 Innis RE. Semiotics. An Introductory Reader. London: Hutchinson University Library, 1988.7 Helman CG. Disease and pseudo-disease: A case history of pseudo-angina. In: Hahn RA,Gaines AD, eds. Physicians of Western medicine. Anthropological Approaches to Theoryand Practice. Dordrecht: D. Reidel Publishing Company, 1985.8 Saussure E Course in General Linguistics. New York: McGraw-Hill paperbacks, 1966.9 Psaty BM, Inui TS. The place of human values in the language of science: Kuhn, Saussureand structuralism. Theor Med, 1991; 12: 345-358.10 Saussure: 67.11 Psaty: 350.12 Ibid: 351.13 Saussure: 114.14 SheriffJK. The Fate of Meaning. Charles Peirce, Structuralism and Literature. Prince-ton, New Jersey: Princeton University Press, 1989.15 Hartshorne C, Weiss R The collected papers of Charles Sanders Peirce, volumes I & II.Cambridge: The Belknap Press of Harvard University Press, 1960.16 Eco U. A Theory of Semiotics. Bloomington: Indiana University Press, 1976.iv Honkasolo: 253.18 Sebeok T. Zoosemiotic components of human communication. In: Innis R, ed. Semiotics.An Introductory Reader. London: Hutchinson University Library, 1988.19 Sheriff: 55.2o Shands HC. Semiotic Approaches to Psychiatry. The Hague: Mouton, 1970.21 Szasz T. The Myth of Mental Illness. London and Toronto: Granada, 1972.22 yon Uexktill T. Semiotics and medicine. Semiotica, 1982; 38: 205-215.23 Honkasolo: 256.24 Ibid: 255.25 Sheriff: 67.26 Ibid: 67.27 Innis: 11.28 Ibid: 13.29 King: 74.30 Honkasolo: 252.31 M~seide P. Interactional Aspects of Patient Care. Thesis. Bergen: Department of Soci-ology, University of Bergen, 1987.32 Psaty: 353.33 Kuhn T. The Structure of Scientific Revolutions. Chicago: University of Chicago Press, 1970.34 Psaty: 346.35 Chinen AB. Modes of understanding and mindfulness in clinical medicine. Theor Med 1988; 9: 45-71.36 Ibid: 47.37 Ibid: 48.38 Ibid: 52.39 Ibid: 50.4o Ibid: 51.
  15. 15. SEMIOTICS AND CLINICALMEDICINE 37741 Bumum JE Medical diagnosis through semiotics. Giving meaning to the sign. AnnInternalMed, 1993; 119: 934-923.42 Ibid: 941.43 Mayou: 534.44 King: 78.45 Whitbeck C. What is diagnosis? Some critical reflections. Metamedicine, 1981; 2:319-329.46 Daniel S. The patient as text: A model of clinical hermeneutics. Theor Med, 1986; 7:195-210.47 Psaty BM. Literature and medicine as a critical discourse. Literature and Medicine,1987; 6: 13-34.48 Budd MA, Zimmermann ME. The potentiating clinician: Combining scientific andlinguistic competence. Advances, 1986; 3: 40-55.49 Cassirer E. An Essay on Man. London: Yale University Press, 1964.50 Innis: 2.51 Baer E. The medical symptom. In: Deely J, Williams B, Kruse FE, eds. Frontiers inSemiotics. Bloomington: Indiana University Press 1986: 140-152.52 Malterud K. Allmennpraktikerens mote med kvinnelige pasienter (The encounter betweenthe general practitioner and the female patients - a clinical method) Oslo: Tano, 1990.53 Rudebeck CE. General practice and the dialogue of clinical practice. Scand J PrimHealth Care Suppl 1, 1992; 10: 1-86.54 Cosieru E. Einfiihrung in die Allgemeine Sprachwissenschafi (Introduction to languagescience). Ttibingen: Francke Verlag T0bingen, 1988.Department o f Public Health JOHN NESSA& Primary Health CareDivision f o r General PracticeUniversity o f BergenUlriksdal 8c, N-5009 BergenNorway