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JOHN NESSA

A B O U T SIGNS AND SYMPTOMS: CAN SEMIOTICS EXPAND T H E

VIEW OF CLINICAL MEDICINE?

ABSTRACT. Semiotics, the theory of sign and meaning, may help physicians complement the 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 interpreting signs 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 general semiotics, which means the study of life of signs within society. With special reference to a case story, elements from general semiotics, together with two theoreticians of equal importance, the Swiss linguist Ferdinand de Saussure and the American logician Charles Sanders Peirce, are presented. Two different modes of understanding clinical medicine are contrasted to illustrate tile external link between what we believe or suggest, on the one hand, 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 N

Even though the expression "signs and symptoms" tends to come out in a single breath, as a unit, the two concepts are often discussed seperately in the medical literature. According to Lester King,1 symptoms are subjective, or intersubjective, verbally expressed sensations, presented in the medical consultation. A sign is more objective. It unravels a disease when perceived and interpreted by a skilled clinician. A clinical symptom is, unlike a sign, transient and volatile, without substantial information.

The distinction between signs and symptoms is one o f the consequences o f biomedicine having become part o f the natural sciences during the last century. In the Hippocratic tradition, a symptom had its own status, giving information for medical observations. A symptom was three-dimentional, in the sense o f pointing to the past (anamnesis), present (diagnosis) and future (prognosis). 2 The Galenic tradition, which was the only authoritative medicine of the Middle Ages, embodied theoretical medical knowledge in texts called Institutes o f Medicine. 3 Semiology (from Greek 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.

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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 symptom, a bodily sensation of some kind. The common assumption is that the symptom may express bodily or emotional pathology. A healthy person has no symptom. The problem is, however, that even in patients presenting with one or more symptoms we often cannot identify any significant pathology; we have no physical findings, all tests are normal .4 The patient nevertheless usually wants an explanation for his or her sufferings, which biomedicine in 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. SEMIOTICS

The word "semeion" stems from the Greek noun "sema", which means "sign, signal, mark, token". The term "semiotics" is understood as the theory of sign and meaning, and has been given various definitions. I use the Saussurian term "the study of life of signs within society". 6 The subject matter of semiotics is messages, any messages whatsoever, and their relation to interpretation, meaning and reference (Figure 1). Meaning and reference are not identical terms. The meaning of a message is given by what the receiver understands by the message, literally how the message is interpreted. The reference of a message concerns the relation between the message and the object in the world the message is referring to. The difference between the terms may be illustrated by a clinical example: A patient complains of abdominal pain. The surgeon, interpreting it as appendicitis, decides on an operation. The peroperative finding is a pale appendix and enlarged nodes. Hence, the meaning of the sign "abdominal

SEMIOTICS AND CLINICAL MEDICINE 365

pain" for the surgeon becomes "a suspected appendicitis". But its reference, namely the source, the object of the pain, is unknown, or perhaps, a viral infection 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 interpreted as 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 semiotics can be used to expand the view of clinical medicine. Theories of signs will be used as key concepts for understanding medical symptoms and their pragmatic and clinical function. Special emphasis will be put on the Swiss linguist Ferdinand de Saussure and the American logician Charles Sanders Peirce, two theoreticans of equal importance to the development of modern semiotics. A clinical vignette will be used as a heuristic device, to illustrate the relevance of semiotics to clinical medicine.

3. CASE HISTORY

A case history presented by Cecil G. Helman may be well known to many physicians: A man in his forties consulted his general practitioner during a busy practice day for two episodes of pain on the left side of his chest. 7 He was afraid that the pain had "something to do with my heart". He was a busy man, and admitted to his doctor that he had been "under a lot of stress recently". He was briefly examined by the general practitioner, who found no physical abnormality, concluding "it's just due to strain, but we 'd better be sure and run a few tests". He was sent to a hospital, told by a doctor there that he had had a small heart attack, "probably anginal in origin". The patient asked for a second opinion by a cardiologist, who found 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 SAUSSURE

Ferdinand de Saussure (1857-1913) was a Swiss professor in linguistics. His theories, also called structural linguistics and semiology, in addition to the widely accepted term semiotics, is primarily a theory about language. Essential in his theory is the term linguistic sign. A sign is, according to Saussure, a dual entity. 8 It consists of both a noise and an idea, a sound that signifies (= signifier) and a concept that corresponds to it (= signified). "Signifier" and "thing signified" are inseparable, as are the two sides of a coin or the inside and the outside of a circle. To have a sign that not

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signifies anything is like having a coin with one side only. The meaning of a sign is a concept to be interpreted according to an idea, not a thing identified as an object (Figure 1). 9 The relation between "signifier" and "thing signified" is arbitrary and conventional. Therefore the same idea can be called "stomach" in English and "Magen" in German.~°

Both medical symptoms and medical diagnoses are conceptualizations of ideas, and hence linguistic signs. And so are the words "strain", "angina" and "hyperventilation", the three different labelling diagnoses taken from the case story. These words, as noise or as written signs, are in themselves without meaning. They get their meaning in relation to an idea, a concept about 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 physical world which the patient is part of. Maybe we could find later on, by an angiographic examination, abnormalities (partly or fully) responsible for his pain. Then we would find that the sign "chest pain" refers to an identifiable extra-mental physical entity, an object in the world. But the meaning of the sign, the "thing signified," is, according to Saussure, independent of this. He regards language as a system independent of the physical, extra-linguistic reality. 11 Language is not primarily a naming- process of objects in the world. This does not mean that Saussure denies the possibility of a connection between language and reality. But according to his notion of a sign as a pure linguistic entity, he prefers to emphasize the social and intersubjective character of all discourse. ~2 Language is "a system of interdependent terms in which the value of each term results solely from the simultaneous presence of the others". 13 Words and concepts are constituted as signs by their simultaneous differences from other signs. A sign both tells what a concept is and what it isn't. By saying "strain", "angina" or any other medical diagnosis, the words act as signs by their simultaneous differences from other signs: It is "strain" that is implied, "'not angina".

5. LOGIC AS SEMIOTICS: CHARLES SANDERS PEIRCE

In addition to structural linguistics, semantic theory was developed mainly by Charles Sanders Peirce (1839-1914). Peirce defined a sign as "something which stands to somebody for something in some respect or capacity. It adresses somebody, that is creates in the mind of that person an equvivalent sign, or perhaps a more developed sign. That sign which it creates I call the interpretant of the first sign. The sign stands for something, its object".14,15


This definition has three elements: The primary sign, the interpretant and the object. The interpretant is a more developed sign giving the primary sign its meaning. According to Umberto Eco, the interpretant can be conceived as the definition of the sign, and it is something that guarantees the validity of the sign. 16,17 The object is what both the sign and the interpretant are referring to. This is a three-dimensional definition of a sign, the triadic relation of sign-object-interpretant is the irreducible character of any sign that signifies.

This may be highly theoretical and difficult to grasp. But since the human mind cannot function without signs, let us for a moment simply replace sign, interpretant and object with the pronouns I, you and it: I speak to you about something. I am the sign, you are the interpretant, and we speak together about an object.

To grasp the Peircian way of thinking in a clinical context, we have to start 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 general practitioner talking to a cardiologist B about what may be the patient's sufferings, his "real disease" C. As in the case story, by presenting the episodes as chest pain the doctor is producing a sign which the cardiologist may interpret as angina pectoris. For the cardiologist, theories about ischaemic heart disease give the sign its meaning as angina pectoris. A has produced one sign, B has produced an equivalent; but yet another sign corresponding to the first one. But what they really are talking about, what the signs "chest pain" and "angina pectoris" are referring to in the physical world, may be quite different. Let us again imagine that the patient had an unrecognized tumor that caused his pain. Then this tumor is the object for the sign - his pain - and hence its reference.

Peirce's triadic relation corresponds well with the clinical situation exemplified above (Figure 2). It has also its parallel in the triadic clinical relation 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.

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Person A

\ Person

Matter C

/ 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.


Sign 1 Object 1

\ / Interpretant 1

Sign 2

(= Interpretant i)

" x / Interpretant 2

I and so on, endlessly ....

Object 2

(= Sign 2 object)

Figure 3. The process of continuous signification.

5.1. Symbolic, Indexical and Iconic Signs

Both sign, object and interpretant are complex entities. Peirce states that philosophy 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 and vocabulary to a medical setting.) Of special interest in medicine is the relation between signs of disease and the disease itself, which is considered as the object of the sign. Between the sign and its object, Peirce differenti- ates signs into three categories: symbolic signs, indexical signs and iconic signs. Human language is a paradigmatic example of symbolic signs, as are the arab numbers 1,2, 3 etc. The connection between signs and objects is artificial and conventional as one has to know the code and master the language to interpret the signs. Communicative approaches to psychiatry and psychosomatics regard symptoms as arbitrary symbolic signs, as

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does psychoanalytic theory. 20-23 In everyday medicine, history taking is primarily 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 meansY Smoke means fire, knocking on the door means that somebody is asking for the door to be opened. Bodily gestures, "body language" have strong indexical attitudes. Indexical medical signs are explored 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 technological visualizations are medical examples of iconic signs. 27

The distinction between symbolic signs, indexical signs and iconic signs is arbitrary and not exact. Hence Peirce himself states that it would be difficult, if not impossible, to find an absolutely pure index, or to find any sign absolutely devoid of the indexical quality. 28 In the realm of medical semiotics these difficulties are seen especially regarding the symbolic and indexical sign pain. Even though the symptom of feeling

- and expressing - pain has the same name for different diseases, it is a significant clinical difference between a patient, in a relaxed atmosphere, telling about instances of abdominal pain or headache, respectively, and a patient showing his pain by rolling around on the floor screaming for help.

5.2. Saussure and Peirce: Two Different Approaches

Independent of, and unknown to each other, Saussure and Peirce developed their respective theories of signs. The differences between their approaches are obvious: Saussure defines the sign as a dual entity, Peirce as a triadic one. Saussure has a linguistic approach, his theory is about human language. Peirce, on the other hand, has a much wider approach. Language is only a part of his semiotics, but he gives us ideas about the relation between signs and the physical reality. Saussure has a very profound knowledge and understanding of human language in general. But he lacks terms and vocabulary 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 explicitly commenting on it - uses a Saussurian concept when analyzing signs and symptoms 29 Marja-Liisa Honkasalo, who teaches medical semiotics in the Department of Public Health at the University of Helsinki, uses a Peircian perspective. 3°


6. APPLYING SEMIOTICS TO A CLINICAL CASE

The clinical vignette may illustrate how we as clinicians structure our thinking, and give meaning to patients' symptoms. None of the applied diagnoses depend on certain clinical signs. Rather, all physicians have by their respective interpretations produced different diagnoses. They are creators of meaning when they conclude that the patient's symptoms means strain, angina and hyperventilation, respectively. All the diagnoses are, in the Peircian sense, different interpretions of the sign "chest pain". The diagnoses may also illustrate the Saussurian sign: because the physicians are proclaiming that the patient has muscular strain, angina and the hyperventilation syndrome, the patient, in a way, "has" these diseases. The diagnoses depend heavily on the doctors' interpretations, since diagnosing is naming, structuring of reality. None of the diagnoses are in essence facts belonging to the external world, but linguistic and cognitive struc- turings of reality, ways of interpreting experiences and perceptions. Even though the patient might have ischaemic heart disease, angina as a diagnosis explaining a specific episode of chest pain is in fact an interpretation, a "reflexive construct", a way of grouping experience into objects in the world. 31 According to Thomas Kuhn, an essential part of scientific research is regrouping of objects in the world. 32,33 It is to produce significant differences creating knowledge. Both diagnoses can be regarded as regroupings of knowledge different from other possible explanations. The presented case displays very clearly that more than one theoretical construction can be utilized to explain a given collection of data. 34

7. MEDICAL SEMIOTICS

A medical student didn't pass an examination because on studying a blood smear under the microscope he stated "I see only dots". What he should have seen, after having studied haematology, was lymphocytes. It was not incorrect to see dots. It was, however, an insufficient and inadequate medical interpretation of the smear.

This example may illustrate the Kantian philosophical statement that we have no direct access to the world. In everyday life as well as in medical settings, the only way to grasp reality is to perceive signs and interpret them through inferences. To see something is always to see it a s

something. Using the case story about the man with chest pain, I will now try to characterize the process of interpreting signs to understand what we do when we attend to patients.

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First, I have to repeat that the diagnoses are not primarily facts belonging to the real world, but interpretations, ways of structuring reality, hypotheses and conjectures. This of course does not mean that a "real world" does not exist, or that we cannot speak about such a world. On the contrary, scientific medicine is based on an assumption about objectivism, truth, reality and methodology. There is supposed to be a physical reality behind the chest pain. And this reality is one and the same even though three different doctors make three different interpretations. This reality is what Peirce calls the object of the sign. The problem arises: What is the relationship between the interpretation of the sign, namely the diagnoses, on the one hand, and reality on the other hand. This is a problem about modes of understanding in clinical medicine, a notion which is discussed in a clarifying way by Allan B. Chinen. 35

7.1. Modes of Understanding

According to Chinen, modes of understanding provide the external link between thought or belief, on the hand, and reality, on the other. 36 We can define a mode of understanding in the Peircian semiotic term as the relationship between a sign, such as a proposition ("chest pain") and the object the sign refers to, e.g. a situation in the real world. Different modes of understanding involve different kinds of relationships between the sign and the referent.

7.2. The Scientific Mode of Understanding

The diagnosis angina pectoris represents a scientific mode of understanding. Angina represents ischaemic heart disease, which is claimed to exist as an empirical, biological fact. The diagnosis is correct or incorrect, depend- ing on objective findings following a specific methodology to unravel coronary 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 To apply a scientific attitude to the case story is to narrow the sign "chest pain" down to a question about somatic disease only.

7.3. The Hermeneutic Mode of Understanding

However, 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 biological being only. To understand a man is to understand a being who understands himself. This acknowledgement requires empathic communication


and interaction with the patient. 38 In the case of clinical medicine, these exchanges involve deeply personal values and meanings, on the part of patient and physician alike, whether explicitly discussed or not. The study of meaning in philosophy is called hermeneutics, a term which covers semiotics as well. The hermeneutic mode includes both personal and inter- personal dimensions of meaning - the patient's or physician's own values and viewpoints on the one hand, and their communication with each other on the other hand. 39

The main difference between the scientific mode of understanding and the hermeneutic one is, according to Chinen, that in the hermeneutic mode, subjective experience and interpretations take precedence over objective facts. That is, the normal reference from subjective belief to objective situation is temporarily suspended, and attention is focused on the subjective side. 4°

This does not mean that no reference, no object exist. Above, I discussed the diagnosis of strain. Strain is just as real as ischaemic heart disease. But it 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 different realities. Different combinations of interpretations are possible, the patient may or may not feel strain, may or may not have angina, may or may not have hyperventilated. In what particular interpretation to rely on in a clinical situation depends on many factors. The everyday clinical interpretation depends on previous experience and on bias of the individual physician as well as on risk factors, the situation and its context, and is due to the art of medicine rather than science.

7.4. Semiotics: Science or hermeneutics?

The aim of medical semiotics is to narrow the gap of uncertainity and give a fuller understanding of the process of clinical work. 41 All symptoms and all clinical signs need an interpretation. Sometimes, this interpretation is due to routine practice. A bleeding wound in the forehead needs no hermeneutic interpretation for medical care. For a patient with a heart arrest, it is meaningless to ask what he could have meant by that. In terms of semiotics, sign and meaning coincide, and a scientific- biological way of understanding takes precedence over a hermeneutic o n e . 42 But this is not the rule. Rather, in clinical medicine, very often we cannot be quite sure. We seldom are immediately certain about a diagnostic problem. In such cases, we have to reason and decide what information is most relevant to solve a pragmatic clinical problem.

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8. DISCUSSION

All clinicians are familiar with history taking, listening to the patient's symptoms which lead us to physical findings and give us a diagnosis. The ensuing treatment follows routine standards. A number of physical symptoms, however, such as abdominal pain, dyspepsia, headache, backache, joint pain, chest pain, palpitations and fatigue lack a satisfactory analytical t e r m . 43 It makes no sense to say that these symptoms are not real. They are 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 course it make sense to ask what kind of reality the symptoms reflect. The clinical challenge emerges when the symptom does not correlate with an identifiable pathology, probably because such a pathology often does not exist. The symptom is not always what Galenos learned, "the shadow behind the disease". 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 showing what is his or her sufferings and agenda. Hence, we perceive the sum total of the patient's signs by both listening to, seeing, feeling, touching and tasting the complex message from the patient. Symptoms experienced and expressed can also be regarded as cultural and communicative acts, attempts to translate subjective sensations into signs that are understood in the 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 a human being requires to organize life linguistically as well as expressing oneself to other human beings in a symbolic way. 48 Man is, according to Ernst Cassirer, the symbolic animal. 49 This is also what Peirce is expressing, insisting on the idea that man is the sum total of the words or signs that man use. 5°

The patient with chest pain got three different diagnoses. None of the 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 different animals in the well-known duck-and-rabbit example, often used in psychology textbooks (Figure 4). To interpret a symptom expressed as a diagnosis necessitates a cognitive structure, a code-set. The general practitioner 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

%__ C__

I I I I I I .

II I


Figure 4. The duck-and-rabbit figure (From Jastrow: Fact and Fable in Psychology).

thus creators of meaning, and the diagnoses get their value as signs of meaning 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 of linguistics. 54 Semiotic interpretations put scientific medicine in a wider context. Semiotics analyzes and interprets what happens with man as a social being, interacting with other persons in an intersubjective way. The interpreting process is endless. The diagnosing is, as a linguistic and pragmatic activity, part of this process. This process is also an integral part of being a doctor, regardless of the physical findings we make.

ACKNOWLEDGEMENTS

I am grateful to Kirsti Malterud of the University of Bergen for her combi- nation of radical critisism and encouragement during many earlier drafts of this paper, to Anders Seim, 1464 Fagerstrand, and to Rolf Wynn, Univer- sity of Troms0, who both have corrected and commented on my different versions.

NOTES

I King L. Medical Thinking. A ttistorical Preface. New Jersey: Princetown University Press, 1982. 2 Honkasalo M. Medical symptoms: A challenge for semiotic research. Semiotica, t991; 87:251-268. 3 King: 77.

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4 Mayou R. Medically unexplained physical symptoms. Do not overinvestigate. Brit Med J, 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 Theory and 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, Saussure and 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.


41 Bumum JE Medical diagnosis through semiotics. Giving meaning to the sign. Ann InternalMed, 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 and linguistic 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 in Semiotics. Bloomington: Indiana University Press 1986: 140-152. 52 Malterud K. Allmennpraktikerens mote med kvinnelige pasienter (The encounter between the 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 Prim Health Care Suppl 1, 1992; 10: 1-86. 54 Cosieru E. Einfiihrung in die Allgemeine Sprachwissenschafi (Introduction to language science). Ttibingen: Francke Verlag T0bingen, 1988.

Department o f Public Health & Primary Health Care

Division for General Practice

University o f Bergen Ulriksdal 8c, N-5009 Bergen Norway

JOHN NESSA