Unexpected Semiotic Implications of Medical Inquiry

Harley C. Shands and James D. MeltzerRulon S. Wells

In the nineteenth century, primarily in the western world, human beings pursued scientific method in a progressive acceleration of innovative research and development. This movement—Whitehead called it the invention of the method of invention—continues in our own period, with further acceleration.

At the beginning of the twentieth century there appeared a quite new movement that changed the focus from object to method, so that scientists began to develop a new kind of self-consciousness in the form of an interest in methodology. Planck had said that reality was approached through the use of symbols in inferential reasoning, but he emphasized that these symbols were like essential spectacles the optical properties of which were unknown. The various methodological or communicational or semiotic discoveries of the present century can metaphorically be described as oriented to understanding the structure of these “eye glasses.”

Our principal interest for a number of years has been in the application of communicational-semiotic inquiry to the medical field (Shands and Meltzer, 1975). There the difference between objective and methodological inquiry is apparent as it is in natural science. Although it is obvious that psychiatry is the principal field in which human communication is the subject matter (in studying relations between persons, characteristic attitudes, orientations, and intellectual skills), investigation of human method has been hampered by the difficulty human beings have in objectifying “myself” and “my own” methods.

Recent epistemological discoveries, stemming primarily from Piaget’s study of the developing intelligence of children in school, have allowed a new look at basic semiotic method. The application of some of these discoveries to psychiatric problems of traditional difficulty has given us a new understanding of some of them. In this discussion, the focus is upon the problem presented by the disability state exhibited by some workers following industrial accidents.

We have been able to identify a characteristic set of semiotic observations regularly found in these disabled workers, most of whom are uneducated, usually remarkably so in a country in which literacy is practically universal. In a very large proportion, the lack of education is explained by the immigrant status of the worker. We believe that the specific cognitive limitation preceded the illness, and that it constitutes a predisposition to develop the disability state. The conclusion repetitively reached is that the accident imposes a catastrophic strain on the limited integrative capacity of the worker so that his capacity to cope seems “fractured” in an irreversible way.

The unskilled laborer,“condemned” to his job by his lack of education (although many give the impression of a good “native” intellectual capacity) is at risk for further difficulty in adapting to an injury that radically changes the condition of his life. The fascinating observable is the worker’s insistence that the “external” change has made a corresponding “internal” change that he can state but cannot describe or understand.

The characteristic complaint encountered is, “I am not the same person I was before the accident, it’s just not me. I was always a good worker and enjoyed my work—now I can’t enjoy anything. All I want is to be like I was before and go back to work.” The problem immediately identified can be described as the loss of identity. This version, however, is very different from other identity losses in psychiatry because the claimant presents typically no evidence of neurotic or psychotic involvement.

We have found Piaget’s notion of conservation precisely applicable. Piaget uses a variety of tests in which the crucial decision has to do with a conflict between qualitative and quantitative decision. The problem presented is that of how a change in shape is related to a change in amount. In traditional terms, the problem is that of appearance vs. “reality” (cf. Planck, above). When a ball of clay is rolled out into a sausage shape, it “looks different” while it is “really the same.”

Piaget’s genetic epistemology is a description of the sequential emergence of more sophisticated ways of processing the data of one’s experience. The progression is characterized by partial “equilibria,” stages of which appear as the ability to “conserve” in more and more complex contexts. Conservation of mass appears when the child of 8 is able to comprehend that a ball of clay rolled out into a sausage has changed its shape but not its mass; conservation of weight after apparent change in form appears at 10, but that of volume does not occur (in Piaget’s norm) until about 12. At around this age, “reflective intelligence” appears and develops through the rest of adolescence. “Reflection” in this sense describes a putative equilibrium between the “inner” and the “outer” structure.

The idea that the universe is “reflected” in “the mind” is one that has long grasped the imagination of mankind. This idea describes an “equilibrium” that in the theoretical work of Newton established itself as dominant for two hundred years, one established as well in Marxism; it is a view now clearly the norm in common sense. The revolution in epistemology that has succeeded Newtonian mechanics in physics (in a “concrete” context involving inanimate matter) is one in which the influence of the means of communication upon that which is communicated has become a principal topic of inquiry. As the implications of this new approach have emerged, it has become clearer and clearer that the equilibrium implied in Newtonian theory is much easier to find in relation to “objects” the behavior of which is regular. The more complex the entity examined, the less regular and more unpredictable it appears and the more difficult equilibrium is to discover. The ultimate in unpredictability is to be found in human systems, in which the “subject matter” is the transactional relatedness between two persons seen as data-processing systems of the most astronomical complexity. If one measures “degrees of freedom” based upon the estimated number of single cells in the brain alone (without the humoral, the genetic and the immunological data-processing systems), the two together give a total of 10^20. cells, each of which has as many as thousands of connections to many other cells.

With this number of potentialities, it is scarcely to be wondered that the twentieth-century revolution in reflexive (that is, self-reflective) human understanding should have been established by the demonstration of finite limits in the physical universe. Such finite limits powerfully support the establishment of conservation: Einstein’s demonstration of the finite speed of light and Planck’s demonstration of the finite mass of the quantum of action “set limits” to the human imagination. Modern semiotic inquiry has gone far toward establishing the conditions under which it is possible to describe anything (or anyone, including oneself), thus further promoting conservation through understanding human limitation.

Perhaps the most stringent of the formulations involved in the describing of description is that involved in the notion of the necessarily dual nature of any of the signs used by human beings in the idiosyncratic anthroposemiotic method. What then appears as a paradoxical measure of a grasp of reflexive “performance” is the human realization of human imperfection, of the trait C. S. Peirce refers to as “contrite fallibility.” To a very considerable extent, the more the human being recognizes his own limitations, the more complex and sophisticated his data-processing development. The two outstanding examples of this relation appear in the principles of “uncertainty” and “complementarity” in which ambiguity is enshrined in modern physics.

Uses of Fallibility

The application of semiotic principles to the field of medicine is in its infancy, although it has long been clear that the physician’s stock in trade is interpretation. The “reading of the entrails” practiced in ancient times on a magical basis has progressively given way to “objective” means of examining those same entrails in various of their formal (such as X ray) and abstractable characteristics such as the patterns made by electrical activity or the analysis of components of various fluids. Again we find the same metapattern in that the grasp of the “concrete” long precedes the grasp of the more complex.

In spite of the fact that madness is as old as man, it is only in the twentieth century that it has become possible to begin to understand the complicated semiotic relation between madness and the human condition. As recently as the middle of the last century, the principal American journal dedicated to the study of “insanity” showed in its first four volumes no indication that any of the savants then learnedly writing suspected that internal family relations had anything to do with madness—even though it was clear to Greek dramatists and to Shakespeare that this was the case (McPeak, 1976). It is an example of the purely “implicit” knowing of ancient times that Freud selected the term “Oedipus complex” to characterize a pattern he found first in relation to his own “neurosis”; it is a striking example of the “tunnel vision” of the genius that he did not adequately pay attention to the fact that many other “complexes” are to be found in the “family romance” of the Cadmus connection (that is, not only patricide and incest but suicide, fratricide, usurpation, human sacrifice, and self-sacrifice).

Again, it remains unclear to psychiatric theorizers as a group that the core of all the problems which human beings have in their relations with each other is to be found in the specific human method in which meaning is implicit in consensus —without being “rooted” in any “objective” context. The basic theme of human communication is clearly stated by the fragile Humpty Dumpty of Alice in Wonderland when he declares that a word means “just what I want it to mean”: the only thing needed to make the statement quite accurate is to replace “I” with “we.” Words mean what two or more members as a group “want them to mean,” and it is this basic fact that makes human misunderstanding so prevalent. In a clear analysis of Einstein’s basic philosophical achievement, Reichenbach has pointed out that he discovered that statements previously regarded as susceptible to demonstration of truth or falsity were in fact matters of definition, as most dramatically demonstrated in the differences in the perception of time described by observers in different frames of reference.

In the specific material we will present here, the influence of consensus is shown most dramatically in the differing use of the term “sign” in two dual units in two quite different frames of reference. In the semiotic context, sign as defined by Saussure is the composite of a signifying and a signified. The two participial forms indicate that the meaning is in process, even though the term “sign” seems to indicate a static form. Saussure defines the former as a “sound image,” the latter as a “concept,” but it is immediately apparent that the internal relatedness of such dual units goes far beyond that limited description. For example, as soon as written technology becomes available to human beings, the whole notion of signifying-signified achieves a different dimension. For the literate the primary referent of the spoken word is its written form: the literate person often asserts that he cannot “grasp” a word until and unless he sees it written, a clear indication of a shift in dominance in the influence of communicative method.

In actual practice, however, the relationship is reversed: if a written word is to “live” it must be spoken, either aloud or in the developed capacity of the literate for “inner speech.” It is interesting to note that sophistication in literacy is indicated by the degree to which overt movements of the lips can be suppressed; on the subway in a metropolis it is not at all uncommon to see readers “mouthing” what they are reading—and only somewhat less common to note persons (with lip movements) “talking to themselves” in the process of silent thinking. Thus, with the advent of writing, the signifying-signified relation assumes a primacy while the referent “out there” assumes a secondary character.

It is in this context that it becomes clear that conservation is a term applying to the possibility of abstracting those consistent forms that endure (cf. Whitehead’s “eternal objects”) from the variability of the “appearances.” The paradoxical human achievement is that of learning the human limitation involved in illusions that seem like realities. The sophisticated human being literally does not “believe his own eyes” when he performs the intellectual task of conserving. It is in the “neutral” context of various forms of numerical measurement that many of these illusions can be shown to be misleading—and it is the ease with which measurement can be shared that establishes its “objective” status. Thus we return to the central theme that all specific human meaning is established in consensus.

Medical “Signs”

Making now a sudden shift, the term “sign” is defined in an entirely different fashion in the specific usages it has in the medical context. In medicine, sign is the partner in a dual unit the other member of which is symptom. The latter term has a series of quite different meanings in philosophical context. In medicine, the two establish a subjective-objective dual unit: a symptom is formulated in a complaint, and the patient reports a chief complaint as the starting point of the written record known as a “history.” The physical examination that succeeds the taking of a history is guided by the patient’s complaints: the physician looks for observable signs corresponding to described symptoms. In the “typical” or “classical” instance, there are clear correspondences between the two; a dependable collection of signs and symptoms constitutes a syndrome from which the physician makes an overall diagnosis (a “knowing through” or knowing in depth) from which the treatment and the prognosis (or “fore-knowing”) emerge by interpretation.

Semiotic Implications of “Progress”

The incredibly complex “armamentarium” (to use an ancient medical term) of the modern physician comprises both investigative and therapeutic modalities of many kinds. Since the model of natural science became dominant in American medicine in the early part of the twentieth century, the overwhelming emphasis in medicine has been given to research in the “basic sciences” of (principally) physiology and biochemistry, with their modern extensions into genetics and immunology. The emphasis has consistently been placed upon “objectivity” with the demonstration of signs more and more remote from the understanding of the unsophisticated. In the present day, the dialect of the specialist in internal medicine has become largely incomprehensible to the psychiatrist, for example, as the signs pursued have become more and more specialized.

Where the physician’s interest focuses on those kinds of abstractings that can be quantified through more and more complex processes of instrumentation, the psychiatrist’s concerns have pursued the analysis of behavior and of human relatedness, demonstrating the derivation of unusual or abnormal patterns of behavior from aberrant relationships within families in the past. In recent decades, in a number of new disciplines derived in part from psychiatric ways of inquiring, more sophisticated observational and experimental ways of examining relatedness have appeared. Ethologists examine animal groups as they live in the wild or in captivity; experimental ethologists observe the variations induced by experimental deprivation of “natural” relations (usually through depriving the infant of ordinary maternal care); psychiatrists-become-behaviorists have helped establish the new semiotic specializations of kinesics and paralinguistics. In all of these, the focus is upon the meaning of behavior as that meaning is derived through interpretation and established (or “ratified”) through the consensus of observers.

The particular application of the general theme that forms the focus of this discussion is the examination of a number of aspects of the behavior of a group of persons formally identified as “psychiatric” patients in an esoteric context. A principal differentiating feature of this group of patients is their own rejection of that description: these persons agree, in a massive consensus, that “there is nothing wrong with my mind” or “with my nerves.” The group has been seen for the evaluation of the degree and derivation of disability following industrial accidents. In two-thirds of a total of 120 claimants seen in about 10 years, the last hope of obtaining monetary compensation for extensive disability is in the establishment of a psychiatric diagnosis, but the claimant insists that although he/she is extensively or totally disabled, no psychiatric label applies. It is a peculiar demonstration of the “negative sign” that this (potentially financially self-destructive) assertion should become a significant part of the ultimate diagnostic syndrome.

What establishes the possibility of a psychiatric diagnosis by exclusion in the first instance is the demonstration of a lack of observable signs expected to go along with the kind of symptoms complained of by the claimant in such an inquiry. The claimant him/herself tends to assert that there is some as yet undiscovered organic illness, often with the notion of a displaced bone or vertebra or a “pinched nerve,” explanations often offered by a chiropractor. An interesting complaint made by disabled persons in this group is that their symptoms become worse in bad weather, a complaint familiar in patients with organic types of arthritis. In this context, with no signs of arthritic involvement this symptom is another “negative” finding with a “positive” connotation.

A Cognitive Lesion?

What has made our inquiry into the syndrome we have termed “disproportionate disability” so intriguing is the manner in which our findings submit themselves to a semiotic-epistemological analysis, with the emergence (to us, anyhow) of hitherto unsuspected connections of significance between the level of development reached in Piaget’s “time table” and the susceptibility or vulnerability to disability states. The question to which we have repeatedly returned is, “Can it be possible that certain entities in the broad psychiatric field are significantly related to ignorance?”

The lack of formal education that is the fate of the great majority of the world’s population in undeveloped countries is clearly and closely related to the social “ill” of poverty, and to the prevalence in such countries of epidemic and communicable diseases, many of which depend for their transmission upon a widespread ignorance of so simple a set of factors as those involved in cleanliness. The startling possibility that has opened up in our investigation is that in the advanced country, the lack of personal development found in those functioning mostly as unskilled laborers (a proportion estimated in England as approximating 30% by Bernstein) is a significant part of predisposition that remains latent until and unless it becomes manifest in the context of two significant events. The first is the occurrence of an accident or injury at work under conditions justifying application for compensation benefits; the second is the involvement of the (now) claimant in the intricacies of bureaucratic process.

The most bizarre and compelling implication of our findings and interpretations is the “self-fulfilling” nature of the prophecy implied in compensation. In other words, and quite without any conscious intent as far as we can tell on the part of the disabled person or of the bureau, the shift in primary context from an ordinary occupational one to that of the bureaucratic maze plays a powerful, perhaps essential role in the genesis of that very disability the compensation board is designed to “treat.” If our interpretation is correct, there is a clear analogue of “iatrogenesis” in this context: where in iatrogenic disease it is the pathological implication of the physician’s “treatment” or the complications of his pharmacopeia that exaggerate or induce disease, in the compensation context it appears to be the activity of that bureau that, quite unconsciously on the part of all concerned, induces the chronic disability it “finds.”

The explanation we have reached is a complex of negations or of falsifications of generally assumed hypotheses. The syndrome consistently found can be described in its several particulars. The principal semiotic interest lies in the total inability of the claimant to describe the “inner” components of his “feelings.” He/she demonstrates pain and limitation of motion, often as noted above with the complaint of increased distress in bad weather; there are many complaints and symptoms. On the other hand, he/she cannot describe any of the emotional complications the psychiatrist expects to find in a patient examined by him.

The psychiatrist expects to find anxiety, depression, or anger, and in working in psychotherapy with “neurotic” patients, this expectation is routinely validated. It comes as a surprise to try to explore “feelings” of this sort, especially with reference to the “inner” correlates of visceral and proprioceptive sensations, only to encounter complete incomprehension on the part of the person interviewed in response to questions about such feeling states. As one listens carefully to many interviewees in this manner, it becomes clear that the expectation held by the disabled claimant is that emotional states are so standard that they do not need to be described. If the interviewer asks about feelings corresponding to postures or facial expressions exhibited, the claimant may agree that he feels “angry,” but in answer to a question as to how that feeling is known, the answer is likely to be, “The same way anyone feels angry.”

The implicit demonstration is that of the remoteness of “private” experience from the awareness of the unsophisticated, uneducated human being, and in turn this becomes a demonstration of some of the complexities of human consciousness and especially of human self-consciousness. Another instance of the ability of the disabled claimant to identify a difference without being able to specify the details of that difference is found in the self-description. The standard comment, in one or another version, is, “I’m just not the same person I was; it’s just not me any more.” The claimant is quite unable to describe “me” or a “self ”—but he/she is able to report the major difference felt.

Again, as one explores the syndrome presented, the ability of such a claimant to report, as it were, from an “outside” point of view is remarkably different from his lack of ability to report inner or private experience except in terms of difference from before. He/she says consistently that there is no longer any feeling of enjoyment in any activity, nothing is any “fun” any more (including sexual activity for both sexes), there is no “interest” in social or religious activities of the accustomed variety. These routine comments appear to have a common origin in the fact that the human being has to have a central point of stability, a “place to stand” in Archimedes’s phrase. Without the sense—no matter how “unconscious”—of being “me,” there is no ability to “lose the self ” in any activity, and without that ability to “forget myself ” the human being does not experience the “absorption” basic to enjoyment. In our experience the claimant remains distressingly self-aware without in any way being able to describe the self, a truly paradoxical problem.

The explanatory suggestion that offers itself is that of the difference between context-dependence and context-independence. The basic problem is that of the abstraction—and conservation—of a self from the context of human relatedness in which one “exists.” The claimant in our experience appears to demonstrate the condition of being “embedded” in, particularly, his occupational context so that when that context is lost (and is replaced by the mysterious context of a bureaucracy from which one may or may not expect to receive some partial monetary compensation, sometime, if certain undefined conditions are met), “myself ”—otherwise unanalyzed—is radically different. The familiar phrase is appropriate; the claimant appears to feel “like a fish out of water”—but since the water has always been so much taken for granted and so little understood in any analytic sense, he/she obviously “does not know what hit him/her.”

The further demonstrable regularly present in these instances is that the claimant shows a remarkable inadequacy in performing very simple cognitive operations, simple, that is, in terms of the development of the ideally “normal” school child studied by Piaget. The most routine demonstration of this cognitive deficit has been found in the similarities test, in which the subject is asked to supply a category in which two apparently different items are to be classed. The question is “What is similar about. . . ?”, e.g., an apple and a banana, or a dog and a lion. The establishment of classes with which to organize experience is one of the first significant cognitive structurings; the claimant shows a remarkable inability to “get the point.” The routine answer given is in terms of difference: he/she is likely to say that “an apple is round and red, a banana long and yellow.”

This deficit, in the Piaget scheme, makes it clear that in the particular context, the subject is unable to perform the “operation” of forming classes. He is, in piagetian language, “pre-operational” in this matter, which means that he is functioning at a level corresponding to that of the 7-year-old child. In a similar demonstration of lack of development, the claimant is often quite unable to perform the seriation elicited by asking him/her to subtract 7 serially from 100; the claimant is likely to have to be asked “7 from 100?” then “7 from the remainder?” again and again: he/she is quite unable to take the instruction and “run” with it. Often his/her subtraction is poor. This indicates a lack of development in the construction not only of classes but of series. What is most startling is that these claimants, prior to the onset of the disability, have shown themselves capable of carrying the adult responsibilities of ordinary family relatedness, rearing children and supporting the family, not infrequently with the children going on to much higher levels of education than the parents were able to enjoy.

When this group is investigated in terms of their backgrounds of experience, what comes through as the most consistent finding is the paucity of formal education, often associated with an early life history of extreme deprivation. A remarkably high proportion of disabled claimants were immigrants, from Southern Europe, Puerto Rico, and from the deep south of the United States, all of which consistently provided very little educational opportunity for the claimants, who tended consistently to come from poor families in which the previous generations were similarly poorly educated.

The poor state of educational achievement that has appeared as a predisposing factor to the development of disability does not seem to have that implication in the context of origin, i.e., in the “old country” or in the undeveloped social system. We have consistently been impressed with the contextual problem in this relation, since it seems that it is the undeveloped person in the developed country who is so much more at risk than is the developed person in the developed country or the undeveloped person in the undeveloped country. There seems to be a close relation to Pope’s warning that “A little learning is a dangerous thing.” The specific predisposition appears to have a high correlation with the experience of breakdown or failure in a context of marginal achievement. Where that marginality can be maintained, there is little or no evidence of the kind of symptoms associated with the disability state.

These observations appear to give a somewhat different coloring to the usual notion of the development of “objectivity.” The significant problem is not so much that of “objectifying” in any simple sense but that of abstracting from a system the regularities that can be counted upon. In the reflexive process of human self-knowledge, the “regularities” involved in knowing oneself are those necessarily present with the “self,” in whatever context, “portable regularities.” This means that to continue to “know oneself ”one must concentrate not upon the geographical or occupational or even familial regularities; instead one must “know” a private world derived by interpretation from those vague and poorly describable inner states in which the relevant sensory data come from visceral, muscular, and postural sources rather than from the traditional “five senses” primarily oriented to the “outer world.” In “undeveloped” countries in which the human being is never alone, he does not need to “know himself ” from inside out, he is always being given feedback by his associates. He does not need to have private feelings since every significant human activity (birth, death, marriage, puberty, and so on and on) is regulated and ritualized in overt manner in group activity. As Lévi-Strauss has emphasized, in the myths that present the ideologies of such “primitive” (that is, preliterate) societies, there are no authors or poets—even artistic activity is a collective process.

These observations support a number of other recent observations of major differences in personality style between persons of middle-class (especially upper-middle-class) and working-class status. The major difference between these groups is that of education; in the United States particularly it is common to find professional persons from working-class families of origin. Many of the claimants we have seen report that a son or daughter is in college; this is especially probable in New York City where an emphasis upon higher free education has long been established. Our intuitive conclusion has been that there is no lack of “native” intelligence in these claimants (with some exceptions); there is instead a remarkable lack of formal education, with a clearly related intellectual incapacity.

In the present atmosphere of egalitarianism, differences of this sort are likely to be overlooked in part as an expression of an official commitment to “equal opportunity” in an interpretation that often means unequal coercion to employ less sophisticated persons. In our experience, however, without taking into account the educational-intellectual deficit in the claimants we have seen, the resulting disorder is completely mysterious.

In studying the literature of development, a theme that recurs time and again is that to become developed it is necessary to become independent of context (cf. Bernstein, 1964; Bruner, 1973) in many of the ways in which human beings have generally been comprehensively context-dependent. To develop as an “individual,” one has to learn to dissociate himself from his family (especially his family of origin), to abandon traditional forms of religion, to adopt a democratic rather than an authoritarian political stance, to learn to regard the other sex as “equal” in striking opposition to traditional forms of enforced submission of women, and to learn to tolerate changes of residence, often repeated changes.

In our experience, we have come to believe that the disabled claimants we have seen have lost self-definition (although they had not developed any consciously formulated self) because of the loss of essential context. In other words, the transfer of self from occupational context to bureaucratic context changes the self in an apparently irreversible way. It then becomes more comprehensible that the claimant should believe preferentially that he has an undiscovered disease. Since he cannot change his own definition of “disease” he interprets symptoms that in a more sophisticated person might be perceived as grief or anxiety as related to “organic” disease. The absolute inability to process relevant data was shown in one case by a young man with a hysterically paralyzed arm and hand who insisted he had to see a “hand doctor.” In the record there was a clear report of his having seen perhaps the most famous hand surgeon in the United States. The claimant had somehow managed to obliterate the fact that he had received precisely the kind of investigation he was demanding.

For us the most interesting aspect of this work is the implication that defining a world is an important part of constructing that world—and when the definition (no matter how poorly formulated) no longer is “in equilibrium” with the world as experienced, the result is not only a change in the world but an irreversible painful change (of a chronic nature) in the self. The demonstration is that the self and the universe are reciprocals, and that a massive change in one changes the other.