Crookshank, Francis. The Meaning of Meaning – T03

Supplement II
The Importance of a Theory of Signs and
a Critique of Language in the Study of
Medicine

By F. G. Crookshank, M.D., F.R.C.P.

Although the Art of Medicine has been greatly advanced, in
many respects, during the last century: although the Practitioners
of that Art do freely draw upon the vast storehouse of facts called
scientific, to the great benefit of suffering humanity; and although
all medical men have some acquaintance with certain sciences of
which the province is in part coterminous with that of the Art of
Medicine, there is to-day no longer any Science of Medicine, in
the formal sense.

It is true that observation and thought have led medical men
to form generalizations which have obtained acceptance; but
there is no longer any organized or systematized corpus, or formulated
Theory, which can be held to constitute the Science of
Medicine, and (in a now obsolete terminology) to form an integral
part of Natural Philosophy.

I say ‘no longer’ for, in other days, such a Science of Medicine
(or, of Physic) did exist, however much and justly we may contemn
the ‘facts,’ the generalizations, and the Theory, by which,
at different times, it was built up. To-day, however, notwithstanding
the abundance of what are called our accurately observed
facts, and the perfection of our scientific methods, writers and
lecturers on Medicine find it needful to protest loudly that
Medicine is not, and never will be one of the exact sciences.

Perhaps Professors and Practitioners do not always pause to
consider what an exact science is, and which are the exact
sciences, and why. But the protestation seems a plea for the
exemption of medical writers from the duties of defining their
terms, and stating their premises; while, by implication, we are
left to accept the inference that the accumulated facts and accepted
generalizations with which doctors are concerned are without
337interrelation or interdependence, and so cannot be arranged in
any orderly fashion, or linked together by any general Theory,
as can be those dealt with by astronomers, chemists, and biologists.

The province of Medicine seems, indeed, thus to constitute a
kind of Alsatia, an enclave in the Universe, of which the exploitation
is only permitted to the licensed few.

Here for the most part interest is arrested, and it excites
neither resentment nor curiosity that Medicine should not be
amongst the subjects whose pursuit may lead to the Doctorate
of Science, and that there should be a great gulf fixed between
the ‘scientific’ and the ‘medical’ studies of the young physician
and surgeon.

The explanation of this indifference is obscure, and to search
it out were perhaps irrelevant, but the present position of Medicine
requires examination.

It may be said, in general terms, that some statement and attempted
definition of fundamentals is necessary to the successful
pursuit of any of the recognized sciences, and no systematic
exposition of any of these sciences is ever made without the
adoption of some point de départ which, as it is implied, agreed,
or perhaps stated, has been determined by earlier examination,
discussion, and decision concerning the nature of things and
knowledge, and our methods of thought and communication.

Certainly, I am in the fullest agreement with the Authors of
this book if they suggest that lately men of science have too often
failed to appreciate that importance of agreement concerning
signs and symbols which was so present to the minds of the Scholastics;
and certainly it cannot be said that the points de départ
adopted by our men of science are always well chosen. But,
after all, it is better to set out boldly and with intention rather
than to wander round declaring there is neither road nor signpost:
and, however defective in form and content many of the
first principles and definitions in our scientific text-books,
systematic expositors do at least admit the necessity for, and the
propriety of some discussion of fundamentals. The case of the
doctors is more parlous.

Medicine is to-day an Art or Calling, to whose exercise certain
Sciences are no doubt ancilliary; but she had forfeited pretension
to be deemed a Science, because her Professors and Doctors
decline to define fundamentals or to state first principles, and
refuse to consider, in express terms, the relations between
Things, Thoughts and Words involved in their communications
to others.338

So true is this that, although our text-books are occupied with
accounts of ‘diseases,’ and how to recognize, treat and stamp out
such ‘things,’ the late Dr Mercier was perfectly justified when,
in not the least incisive of his valuable papers, he declared that
“doctors have formulated no definition of what is meant by ‘a
disease’,” and went on to say that the time is now arrived in the
history of Medicine when a definition of her fundamental concepts
is required (Science Progress, 1916-17).

Dr Mercier was perfectly justified in his statements, because
he was writing of the Medicine of to-day. Had he been acquainted
with such ‘introductory chapters’ as those of Fernel
(1485-1557) entitled respectively “Quo doctrinæ atque demonstrationis
ordine ars medica constituenda sit” and “Morbi
definitio, quid affectus, quid affectio,” he would not have failed
to insist that, when Medicine was a Science, even though less
‘scientific’ than to-day, some definitions were attempted, some
principles were asserted and some distinction was admitted
between Names, Notions, and Happenings.

Nowadays, however, though we accumulate what we call
‘facts’ or records of facts without number, in no current text-book
is any attempt made to define what is meant by ‘a disease,’
though some kind of definition is sometimes attempted of ‘disease’
and of particular diseases. In a word, no attempt is made to
distinguish between what we observe in persons who are ill,
on the one hand, and the general notions we form in respect of
like illnesses in different persons, together with the ‘linguistic
accessories’ made use of by us for purposes of communication
concerning the same, on the other.

It is true that Sir Clifford Allbutt did never cease to tilt,
though in a somewhat lonely field, at the ‘morbid entities’
which some people tell us diseases are, and not the least pungent
of his criticisms may be found in the British Medical Journal,
for 2nd September 1922, on p. 401.

But the hardy and rare few who have sought (though in
language less picked and perhaps less peregrinate) to express the
same truths as Sir Clifford, have had hard measure dealt them.

They have been contemned as traffickers, not in the ‘concrete
facts’ and indifferent reasoning proper to Medicine of the
Twentieth Century, but in wordy nugæ and in something contemptuously
called Metaphysics. For only ‘mad doctors’ may
in these scientific times dabble in Philosophy without loss of
their reputation as practitioners!

And it is perhaps a sign of the times that the admirable essay
339contributed by Sir Clifford Allbutt to the first edition of his
System of Medicine in 1896, in which were discussed, in inimitable
style, such topics as Diagnosis, Diseases, Causes, Types, Nomenclature
and Terminology, should have disappeared from subsequent
issues. This essay is now seldom mentioned: perhaps it
is even less frequently read. But, to the present writer, in 1896
a raw diplomate, it came as something of a revelation for which
he has ever since been humbly grateful.

Now it is true that all teachers and professors of Medicine
— save those who, though ‘qualified’ are empirics, or ‘unqualified’
are quacks — are dependent in the communication of their
researches to their fellows and of instruction to their pupils,
upon the use they make of Symbols, and upon their understanding
of the difference between Thoughts and Things: if, that is, they
are not to set up Idols in the Market Place. But, one result of the
desuetude into which has fallen the custom of prefacing our
text-books with such preliminary discussion as may stimulate,
if not satisfy, the thoughtful and intelligent, is that few now
comprehend the distinctions between Words, Thoughts, and
Things, or the relations engaged between them when statements
are communicated.

Common sense, it is true, saves from detection and gross
error those who practise their art empirically: so long, that is, as
they do not seek or obtain publication of their occasional addresses
in our medical Journals, for it is precisely in our most orthodox
periodicals and in the Transactions of our most stately Societies
that the most melancholy examples of confusion and error arising
from a neglect of fundamentals may be seen.

Particularly is this so when any ‘new’ experience or idea
comes up for discussion, and consequent assimilation or rejection;
and it was a very special case of this nature that, in 1918, turned
the thoughts of the present writer back to what he had learned
from Sir Clifford Allbutt in 1896, and that has since led him to
very sincere appreciation of the purpose and accomplishment of
the Authors of this book.

It is thought that some useful purpose may be served if some
exposition of this special case is here attempted, and that particular
attention may thereby be drawn toward the present difficulties
in medical discussion and statement: but, before any such
exposition is commenced, it is necessary to say something, in
general terms, concerning the confusion that now attends debate
owing to persistent failure to distinguish between what I have
340elsewhere called Names, Notions and Happenings (Influenza:
Essays by Several Authors, Heinemann, 1922), and the Authors of
this book, Words, Thoughts and Things.

Medical men, in the daily practice of their Art, are, in the first
place, concerned with the disorders of health that they observe,
and are called upon to remedy, in respect of different persons.

Disorder of health is recognized by certain manifestations,
usually called symptoms, which are at once appreciated by the
sufferer and often by the observer. There are also others: of
these, some, called ‘physical signs,’ require to be deliberately
sought by the clinician, and the rest (of inferential or indirect
importance only) involve recourse to the methods and appurtenances
of the laboratory.

As, however, experience has outrun the limits of individual
opportunity, it has long been convenient, for the purpose of
ready reference and communication, to recognize the fact that,
in different persons, like groups of manifestations of disorder
of health occur and recur, by constructing certain general references
in respect of these like groups. These general references
constitute disease-concepts; or, more simply, diseases, and are
symbolized by Names which are, of course, the Names of Diseases.
But, as time goes on, and the range and complexity of our experiences
(or referents) extend, we find it necessary to revise our
references and rearrange our groups of referents. Our symbolization
is then necessarily involved and we have sometimes to
devise a new symbol for a revised reference, while sometimes we
retain an old symbol for what is really a new reference.

These processes are usually described as the discovery of a
new disease, or the elucidation of the true nature of an old one,
and when accurately, adequately, and correctly carried out are
of very great advantage in practice, rendering available to all the
increments in the personal experience of the few. But when, as
so often happens, a name is illegitimately transferred from the
reference it symbolizes to particular referents, confusion in thought
and perhaps in practice is unavoidable.

Lately, it was reported that a distinguished medical man had
declared bacteriologists to have recently shown influenza to be
typhoid fever. What was said was, without doubt, that certain
cases thought to be properly diagnosed as influenza have been
shown, by bacteriological investigation, to be more correctly
diagnosed as typhoid fever. But, in journalistic circles the
pronouncement was at once taken to imply that the disease
“influenza” is really the disease “typhoid fever,” and an appropriate
341paragraph was prepared, trumpeting the discovery much
in the way that it might have been announced that Mr Vincent
Crummles really was a Prussian.

This anecdote illustrates, it is true, confusion prevailing in the
lay mind; but it is a vulgar medical error to speak, write, and
ultimately to think, as if these diseases we name, these general
references we symbolize, were single things with external existences.

It is not to be thought that any educated medical man really
believes ‘a disease’ to be a material thing, although the phraseology
in current use lends colour to such supposition.

Nevertheless, in hospital jargon, ‘diseases’ are ‘morbid
entities,’ and medical students fondly believe that these ‘entities’
somehow exist in rebus Naturæ and were discovered by their
teachers much as was America by Columbus.

Teachers of Medicine, on the other hand, seem to share the
implied belief that all known, or knowable, clinical phenomena
are resumable, and to be resumed, under a certain number of
categories or general references, as so many ‘diseases’: the true
number of these categories, references, or ‘diseases’ being
predetermined by the constitution of the universe at any given
moment.

In fact, for these gentlemen, ‘diseases’ are Platonic realities:
universals ante rem. This unavowed belief, which might be
condoned were it frankly admitted, is an inheritance from Galen,
and carries with it the corollary that our notions concerning this,
that, or the other ‘disease’ are either absolutely right or absolutely
wrong, and are not merely matters of mental convenience.
In this way, the diseases supposed to be extant at any one moment
are capable — so it is thought — of such categorical exhaustion as
are the indigenous fauna of the British Isles and the population
of London. That our grouping of like cases as cases of the same
disease is purely a matter of justification and convenience, liable
at any moment to supersession or adjustment, is nowhere admitted;
and the hope is held out that one day wfr shall know all
the diseases that there ‘are,’ and all about them that is to be
known.

In the meantime, so prevalent has become the vice or habit
of considering ‘diseases’ as realities in the vulgar sense of the
word, that no adverse comment was excited when, lately, in an
official document (Forty-eighth Ann. Rep. Local Govt. Board,
1918-19, Med. Supplement, p. 76) it was said that “in the short
experience of encephalitis lethargica in this country it is already
apparent that its biological properties are altering…”342

That this attribution of “biological properties” to a disease
was no mere lapsus calami is attested by the fact that the phrase
was somewhat complacently repeated, by the author himself,
in the Annual Report of the Chief Medical Officer of the Ministry
of Health, 1919-20, on p. 366.

To elaborate any warning against the use, in official publications,
of such absurdly ‘realist’ forms of expression as this
would seem, in view of what has been so cogently said by Sir
Clifford Allbutt, to be superfluous, at least. Yet warning is
necessary when we find one who has done such yeoman service
as Sir James Mackenzie declaring that “disease is only revealed
by the symptoms it produces;” Disease, and diseases, say the
realists, must be ‘realities’ if they are agents that produce
symptoms. So, Sir James Mackenzie, who has so powerfully
insisted on the importance of investigating symptoms, and who
has so strongly protested against our subordination to the tyranny
of mere names, becomes the unconscious ally of those who engage
in a hunt for a mysterious substantia that has ‘biological properties’
and ‘produces’ symptoms.

In modern Medicine this tyranny of names is no less pernicious
than is the modern form of scholastic realism. Diagnosis, which,
as Mr Bernard Shaw has somewhere declared, should mean the
finding out of all there is wrong with a particular patient and why,
too often means in practice the formal and unctuous pronunciation
of a Name that is deemed appropriate and absolves from
the necessity of further investigation. And, in the long run, an
accurate appreciation of a patient's “present state” is often
treated as ignorant because it is incompatible with the sincere use
of one of the few verbal symbols available to us as Proper Names
for Special Diseases.

In this connection allusion may be made to the enforced use
of certain verbal symbols by the Army during the late War.

By the judicious use, under compulsion, and at proper times,
of such linguistic accessories as P.U.O. (pyrexia of unknown
origin) and N.Y.D. (not yet diagnosed) the inconvenient appearance
in official reports of unwelcome diagnoses could always be
avoided, and a desirable belief in the absence of certain kinds of
illness could easily be propagated. No doubt, for official purposes,
some uniformity of practice in the use of symbols is necessary;
but it should not be forgotten that official statistics, which,
in theory, should reveal to us what happens, or has happened
in the field of clinical experience are, in fact, little more than
analyses of the frequency with which certain forms or usages in
343symbolization have occurred. And this criticism has even more
force when it is remembered that official statistics often bear
reference to symbolization for which no official practice — correct
or arbitrary — has been defined. Thus, the Ministry of Health
has, during the last few years, published statistical tables hailed
as showing the different kinds of prevalence in successive years
and at different seasons, of what is called encephalitis lethargica,
and the difference between these prevalences and those of certain
‘analogous diseases.’

Now the true lesson to be drawn from these statistics is not
that the ‘biological properties’ of any of these ‘diseases’ is
changing, but that medical men are symbolizing various clinical
happenings, in different way at sundry times, and in divers places,
and that the practice of the same doctor, in this respect, has
changed since 1918 in response to change in his notions concerning
the group of ‘analogous diseases’ in question.

In a word, medical statistics relate to the usage of symbols
for general references, whether or no the symbolization is correct
and the references adequate, rather than to things, occurrences,
or happenings. They have no necessary value, other than as
analyses of symbol-frequency, unless the relation of the symbols
to the reference and of the reference to the referents be agreed
after that process of discussion, so abhorrent to the medical
mind, and so generally stigmatized as unprofitable word-chopping.
Yet surely, if we desire analyses of notifications of disease to be
accepted as evidence of what has happened in the clinical field,
we must act as good accountants, and compare the records in the
books with the cash in hand and the evidences of actual transactions.

Related to the question of statistical values is that of Research,
when paid for or subsidized by the State, and controlled or directed
by Official Bodies. In principle, such research nearly always
takes the ostensible form of Investigation into Diseases.

Now without doubt, sincere official investigation into the
nature and relation of the general references we call ‘diseases’
would be productive of some good, but what the public imagine
and desire is inquiry into what happens. It is not suggested that,
in practice, such inquiry is entirely omitted: yet, too often what
takes place, and what reflects the greatest official lustre upon the
investigators, is neither inquiry into diseases nor into happenings,
but something as little useful as would be an investigation into
the Causes of Warfare, by a Committee of Intelligence Officers
devoting themselves to an Examination of Prisoners captured in
344the Trenches and a Description of their Arms and Accoutrements.

Something visible, like a bullet, is what brings conviction to
the minds of ‘practical men’; and so, when epidemiologists
discuss certain general references, that they call ‘epidemic
constitutions,’ hard-headed and practical investigators call for
the production of one such, on a plate or charger, like the head
of a John the Baptist (cf. Sir Thomas Horder: Brit. Med. Journal,
1920, i., p. 235).

Over and above all this, the emotive use of language so sways
the intellect that phrases suggesting the ‘real’ existence of diseases
as single objects of perception lead doctors to think as if these
diseases were to be kept away by barbed-wire entanglements,
or ‘stamped out’ by physical agencies ruthlessly employed.
And we not merely hypostatize, but personify these abstractions,
going on to speak of the “fell enemy of the human race which is
attacking our shores” whenever a change in meteorological
conditions lowers the resistance of the population to their normal
parasites, and coughs and colds abound in consequence.

Then there is inevitable reaction, and some perverse sceptic,
without thinking what he means, declares ‘Influenza’ to be but
a label, whilst another, thinking confusedly, maintains ‘it’ to be,
not a disease, but a syndrome, or symptom-group.

It thus happens that, in the course of debate (on, for example,
Influenza) by one the name will be treated as a mere flatus vocis,
by another as the name of some general reference, vague or defined,
and by a third as the name of some object with external and
‘real,’ if not material, existence.

None of the disputants will discuss the correctness of the symbolization
involved, or the adequacy of the reference, whilst
someone is sure to imply that positive or negative facts alleged
in respect of ‘Influenza’ can be proved or disproved by examination
of two or three ‘cases’ known to be ‘cases’ of Influenza, a
disease which, ex hypothesis has properties and qualities as definite
as the height of Mount Everest or the weight of a pound of lead,
and only requiring discovery and mensuration by properly
accredited experts.

Any call for definition is met by citation of John Hunter's
dictum that definitions are of all things the most damnable:
any demand for precision in language or in thought, by the asseveration
that Medicine is not an exact science.

On this point at least, there is general agreement.

But, are we content to leave the matter thus? Ought we to be
345content so to leave it? Are we to acquiesce in the implication
that thoughtfulness need be no part of the equipment of the
physician? Surely, to the thinker, the right use of words is as
essential a part of his technique as is, to the bacteriologist, the
right use of the platinum loop or the pipette; and there should
be no need for shame in acknowledging that thought, and the
expression of thought, require an apprenticeship no less severe
than do the cutting of sections and the manipulation of a capillary
tube. Yet, while there are not a few manuals of laboratory
technique, for the use of medical students, there is none devoted
to the elucidation of the fundamental principles of Medicine,
and of fundamental errors in thought and communication.

Under these circumstances it seemed to the present writer
a year or two ago that some useful end might be served if he
attempted to clear up some of the sources of confusion, already
indicated, by writing in terms of the great scholastic controversy,
pointing out how to-day the Scholastic Nominalist is represented
by the sceptic who says ‘Influenza’ is only a name, and the
Scholastic Realist by him who teaches Influenza to be a ‘morbid
entity.’

One or two essays were therefore written, which have been
since reprinted, wherein it was suggested that safety lay in the
adoption of the Conceptualist position ascribed to William of
Occam in the Encyclopœdia Britannica (11th ed., arts. ‘Occam’
and ‘Scholasticism.’) There (Vol. 24, p. 355) we are told that
“the hypostatizing of abstractions is the error against which
Occam is continually fighting”: that for him “the universal is no
more than a mental concept signifying univocally several singulars”
and “has no reality beyond that of the mental act by which
it is produced, and that of the singulars of which it is predicated.”

Now, for us who are doctors, the universals with which we
are most concerned are those general references that we call special
diseases, and our frequent singulars are the symptoms and
‘cases’ that we observe, so that this hypostatizing of abstractions
is the very error against which Sir Clifford Allbutt has ever
fought, while the spirit that inspired Occam — “a spirit which
distrusts abstractions, which makes for direct observation,
for inductive research” — is the spirit that still informs the work
of all true clinical physicians. This spirit is the spirit of Hippocrates
himself, who “described symptoms in persons and not
symptoms drawn to correspond with certain ideal forms of disease”
(Adams). But our modern ‘researchers’ far outstrip in their
unconscious realism the philosophy of their unavowed Master,
346Galen the great Neoplatonist, and describe entities at which even
he would have jibbed, without scruple or misgiving.

However, even if we avoid the fallacies of the realists, we must
none the less avoid contenting ourselves with the mere collecting
of singulars on the one hand, and assenting idly, on the other, to
some of those inconveniences of conceptualist expression that
have been pointed out in this book (vide supra, pp. 99-100). It
may be that some of these latter arise from the lack of expertness
of amateur expositors (amongst whom the present writer would
include himself) rather than from any weakness inherent in
Conceptualism; but they may be acknowledged, and common
cause may be made with the Authors in their attempt to provide
a more excellent way.

Now, although it is not proposed, in what follows, to express in
the terms of these Authors the difficulties which (to write emotively)
beset the path of the thinking physician, it is hoped, by the
exposition of a special case, to reinforce, from the point of
view of a physician, what has been said by them in their plea
for the general adoption of a Theory of Symbols.

The special case which will now be stated is that which has
been already mentioned as having definitely directed the attention
of the present writer, a few years ago, to the questions discussed
in this book; and it is felt that, whether or no the views held by
him as to the true solution of the difficulties are valid, the difficulties
themselves will not disappear unless the basic issues are
first made plain in the light of a Theory of Signs and a Critique
of the Use of Language.

Some eighty years ago, an orthopædic surgeon named Heine,
practising near Stuttgart, observed the affliction of a number
of young children by a form of palsy of one or more limbs, that
came on more or less acutely and that was followed by wasting
and marked disability. This kind of illness had been earlier
recognized by others, but had never been so well described as
by Heine. Heine's account attracting general attention, and his
observations being generally confirmed, a definite general reference,
or ‘disease,’ became acknowledged, to which, in England,
the name ‘Infantile Spinal Paralysis’ was attached, it being
admitted that the palsy and wasting were dependent upon lesion
of the spinal cord. Further experience, and the examination
of the spinal cord in cases that died some time after the onset
of the palsy, extended our knowledge of the cases, and the
symptoms were definitely connoted with lesions of what are called
the anterior horns of the grey matter of the cord. The lesions
were regarded as, in the beginning, of the nature of an acute
inflammation, and the extended clinico-pathological concept
was symbolized by the expression ‘Acute Anterior Poliomyelitis.’347

Many years later, Medin, a Swede who had made extensive
observations in practice, showed conclusively that cases of the
kind thus indicated occurred in association with each other, or,
epidemically, and also in epidemic association with other cases
whereof the symptoms were cerebral and due to lesions situate
in the brain.

Medin's pupil, Wickman, carried observation still further.
He recognized the epidemic association of cases of the nature
described by Heine and Medin with cases of yet other clinical
types, all manifesting disordered function of some part of the
central nervous system. More than this, he showed that in
different years, or in different epidemics, different types of case
prevailed, though all cases agreed in the general nature of the
lesions found at post-mortem examination.

To the broad general reference that his clinical genius allowed
him to construct, resuming a wide range of cases of different
clinical aspect depending on the different localization of the acute
process in the nervous system, he gave the name of Heine-Medin
Disease.

In later work he broadened the base of even this great synthetic
concept, pointing out that, at the onset cases of Heine-Medin
Disease (as conceived by him) frequently manifested acute
catarrhal (or influenza-like) symptoms and occurred in close
association with other cases of acute catarrhal nature that did
not manifest any signs of nervous disorder. These cases he
regarded as ‘abortive’ cases of Heine-Medin Disease.

But Wickman proceeded too fast: for, in England, where
even yet his work, and that of Medin, have been insufficiently
studied, it was said that a case of nervous disorder due to inflammation
of the brain could not possibly be one of Acute
Anterior Poliomyelitis, which, as all the world knows, is a Disease
affecting a limited portion only of the spinal cord!

Talk about a new disease, called Heine-Medin's, was regarded
as a rather unworthy attempt on the part of some foreigners
to detract from the prestige of English observers who had adopted
the views current before Medin and Wickman began their
researches. Clearly, it was said, their cerebral cases must be
cases of quite another disease, one which attacks the brain, and
not the spinal cord. The name Acute Polio-encephalitis was
then devised, to meet the situation, in spite of Strümpell's
earlier warnings against any such unnecessary multiplication of
diseases. The maintenance of this purely artificial distinction
between what may be called the two ends of the Heine-Medin
spectrum was later urged when it was found that the experimental
reproduction of symptoms and lesions in monkeys (as a result
of inoculation of those animals with portions of diseased tissues
from man) was less successful when the inoculated matter was
taken from brains than when from spinal cords. Later still,
the separate notification by practitioners of cases of ‘Acute
Poliomyelitis’ and ‘Acute Polio-encephalitis’ was required, and
so little was the work of Wickman appreciated even in 1918,
that Sir Arthur Newsholme, then Chief Medical Officer to the
Local Government Board, wrote of “the many forms of the
disease — or group of diseases — to which nosologists at present
attach the indiscriminate label ‘Heine-Medinische Krankheit.’”
348(Report of an Inquiry into an Obscure Disease, Encephalitis
Lethargica: Reports to the Local Government Board on Public
Health and Medical Subjects, New Series, No. 121.)

Even now separate notification of these two ‘entities’ is
required, though no guidance is afforded to the practitioner as
to his course of action when, as so frequently happens, symptoms
of involvement of both spinal cord and brain are present at the
same time.

But to turn back. Before the Great War physicians in the
United States began to recognize whole series of cases and
epidemics of the nature so faithfully described by Wickman,
and so ill understood in England. These epidemics culminated
in the vast prevalence in and about New York known as the
great epidemic of 1916.

All the characteristics resumed by Wickman in his great
general reference, and symbolized by him as Heine-Medin Disease,
were at this time recognized and studied by the American physicians,
but, unfortunately, the name ‘Acute Poliomyelitis’ was
retained, apparently on the lucus a non lucendo principle, since
lesions were described, not only in the grey but in the white
matter of the brain and spinal cord.

Happily the ridiculous attempt to discriminate between
‘Poliomyelitis’ and ‘Polio-encephalitis’ was not made.

The American physicians, however, except in symbolization,
went even further than did Wickman; and Dr Draper, perhaps
the ablest of the commentators, in Acute Poliomyelitis defined
his concept as one of a general infectious disease in the course
of which paralysis is an accidental and incidental occurrence,
adding that, though the nervous system is not always involved,
when it is the lesions may affect almost any part thereof (cf.
Ruhräh and Mayer, Poliomyelitis in all its Aspects, 1917).

Draper's conception, far wider than even that of Wickman,
is, so far as it goes, absolutely justified when the assembled experiences
are considered.

The only doubt (and it is one which I know Dr Draper himself
shares,with me) is whether a still wider reference, or synthetic concept,
is not required if certain observations in the clinical field,
more recent than those of 1916, are to be adequately dealt with.

However this may be (and the point will be discussed) the
retention by the American physicians of a quite incorrect symbolization
was very unfortunate. For we Englishry were, in
1916-17, too busy to think accurately, and, hearing that, in New
York, there was a certain epidemic called poliomyelitis, with
manifestations quite other than those we were accustomed to
identify by that name, we put down many of the accounts received
as due to New World phantasies.

Indeed, in 1918, one of our most eminent authorities told
me that, from personal experience in New York in 1916, he
could vouch that most of the cases put down as poliomyelitis
(in Draper's sense, that is) were nothing but influenza! This
statement was made as a sort of reductio ad absurdum, but my
informant did not know that for years Brorström abroad, and
Hamer at home, had been maintaining poliomyelitis (in the old
sense) to be a manifestation of the incidence of influenza on the
nervous system. 349

Now, late in 1917, and early in 1918, the present writer (who
at that moment was enjoying rather unusual opportunity for
the study of disease en masse) began to notice the occurrence of
peculiar cases of nervous and influenza-like nature which led him
to make first the forecast that 1918 was to be a year of pestilence,
and then that we were about to experience an epidemic of
Heine-Medin Disease of the cerebral, or ,‘polio-encephalitic’
type.

As a matter of fact, shortly afterwards, nearly all the ‘types’
of Heine-Medin Disease described by Wickman were to be
identified in London, although the cerebral forms prevailed
(Crookshank, Lancet, 1918, i., pp. 653, 699, 751).

But, unfortunately, this prevalence as a whole was overlooked,
and attention was focussed upon a relatively small number of
cases with intense symptoms of unfamiliar type, which were at
first thought to be cases of what is called ‘botulism’ and (it was
hinted) due to poisoning by food-stuffs sent from Germany with
evil intent. Now the history of the concept symbolized as
‘botulism’ is, in itself, fantastic beyond belief, and deserves
examination.

It is possible that it is valid, and adequate, for a certain number
of experiences, or referents: but that is another story. What is
known is that the name ‘botulism’ has been repeatedly applied
to cases which, although corresponding clinically to the description
given of cases of botulism, yet have nothing to do with
poisoning by the products of the kind of bacillus called B.
botulinus — the conceptual cause of botulism.

Whether or no such a form of poisoning is ever met with in
the field of experience is here neither affirmed nor denied, but it
is now everywhere admitted that the peculiar cerebral cases of
the spring of 1918 already alluded to had nothing in the world
to do with this famous bacillus and its products, mythical or
existent. Before, however, the false diagnosis of botulism had
been abandoned, I had expressed the view that these cases fell
within the ambit of the Heine-Medin Disease, or general reference,
and represented as it were an extreme ‘type’ of that ‘disease.’
This view was adopted by the late Sir William Osler, and also
(though with some degree of reticence) by Dr Draper, who, on
service in France at the time, was asked to report on the subject.
My own ideas, elaborated later in 1918, when in the Chadwick
lectures I traced the growth of the Heine-Medin concept and
showed its applicability with but little extension to the cases in
question, met with little public support, for the Local Government
Board, rapidly abandoning the attribution to botulism,
found out that one Von Economo, an Austrian alienist, had
described cases of the same nature a year earlier as cases of a
‘new disease’: encephalitis lethargica. This name had been
chosen because lethargy was a prominent symptom, and an
inflammation of parts of the brain a prominent lesion.

Since the English cases at first called ‘botulism’ corresponded
closely to those seen by Von Economo, it was felt that they were
cases of the disease he had described; in accordance with the
maxim of Pangloss that things cannot be otherwise than as they
are. It was also felt that they could not be cases of poliomyelitis
— for reasons already indicated. Sir Arthur Newsholme's slighting
350references to Heine-Medin Disease were balanced by the
suggestion of one of his assistants that many cases thought in
the past to be cases of that malady were really cases of encephalitis
lethargica, although Sir Arthur had also said that the cases in
question did “come within the wide limits of the commonly
accepted definition of the Heine-Medin disease” (Report of an
Inquiry into an Obscure Disease, etc., pp. 2, 36).

Encephalitis lethargica it had to be then, and so that entity
was created, and another notifiable disease added to the list of
‘analogous diseases’ headed by Acute Poliomyelitis and Polioencephalitis.

It was wickedly hinted, however, that the only way in which
these ‘Protean’ diseases, that so annoyingly mimicked each
other, could be definitely distinguished was by the different
official forms on which they were to be notified!

Perhaps this gibe was hardly fair, for the official authorities
certainly said that poliomyelitis occurs in the summer, attacks
children, and implicates the spinal cord, while encephalitis
lethargica occurs in the winter, attacks adults, and involves a
certain portion of the brain; and this attempt at distinction
seems still to be maintained, though it has been said that “the
arbitrary differentiation of polio-encephalitis as a notifiable disease
has proved a useful measure and has provided a sort of half-way
house for borderland cases” (Report C.M.O. to the Minister of
Health, 1920, p. 64).

It would appear that the general reference ‘polio-encephalitis’
is then maintained to provide a half-way house for cases that
will not fit into other categories — surely, an admission of their,
inadequacy — in spite of the earlier admission that ‘its cause’
is the same as that of poliomyelitis (Annual Report of C.M.O. to
the Minister of Health, 1919-20, p. 260).

But the practical difficulty that, in spite of official rulings, it
is often quite impossible logically to assign a case to either of the
two categories — poliomyelitis and encephalitis lethargica — for
some spinal cases occur in the winter and sometimes in adults,
while some cerebral cases occur in the summer and not infrequently
in children — has been resolved with great acceptance
by Dr Netter of Paris, an ardent upholder of belief in separate
‘entities.’

Netter explains away the fact that the cases are less easily
differentiated than are the official descriptions, by averring that
the two diseases mimic each other and that there is a poliomyelitic
form of encephalitis and an encephalitic form of poliomyelitis;
thus honouring once more the philosophy of Pangloss.
But Netter's solution seems as truly helpful as the classification
of a heap of playing-cards into ‘red court’ and ‘black
plain.’

On finding the king of spades, instead of admitting that an
untenable classification had been set up, one could easily say that
a ‘red court’ of the ‘black’ type had been found, and would
claim the position to be strengthened by the finding of the two
of diamonds — clearly a ‘black plain’ of the ‘red’ type. This is
the logic of Medicine to-day.

It is not to be wondered at that, under the circumstances,
confusion is becoming worse confounded; that doctors notify
351cases in whatever terms they please, and that the officials of the
Ministry of Health are reduced to explaining the disconcerting
uncertainty of their statistics by alleging a change in the biological
properties of a disease!

More troublesome still, there is the unwelcome task of disposing,
statistically, the cases of ‘encephalitis lethargica’ which refuse
to display lethargy!

The really serious aspect, however, of the present state of
uncertainty and confusion arising from the reluctance to face
fundamental questions and to discuss what is meant by ‘a disease,’
is this, that observation is hampered, communication is difficult,
discussion useless, and generalization impossible. And, in a
large measure, the blame attaches to official investigators who,
taking charge of affairs in 1918, did not properly set out to investigate
the whole of the relevant circumstances, the whole pack
of cards, but confined their attention to the cases attracting most
attention, the cards that lay uppermost. They should have first
discussed all available referents; but, as the title.of the official
report shows — An Inquiry into an Obscure Disease, Encephalitis
Lethargica — the real question at issue was begged from the first.
It was assumed that there were two existent entities — Poliomyelitis
and Encephalitis Lethargica — and the investigators then
proceeded to inquire whether or no these entities were ‘the
same,’ finally concluding that they were not. No one, of course,
disputes the difference between the two references, but the
official investigators did not discuss the adequacy of the two
references in respect of the referents, or the advantages of maintaining
(as some of us proposed) the single reference symbolized
as Heine-Medin Disease. Had the latter course been followed,
we should have been spared the melancholy spectacle of men of
science distinguishing specifically between three ‘entities’ by
regarding each as characterized by a special feature sometimes
present to all (Crookshank, British Medical Journal, 1920, ii.,
916). Yet so it was: and, by a report on the designs of the
queen of clubs and two of hearts we were called upon to know the
characters of the two groups: the ‘red court’ and the ‘black
plain’!

And so, those of us who, casting the eye as it were over all
the cases in a prevalence, see order, gradation, and continuity,
as well as the need for cross-referencing amongst all the members
of a series, are treated with as much disdain as if we declared one
end of the spectrum to be the same as the other! We desire to
bring our experiences under as few general references as are
possible and are compatible with practical working in communication:
we are told that we are confusing separate entities,
diseases that are analogous but sui generis, and not the same!
Moreover, our offence is the more heinous in that we have come
to see that the physicians of the 16th century were right in
maintaining with Brorström and Hamer of to-day, that the
nervous cases brought by Wickman under the Heine-Medin
reference, together with those called ‘Encephalitis Lethargica’
by the Ministry of Health, occur epidemically at the times
when the respiratory and gastro-intestinal catarrhs that we call
Influenza abound (Cf. op. cit., Influenza: Essays by Several
Authors).352

It is unthinkable, say in effect the officials, that Influenza,
Poliomyelitis, Polio-encephalitis and Encephalitis Lethargica,
should all be “the same”! The cases we call influenza are not
those we call by any of the other names, and we can trace no
relation between the cases we call by these different names except
those of time and space! (Cf. Rep. C.M.O. to Min. of Health,
1919-20, p. 48.)

It is, however, only fair to state that, in a more recent document
(Min. of Health: Reps, on Pub. Health, etc., No. II, Encephalitis
Lethargica) it is no longer suggested that, in 1918, we were
present at the birth of a new disease; that of a new conception
is spoken of instead. But, is there a difference? And after all,
scholastic realism comes to the front again, for Prof. MacIntosh's
dictum that “encephalitis lethargica is a disease… distinct
from analogous affections” is quoted with approval (loc. cit., p. 126),
while the British Medical Journal (1922, ii., p. 654) declares the
report in question to show that encephalitis lethargica and
poliomyelitis have separate identity!

It may be asked, does anyone who writes thus mean only that
the concepts are different? We admit so much: but we question
their validity, or adequacy. Their validity and adequacy appear
even more gravely perilled than before, when the official apologist
goes on to write of certain cases and epidemics in Australia in
1917-18, which some of us would bring under the Heine-Medin
umbrella, but which do not correspond to any one of the favoured
official references. The Ministry of Health's representative,
abandoning for the nonce all talk of Protean characteristics,
changing biological properties, and half-way houses, declares that
the Australian “condition appears to be quite distinct from”
encephalitis lethargica, and (presumably) from all other entities,
separate identities, analogous affections and diseases sui generis.
So that, again unafraid of Occam's razor, once more are entities
multiplied without necessity.

Moreover, the retention of the symbol ‘Encephalitis Lethargica’
for a reference which, whatever its constitution for the
moment, has to serve for referents which are frequently not
lethargic and are usually more than encephalitic, is itself admitted
to require justification. The retention of this name, we are told,
is justified by right of primogeniture and the “fortune of illustrious
parentage”: by its “clothing the concept in the language
which is common to scientists of all countries”; and “partly,
perhaps, for euphonious reasons” (Ibid., p. 1).

Perhaps, when Medicine is again a Science, we shall require
something more than ‘euphonious reasons’ from our officials
when discussing the accuracy of symbolizations, but one excellent
example of ‘euphonious reasoning’ must here be given. It is
this: that “no reliable evidence is forthcoming in favour of the
identity of influenza and encephalitis lethargica.”

Here, though we have not the faintest indication of the sense
in which the official writer uses the words ‘influenza’ and
‘encephalitis lethargica’ — though we know not whether he has
in mind the names (symbols) or the concepts (references) — we
may be in agreement with him. It is unthinkable that there
should be reliable evidence in favour of the identity of different
names, concepts, or happenings.353

I would as soon believe in the identity of the two ends of a
stick. Nevertheless, though I fully and frankly admit that one
end of the stick is not the other; is in fact distinct from it (even
though ‘analogous’ thereto); has separate identity, and is an
end sui generis, I know that I shall fail to advance appreciation,
in official quarters, of a point of view which, though possibly
impolitic, is at any rate not intrinsically irrational.

It seems clear then that, under the conditions of discussion
imposed by present habits of thought and expression, debate is
little profitable: at any rate, in Medicine.

Ultimately, no doubt, the pressure of collective experience
will lead to the formation of fairly sound and workable, though
unscientifically constructed and chosen, references and symbols
concerning all the clinical and epidemiological happenings here
alluded to: that is, if common sense be not, as usual, overborne
by pseudo-science and mere jargon.

But there should be, and is, a better and more speedy way: —
namely, to make up our minds at the beginning concerning the
questions treated of in the present volume.

It was with some such purpose as that of the Authors of this
Theory of Signs that, six or seven years ago, the present writer,
at a meeting of the Epidemiological Section of the Royal Society
of Medicine, attempted to expound the distinction between
Names, Notions and Happenings, or (as may otherwise be said)
between Words, Thoughts and Things. He met with but scant
applause, and was told by one of our most distinguished medical
administrators that only a Christian Scientist could doubt the
reality of Toothache, for example. He had it at the time of
speaking, he said, and so was quite sure about it. After this, the
debate came to an end, but the paper then read has been reprinted
in the book of essays on Influenza to which reference has been
already made, together with some further attempted elucidation
of the questions at issue.

There can be no doubt of the importance to Medicine, if
Medicine is to resume her place amongst the Sciences, of the
further exploration of these issues by some such way of approach
as that sought by the present writer, and far more ably considered
by Mr Ogden and Mr Richards.

The object of this note will have been attained if, by the
presentation of a living problem of to-day, the necessity to
Medicine of a Theory of Signs, is brought home to her Professors
and Practitioners, but it is hoped that, in a future
volume in this Library, it may be possible to include a study
354of the whole subject under the title of The Theory of Medical
Diagnosis.

In the meantime, however, Dr Simon Flexner, the celebrated
investigator and authority, of the Rockefeller Institute, nailing
his labels to the mast, declares himself, in the American Journal
of the Medical Sciences for April 1926, “as one holding the view
that epidemic influenza and epidemic encephalitis are distinct
entities.”355