Thursday Review: “Making Sense”

It’s no wonder that Asher’s lecture titled “Making Sense” is devoted entirely to the use of language and its use in shaping how medical information is conveyed.

People have always known that language is powerful. Asher quotes a wide range of literature throughout the talk, among them the beginning of John’s Gospel, In the beginning was the word, and the story of Rumpelstiltskin. The idea that knowing something’s name gives one power over it is an old, old human belief. So much so, that the idea made it into a fairy tale some 4,000 years ago.¹

Asher’s main point is that the use of words and the meanings we give them can have a profound effect on the progress of medicine. At times, Asher gets close to talking about what Robert M. Pirsig called “Phaedrus’ knife”,² which is the “tool” we use to mentally cut apart our experiences of the world into separate things. After we mentally understand that this thing is different from that thing, we can give them names that differentiate and abstract them.

Asher talks through many of the ways that Phaedrus’ knife slips, that is, the ways which a medical meaning is prevented from arriving intact at its destination:

• A name is “born”, and only then is a disease is applied to it
• Something exists which has no name
• A patient is placated because a name exists for their condition
• A patient becomes anxious because a name sounds serious
• A word or term has been used incorrectly for so long, the incorrect or non-specific meaning has become understood as the meaning
• A medical pathology has been named for an apparent cause which is not what causes the disease
• Naming by conjecture (a broader application of Naming by apparent cause)
• Bad style (one of Asher’s favorites, by which he usually means obnoxious prolixity and the malignant hypertrophe of language)

Like I’ve mentioned in this series before, it’s been nearly 60 years since Asher gave this lecture, so I’m positive some — if not most — of the examples he gives have become outdated. I’m also positive someone working in a clinical setting wouldn’t have to think terribly hard to come up with contemporary examples of these phenomena.

Names and diseases in search of each other

There are several examples of a label in search of symptoms, and Asher says that his examples are due to a misapplication of the terms. This is certainly understandable. Going back to the Rumpelstiltskin effect, if we imagine some pattern exists, it’s difficult to keep it in existence, keep talking about it and using it in a medical setting unless we gain some power over it by naming it.

In Asher’s examples, Drs. P. K. Pel and W. Ebstein described chronic relapsing fever probably due to brucellosis several years apart. Asher asserts that someone noticed that patients with “Hodgkin’s disease” exhibit a fever with a period of about a week, and somehow, this was connected with the “chronic relapsing” of “Pel-Ebstein fever”. Asher doesn’t think Pel-Ebstein fever exists, but nonetheless:

It does not matter whether or not Pel-Ebstein fever exists, my contention remains the same: the bestowal of a name upon a concept, whether real or imaginary, brings it into clinical existence.

Asher is uniquely qualified to claim this: aside from his medical writings, Asher is perhaps best known for naming Munchausen’s syndrome. A rose without a name, he says, may smell as sweet, but it has far less chance of being smelt.

I have only once named a disease and that was Munchausen’s syndrome. I discovered nothing about it; I only described something that most doctors knew already and gave it a name. Yet the effect of christening it astounded me: case-reports, articles, and correspondence on the subject have continued ever since, both here and abroad; new names are added to make it more confusing [Munchausen’s syndrome is currently known as “Factitious disorder imposed on self”], and new explanations offered for its occurrence (in America the allegation has been made that it is only caused by the National Health Service).

According to Asher’s examples, simply naming something is enough to convince others it actually exists, even if most doctors knew. Once this thing which was known had a name, it could become the subject of study and debate… and complication.

The comfort and horror of names

From my own experience, I know that simply having a nurse or a doctor announce the name of something can be a calming experience. Last year, I had symptoms that first reminded me of a cold, then reminded me of the flu, and then I broke out in painful blisters. I tried to keep myself calm, but in the back of my head, a small, persistent voice kept asking, “What if it’s some weird flesh-eating bacteria?”

It wasn’t, of course, and after a nurse took my symptoms the next morning, she casually asked, “Have you ever had shingles?” before she left the exam room. There was a huge relief when the doctor confirmed, that yes, I have shingles. Reflecting back on the experience, the relief I felt didn’t come when receiving prescription anti-viral medication, or when talking to the physician about the course of the disease. I felt relief when the doctor was able to name what the nurse knew at a glance. It was almost as if the MD had said “Shingle-stiltskin!” and my fears disappeared in an enraged cloud of smoke.

With his usual humor, Asher confirms that this is not new, but not always useful:

However uninformative the name of his illness may be a patient feels his foe is partially vanquished once he knows its name. We all know the conversation:

“I seem to have an inflamed tongue, doctor. Will you have a look at it?”

“Ah, yes. You’ve got glossitis.”

“Thank you, doctor. It’s all right now I know what it is.”

The opposite is also true: Other words appear to hold power against the patient. There was a time when people didn’t even want to say “the C-word”, there was such fear of a cancer diagnosis. Patients might have stories in their head of one clinical term being worse than another, too. If you tell a woman she has rheumatism, she asks, fearfully and tentatively: But is it arthritis, doctor?

Corrections, causes, and conjectures

All along, Asher asks other practitioners to recognize the power language has, and for that reason, and use it correctly with care and reverence.

One of the interesting examples he gives of a wrong term being used so often it’s become correct — or at least appears correct — is “lymph gland”. I don’t know if this is a product of the time Asher was writing in, or the fact that I grew up in the United States, or both, but I’ve only ever heard the “correct” term, “lymph node”.

The broadest discussion in the speech is dedicated to the different ways physicians and researchers name medical concepts by conjecture. A specific subset of this is naming things by their apparent causes. If it turns out the name isn’t actually the cause, at best there might be some wasted time and energy, or at worst some bad outcomes. Asher discusses “ruptured plantaris syndrome”, a collection of symptoms which would exist if a plantaris muscle ever ruptured, but which is applied to situations in which the plantaris doesn’t rupture:

It illustrates a fault in nomenclature which causes more trouble than any other of the semantic abuses … Because the name of a pathological process (rupture of the plantaris) has been placed upon a syndrome (sudden unexplained pain and bruising), we are in an impossible position. We do not know to which it applies—the pathology or the symptoms—and so we are convinced, unthinkingly and uncritically, without a shred of evidence, that the one causes the other. It is immaterial to my argument whether or not rupture of the plantaris muscle does really cause these symptoms; yet all the same you may be interested to learn that it almost certainly does not. I have searched the literature and found one genuine case of ruptured plantaris muscle³ (n.b.—I mean muscle, not syndrome)…

It’s not just a cause/effect relationship that causes healthcare providers to not say what they mean. Broadly speaking, these are “conjectural names”, and can be used even when the name isn’t even a conjecture:

When a physician writes “diminished air entry at the right base” he does not believe that any less air is entering the right base; he only means that the breath sounds are fainter there. Yet when a physician feels sure the lung is solid and that no air is entering it, he never uses the words “diminished air entry”.

…

Of the 37 doctors who said they used the expression “diminished air entry”, 23 admitted that they never meant what they said, and 25 also revealed that when they really believed less air was entering the lung they would not dream of saying “diminished air entry”.

Of the various other miscellany, Asher also complains about business jargon, which is funny coming from the late 1950s: nobody says anything: they state, or worse still, they intimate that. … Nobody looks ahead: they envisage a long-term policy.

Ultimately, Asher spends so much time on words because words are the basic unit of transmittable meaning in any community, and if that meaning is corrupted or unclear, none of the other communication, however well-meaning or well-crafted, is going to have any effect.

The words we use can either fill stories with meaning, or empty them, and quickly. Asher quotes Matthew Arnold’s poem A Wish:

Nor bring to watch me cease to live
Some Doctor, full of phrase and fame
To shake his sapient head and give
The ill he cannot cure—a name.

Sources

The article reviewed: Asher, Richard. “Making Sense.” Lancet 2, no. 7099 (1959): 359–65.

¹ Silva, Sara Gra&ccedila da, and Jamshid J. Tehrani. “Comparative Phylogenetic Analyses Uncover the Ancient Roots of Indo-European Folktales.” Royal Society Open Science 3, no. 1 (January 20, 2016): 150645. https://doi.org/10.1098/rsos.150645. ↑

² Pirsig, Robert M. Zen and the Art of Motorcycle Maintenance: An Inquiry into Values. Morrow, 1974. ↑

³ Croce, Edmund J., and George K. Carpenter. “Rupture of the Plantaris Muscle.” The Journal Of Bone & Joint Surgery 26, no. 4 (1944): 818–20. ↑

Featured Image: Richard Asher, photograph provided by his family, used under a CC BY-SA 3.0 license, via Wikimedia Commons.