2284: Timid souls among the ruins

2284: Timid Souls among the NICHOLAS P. CHRISTY, M.D.

T he archeologist squats in the rubble of the Countway Library, identified as a part of what had been the

Harvard Medical School at 42’21’ N latitude, 71°05’30” W longitude on the old grid maps, a site shown in some atlases as “Boston.” Narrowing her eyes against the radioactive dust, the paleontologist checks her time- piece: 1400 hours on a summer day in 2284. A super- seding civilization or two have engulfed the 20th century’s, have come, and thrived, declined, and gone their ways. The incumbent Government has programmed this student of dead languages to exhume the written record of the past 300 years. MESS, the Medical-Etymological Sub-Section of DEHD (Department of Historical Dis- tortion), has charged her with the specific task of digging through the remains of medical libraries so as to reconstruct a picture of medical practice in the post- Industrial Revolution era. This project forms part of Government’s broader effort to recapture the recent past-necessarily a piecemeal job because of the widespread destruction incident to the post-neutron period. Her assignment is twofold: to find and preserve whatever elements might be useful in controlling a sparse, ailing, depressed, and lethargic populace; and to destroy all material that might induce further de- pression or, more dangerous still, might provoke en- lightenment [l].

Adjusting her isotope-proof goggles, i-4082-for that is her name-raises her hammer and resumes her gingerly approach to the stacks of this ancient book repository. Tap-tap-tap. A final tap raises only more dust; then suddenly a dark tunnel opens up. In the gloom, scattered amid the debris, she can make out heaps of torn pages partly incinerated, chunks of burned books. Advancing, peering, she deciphers the titles on dis- colored bindings: “Journal of Appl . . . ,‘I “. . . Biological Chemistr . . ,” “Annals of . . . ,I’ “American Journal of Medi . . . ,I’ “. . . Pharmacolog .” She muses: “These are medical periodicals_’ Summoning her

collection team by beeper, l-4082 gathers in the pre-

Ruins

cious remnants, orders the preservatives to be sprayed on the decaying paper, directs the cataloguers to make their lists, arranges for the transport of the papyri to her cubicle. For the next several months, she scrutinizes and translates the documents. From this study, a report emerges that will have significant impact upon the Government’s SP (Stultification Program), a subdivision of CLAM (Control through Linguistic Adjustment and Manipulation) [ 11. Excerpts from 1-4082’s critique follow. “To: CLAM (SP) Thru: DEHD (MESS) From: l-4082 Subject: Medical Language of the Late 20th Century: Characteristics; Recommendations 1. Agent archeologist respectfully submits this report under mandate from addressee to obtain medical writings of the subject time period for use in providing historical information suitable for confusing the people without disheartening them. 2. Materials. 453 kilograms of charred paper, portions of medical magazines and books, variously dated 1950 to 1983 A.D. Roughly 90 percent of the printed texts are undecipherable owing to incineration. The residue is all but unreadable for reasons spelled out in paragraph 3. 3. Language; Linguistic Methods. The language is “Modern English,” a hybrid of ancient Teutonic tongues with Romance strains, infested by borrowings from the pre-archaic Latin and Greek linguistic families. From the few extant fragments, it is plain that this medical technese is not English as the Government has recon- structed it from newspapers, works of fiction, accounts of voyages of exploration, and other normal sources. Accordingly, agent has decoded these papers by standard Governmental cryptographic methods (Ap- pendix 7).

From the Brooklyn Veterans Administration Medical Center and the Department of Medicine, Downstate Medical Center, State University of New York, Brooklyn, New York. This work was presented in part at the 47th Annual Meeting of the Peripatetic Society, New York, New York, March 11, 1983. Requests for reprints should be addressed to Dr. Nicholas P. Christy, Brooklyn Veterans Administration Medical Center, 800 Poly Place, Brooklyn, New York 11209.

January 1984 The American Journal of Medicine Volume 78 3

MEDICINE, SCIENCE, AND SOCIETY-CHRISTY

4. Nomenclature. The basic written medical language is termed PET (Pseudo-English Technese). A subvariant, MEDSPEAK, is the spoken lingua franca used within the medical profession, particularly when teams of physicians and trainees visited patients for the dual purpose of CD (care delivery) and teaching [2]. 5. MEDSPEAK, the Spoken Language. Elaborate words when plain, short ones would do; cryptic brevity through abbreviations in code; neologisms; linguistic smoke screens like “occasionally,” “not really,” and “es- sentially” (see Appendix 22) [2]. 6. PET, the Written Language.

Solecisms (crimes againsf the rules then in force of grammar and logic). These abound. “The choice is for a person to either rely on their taste, or to eliminate salt from their diet.” “ We . . . have recognized an ‘obligatory runner’ whom we believe represents an unusual case of anorexia nervosa in a man.” Many other patients are described as “more unique” or “very unique” or “fairly unique,” suggesting “more one” or “exceedingly one” or “pretty much one.” This is a puzzle, since the antique word “unique” means “only one exists” [3].

Faulty Punctuation. Medical writers use too little or too much. Too little leads to ambiguity [4]. Too much-e.g., too many commas-induces coma in the reader. A peppering of commas acts as dust in the eyes.

Bent Syntax. This literature teems with examples [4]. “The patient’s face resembled acromegaly” [3]. An apple resembled a chair. The intended meaning: the face was like that seen in acromegaly. “The patient is fibrillating” suggests that the entire person is atwitch with tiny muscle spasms, but what the writer wishes to convey is “atrial fibrillation,” a dysrhythmia of the heart only [3]. Critics of the 1970s have provided many ad- ditional samples [4].

Abbreviations in Code. Pronounceable or not, acrostic or not, these shorthand phrases keep secrets. In patients’ records, SHEENT is not a piece of scatology, but short for “skin, head, eyes, ears, nose, throat.” Another puzzle for the cryptographer: “euboxic,” sig- nifying that the colored line in printouts of laboratory data passes through all the gray boxes, denoting the normal range of values. A euboxic patient is a well patient. Other abbreviations do harm through ambiguity. “LP OD” represents either “daily lumbar puncture” or “lavatory privileges every day.” “ALS” can stand for three things: “amyotrophic lateral sclerosis,” “average length of stay,” or “advanced life support.” Still others seem unnecessary, taking up as much time as what they replace: “CP” for “chest pain.”

Passive Voice. Here is a powerful method for placing distance between writer and reader, slowing the nar- rative pace, abjuring responsibility, and clouding meaning. “The research was supported by . . . ,” “The

dogs were employed . . . ,I’ “The specimens were mixed and shaken . . . ,” “ The patients were instructed

7, ‘I . . . , . . . and the drug was administered . . . ,I’ “The conclusion was drawn that . . . ,I’ “The situation must be kept an eye on” [4]. Nobody ever “does” anything. Everything “is done.” For a fuller treatment of this usage, see reference 5 [5].

Neologisms. A “fascinoma” is an interesting case. A patient who comes to a bad end is a “horrendoma.” (See also the aforementioned “euboxic.“) The use of new coinages is a large subject that will form the basis for a separate report. Reporter notes that neologisms are the hallmark of schizophrenia, the most common form of insanity in this period.

Excessive Abstraction. A cardinal rule of writing had always been that the specific holds the reader, general statements lose him. Yet “Teaching hospitals . . . are complicated institutions.” “An entirely different approach will be required for the process of identifying and addressing the needs and priorities for better . . .” The reader is not tempted to read further [ 61.

Excessive/Obsessive Qualification. PET contains notably few flat statements. Presumably in the name of scientific caution, medical writers of this time produce sentences that give something, then take most of it back. The net information or conviction transmitted is therefore minimal. “It is usually wise, unless there is good reason to the contrary, to start treatment with the least toxic drug” [6]. Even by 20th-century standards, this is an inoffensive opinion, hardly needing the qual- ifying clause “unless . . . contrary” to make the sentence more inane. Perhaps the writer meant to write “most” for “least.”

The evasions of MEDSPEAK have been alluded to before (paragraph 5) [2], but the most startling quali- fications are to be found in scientific and didactic PET. Beginning an article on vitamins, a pharmacologist is willing to say, IL. . . there is little unequivocal evidence that vitamin E is of nutritional significance or is of any value in therapy,” a definite assertion only slightly watered down by “unequivocal,” but, as prose of this sort goes, still straightforward, even confident. By the time he reaches the end of the chapter, the author has lost his courage: “With the possible exception of its potential value in treating the anemias associated with extreme protein calorie malnutrition, prematurity, or acanthocytosis . . ., results with alpha-tocopherol have in general been so disappointing that the conclusion seems justified that, at present, there is no persuasive evidence that vitamin E has any therapeutic use” [ 71. The sentence contains six qualifiers: “possible,” “potential, ” “in general,” “seems,” “at present,” “persuasive.” Flawed, cumbersome, and waffling the sentence may be, but as protective coloration for the author it is flawless. All the meanings are so dilute that

4 January 1084 The American Journal of Medicine Volume 78

the reader can scarcely taste them. Therefore, the writer, having said practically nothing, has insured himself against any attack, unless a carping critic should accuse him of failing to commit himself.

DoubletalklDoublethink [ I]. This is the pet qualification of PET, the ultimate ambiguity. The writer gives with one hand, then takes all away with the other. The net communication is zero. A printed transcript of grand rounds records a house officer’s presentation: “This man is stable except for uncontrollable hypertension.” The patient is stable but unstable. An extract from lecture notes in a department of surgery: “This proce- dure is necessary but not essential.” The reporter cannot riddle out the meaning of this entry.

The dictionaries of the era define “doubletalk” as “a mixture of sense and nonsense . . . deliberately ambiguous language” [I]. The reporter offers two hypotheses: either these writers of doubletalk suffer from “doublethink” [I], “the simultaneous belief in two contradictory ideas,” or they are afraid to say anything that might later prove to be slightly incorrect. That is, in the terminology of the time, these authors are either schizophrenic (“split brained”) or pathologically timid (see later, Summary/Conclusions). A third possibility exists: that they are “equivocating,” a quaint, Latinate word meaning “to use ambiguous language, especially with intent to deceive; hence, to lie.” The reporter re- jects this possiblity as far-fetched.

Euphemism. This common usage, known as MARSHMALLOWSPEAK [8], the practice of saying something without saying it by softening the meaning to the point of unintelligibility, was popular in 20th- century medicine, but flourished also in advertising, law, business, government, and politics. Euphemism, sub- stituting “an inoffensive or mild expression for one that may . . . suggest something unpleasant,” pervaded the air breathed by the people of that time. An atomic weapon is a “peacekeeper.” Soybeans are “meat extenders,” An apartment is a “living unit” (on the basis of verbal evidence, reporter thinks this should mean “organism,” “ a single creature capable of independent life”). Running a hospital laundry is “textile manage- ment.” In such a climate of circumlocution, physicians gravitate naturally toward using “erythematous” for

“red,” “ technologist” for “technician,” “diaphoresis” for “sweating” [8], “altered skin integrity” for “bed- sores.”

Reporter concludes that three main motives underlie medical euphemisms: pedantry, the unabashed wish to conceal, and the notion that a softer expression spares the sensibilities of the recipient [8]. The roundabout communication of euphemism probably brings-not relief to the reader or the hearer-but confusion, anxiety, and annoyance [8].

Undue Compression. Related to excessive abbre-


viation, this habit pervades the scientific abstract. “The A response to M is mediated by M’s antagonist activity at the receptor level. Response to the D agonists, D and B, are dissociated indicating that a new type of D receptor may inhibit A secretion” [6].

Prolixity. The use of too many words makes long- windedness the most typical feature of 20th-century medical prose. “After” turns into “following upon,” “prior to” becomes the inflated version of “before” [2]. The writers of the time in question are capable of more than that: “It appears from these several considerations that the demonstration of coronary calcification by the simple, relatively inexpensive, and non-invasive tech- nique of cardiac cinefluoroscopy represents an important addition to the diagnostic armamentarium of the clinician.” 7. Medical Writings Exempt from the Aforementioned Errors. There are three categories. The first is papers written by medical scientists who are not native English speakers. They stick to the simple style because they do not know English well enough to elaborate. The re- sult: readers can understand what they say. The second group comprises the so-called “case report.” When physicians write of dramatic illness in patients they have seen themselves, when they treat of guts and gore and disaster, the prose is terse, vivid, clear, instructive, and sometimes memorable.

The third type is a great rarity: the seminal, technical report that gives significant material in an understand- able fashion. Such a paper is the Watson-Crick report on the molecular lstructure of nucleic acids [9]. This paper, important in its time, is said to have caused more stir in biology, biochemistry, and genetics than any other of the century. It (contains only 880 words. The sentences are simple: “We wish to suggest a structure

.” “This structure has novel features . . . ;” “. . it . . . , has two helical chains each coiled around the same axis

.‘I and so on [9]. Before being superseded by . . . , Government’s laudable polemical method for settling scientific disputes [ 11, works like the Watson-Crick article could serve as models, standing out in stark contrast to the obscurantist scientific prose surrounding them. (For the recommended disposition of the Watson paper [9], see paragraph 9, Recommendations.) 8. Summary/Conclusions. PET, the official medical language of the 20th century in the region designated “USA,” has been studied in the manner indicated. The “readable” 10 percent of material unearthed from the Boston area is not in good repair, but that is not all that is wrong with it. Medical-scientific prose of this period displays at least 12 stylistic flaws, which have been analyzed according to prescribed methods. The data compel the following inferences:

l PET is no human language. l PET conveys little meaning.



0 Internal evidence demonstrates that PET is not designed to communicate.

0 The attributes of PET permit these hypotheses about its practitioners:

(1) Physician-writers have no training in the use of words.

(2) Physician-writers are in the main mentally deficient.

(3) Most physician-writers are in the parlance of the time “insane.”

(4) Physician-writers habitually take some sort of mind-scrambling drug or drugs.

(5) Physician-writers created PET as a giant hoax; medical language is a vast, corporate “in-joke.”

(6) Physician-writers are at bottom timid souls unable to express a straightforward thought simply and clearly.

The data do not allow a definite statement whether this defect is innate or learned. Evidence from outside the profession suggests that physicians learn to talk and write this way [2,5]. Nothing in the rest of the civilization supports the idea that the cowardice exposed in PET could have stemmed from an inborn linguistic error afflicting only this small segment of the population.

The question is: which hypothesis is the most likely? Numbers 2 and 3 fail on statistical grounds. The reporter cannot completely exclude 1 and 4; and 5, although extreme, is not impossible, given the frivolity of the times. On balance, hypothesis 6 appears to explain best the phenomenon of PET. Perhaps timidity of utter- ance-echoing and, in the end, fostering timidity of thought-became deep-rooted, widespread, and all- embracing, conceivably playing a major role in the downfall of 20th-century institutions. 9. Recommendations. MESS will be well advised to suppress all case reports from this language sample, all papers written by non-native English-speakers, and all competently written scientific works like the Wat- son-crick article cited [9]. These purvey information clearly. They threaten to edify, perhaps to exhilarate. Therefore, they are by definition counterproductive and inimical to the aims of the Stultification Program

(SP). The remainder of the Countway material should be

preserved and promulgated to HCP (health care pro- viders), and to the public at large as well. If the arche- ological teams now working at the sites of the New York Academy of Medicine and the National Library of Medicine in ‘Bethesda” can discover more documents, one hopes in a better state of preservation than these, the Government’s purpose will be well served. “More documents” means a greater volume of gray and toxic prose. The extant populace, debased as they are, may actually come to believe that medical life, and by ex-

tension real life, resembled what they find in PET. Since no reality is reflected by PET, reading it will produce a gratifying level of historical distortion, and thus induce a satisfactory state of stupefaction in all its readers.”

The report by l-4082 was accepted by the Chief of MESS who forwarded it to CLAM with the following memorandum: “To: Director, CLAM (SP) From: Chief, DEHD (MESS) Subject: Report by l-4082 on PETIMEDSPEAK End: Subject Report with Appendixes 1. The attached report by agent archeologist l-4082 is forwarded, approved. 2. The tendency of l-4082 to editorialize and attempt humorous sallies is of course unacceptable and has been dealt with by a standard letter of admonish- ment. 3. It should be noted that the crimes against orthodoxy [l] referred to in paragraph 2 are mitigated by 1-4082’s long immersion in PETIMEDSPEAK. Addressee will concur that protracted exposure to such gnarled prose must inevitably addle the brains of the hardest- headed. 4. The undersigned opines that the timidity shown to be rampant in PET can be put to good use by Govern- ment. Ritual readings-open-air readings by the public, aloud, in unison, from the preserved texts* of PET- may prove to be salutary, inculcating in the popular mind an enhanced level of general, poorly-defined, free- floating, nameless, useful anxiety. An anxious people is a docile people. 5. The recommendation to suppress the good papers, a minute fraction of the total, and to preserve and broadcast the rest-the windy, the prolix, the graceless, the uninformative, the obfuscatory-has only one pitfall. Large doses of PETIMEDSPEAK may further depress the populace. Surely CLAM will agree with MESS that this is no serious objection. A depressed people is a malleable people. The central and long-range aspira- tions of Government will triumph in any case, for there is no chance that reading the medical language of this dead era will instruct or humanize the profession or the population, much less enlighten them . . .”

l Historical addendum: In a subsequent memorandum to the director of CLAM, the chief of MESS gave it as his opinion that PET could be fed to the people as is, pristine and intact, without alteration or emendation. All other languages hitherto resurrected had required extensive editorial revision before they could pass muster as suf- ficiently stultifying. In contrast to those languages, PET was deemed intrinsically numbing enough to suit any end of Government, conveying nothing and conveying it unpleasantly. An ignorant people is a pliable people.

6 January 1964 The American Journal of Medicine Volume 76

MEDICINE, SCIENCE. AND SOCIETY-CHRISTY

REFERENCES

1. Orwell G: 1984: a novel. New York: Harcourt Brace, 1949; 6. Crichton M: Medical obfuscation: structure and function. N Engl

301-314. J Med 1975; 293: 1257-1259.

2. Christy NP: English is our second language. N Engl J Med 1979; 300: 979-981.

3. Fowler NO: Vexatious expressions in current medical writing. Am J Cardiol 1979; 44: 1217-1218.

4. Dirckx JD: The language of medicine. Hagerstown: Harper & Row, 1976; 137-143.

5. Christy NP: Is language the dress of thought? Trans Am Clin Climatol Assoc 1979; 91: 98-106.

7. Cohn VH: Fat-soluble vitamins. Vitamin K and vitamin E. In: Goodman LS, Gilman A, eds. Pharmacological basis of ther- apeutics, 5th ed. New York: Macmillan, 1975; 1591-1600.

8. Christy NP: Calling a spade a spade. Hosp Pratt 1982; 17: 138H-138M.

9. Watson JD, Crick FHC: Molecular structure of nucleic acids: a structure for deoxyribose nucleic acid. Nature 1953; 171: 737-738.


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2284: Timid souls among the ruins