IS LANGUAGE THE DRESS OF THOUGHT? NICHOLAS P. CHRISTY, M.D. BROOKLYN, NEW YORK
"Language is the dress of thought," wrote Samuel Johnson (Figure 1) in the Lives of the Poets when assessing the diction of Abraham Cowley. The core of Johnson's idea here is typically 18th century-language is decoration: "... as the noblest mien ... would be degraded by (the) garb ... of rustics ... ., so the most splended ideas (will) drop their magnificence, if they are conveyed by words used commonly upon low and trivial occasions" (1). This is part of Johnson's view; the rest of it, less typically 18th century, we will see at the end of this essay, whose burden is: language is not the dress, but the costume, the disguise of thought, whereas language and thought should-ideally-be inseparable. These assertions lead to the question: what is the origin of language? Love, Charles Darwin believed. Love and music. In The Descent of Man, he surmises: "Language owes its origin to the imitation ... of various natural sounds ... primeval man probably first used his voice in producing true musical cadences, that is in singing ... this power would have been especially exerted during the courtship of the sexes,-would have expressed ... love, jealousy, triumph .. ." (2). Whatever was the origin, some kind of spoken language has existed for 100,000 years in Western Europe, and the oldest written language dates from about 4000 B.C. in Sumer (3). "In the beginning was the Word" (John i:1). Not likely. In the beginning, more likely, was the song or the grunt or the yell. When words became the coin of language, linguists agree that names came first; psychologists infer that things led to names, names led to new things, later, to ideas (4). In most historical periods, medicine and medical language have not been notably accessible or clear. Hermetic obscurity is more usual (5), despite what Aristotle laid down in the Rhetoric: "Language which does not convey a clear meaning fails to perform the very function of language" (6). For the sake of science, clarity is required to convey the names of things, processes, concepts. In aid of humanism, clear communication From the Brooklyn Veterans Administration Medical Center and the Department of Medicine, Downstate Medical Center, State University of New York, Brooklyn, New York. The work reported here was partly done during a sabbatical leave from Columbia University at the National Humanities Center, Research Triangle Park, North Carolina 27709, January-June, 1979. Requests for reprints should be addressed to Nicholas P. Christy, M.D., Chief of Staff, Brooklyn Veterans Administration Medical Center, 800 Poly Place, Brooklyn, New York, 11209.
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FIG. 1. Samuel Johnson (1709-1784). This portrait is by Sir Joshua Reynolds and was done at about the time (1782-1784) Johnson wrote the Lives of the Poets (1779-1781).
with patients is a mandatory "function of language." Yet clarity is a rarity (6, 7). Let us see what are the aims and functions of our famously obscure medical language here and now. We may learn to what extent medical language is the dress of medical thought. In a recent report on spoken medical English-the language of rounds, MEDSPEAK-I suggested that the communication accomplished thereby is limited and offered four reasons for MEDSPEAK's obscurity: a need to appear learned-big words when small ones will do; a need to be brief and condensed through acrostic abbreviations*-forms of short* Some abbreviations are hard to decode: NPBAH for "no psittacine birds at home," ADL for "activities of daily living," SMO for "laboratory slips made out." Some are ambiguous: HNP for "herniated nucleus pulposus" or "human neurophysin," LAP for the
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hand, literally, SHORTMOUTH; the need to hide, to avoid making a commitment or decision by the use of vague, ambiguous, and sometimes mendacious qualifiers like "essentially"t; and the need for hangman's humor to allay feelings of distress on the part of the doctor confronted by critically ill patients (6). A fifth need is to be perceived as a member of the club, of the cult, of the priesthood (5). The common result of these five needs is a jargon which puts distance between the speaker on one side, and, on the other, the patient, the disease, and any other listener. In turn, the effect of this distance is dimness, obscurity, some of it unconscious, some conscious and deliberate. The topic is not elucidated, but clothed-hidden in words (1, 6). The bad state of written medical English has also become a popular whipping boy. Besides the willful obfuscation that Crichton has detected, Ingelfinger and others have blamed poor school and college education in reading and writing, failure of doctor-authors to expose themselves to good English style by reading decent literature, authorship "by committee," and the overgrowth of jargon brought on by a fast-growing technology (7). Elsewhere, I have suggested that the causes lie deeper: indistinct thought, a defect not peculiar to doctors; and the pressure to publish in order to advance one's career. These two afflictions also lend obscurity
(7). "Most men think indistinctly and therefore cannot (write) with exactness," said Johnson (1755), recognizing the close relationship between thought and expression (Fig. 1). Indistinct thought has many causes. There is double-talk, often found in patients' charts: "Not suicidal but may harm self if left unattended," that is, "Yes, but no." There is stating the obvious, found everywhere; the prevailing style must influence medical writing. Ten years ago, the AEC comments on radioactivity in the drinking water of a nuclear plant, found to be due to a hose connecting the drinking water supply to a tank 3f radioactive waste: "The coupling of a contaminated system with a potable water system is considered poor practice ...". In 1979, the Chairman of the Federal Reserve Board top of the thighs when you sit down or "leukocyte alkaline phosphatase." Some serve more than one purpose; this one is impenetrable and inappropriately breezy at the same time: "stool for BOP" means "stool for blood, ova and parasites." t "Essentially" has a peculiar property: it can drain the meaning out of any sentence (6). Example: "The patient was essentially afebrile before admission." The range of interpretations is wide. "The patient had no fever." "The patient had a little fever but I don't know how much." "The patient felt feverish but didn't take her temperature." "The patient had a low grade fever for 7-10 days before she came in" or "She had a high fever but for only 1-2 days." "Her temperature was not much above 101'F. for less than two weeks before admission." And so on. This illustrates Bloomfield's Second Law of Linguistics: "if a sentence has many meanings it has no meaning."
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remarks on inflation: "If we do not control inflation, I do not think our economic system will be able to work efficiently...". This kind of writing in the public press cannot help but influence medical prose. Instructions for the emergency room treatment of rape contain this first sentence: "In general, rape is a traumatic experience for women." Published scientific articles tell us that cigar smoke is as irritating to the bronchi as cigarette smoke (7). There is adherence to Thurber's Rule: "Don't get it right, just get it written" (7). Leaving out as unfair game the chess or bridge columns of any newspaper, here is a commentary about the string quartets of Bela Bartok from a 1949 program note: "Subtle shifts of sonorous balance serve to delineate phrase structure in a texture where cadential articulation, no matter how tangentially and sparingly used, can easily create sonorous inconsistency.... Unique timbral characteristics serve to endow an ambiguous harmonic aggregate with an individuality which makes it possible for it to function referentially in the role of a 'tonic sonority'." That is Milton Babbitt, composer and a Professor of Music at Princeton. Here is a comparable specimen of Harvey Cushing (1910), by some deemed a masterly medical writer: "The persistence of the characteristics of infantilism in a number of our puppies subjected to a partial hypophysectomy, and the occasional evidence of secondary atrophy of the sexual organs, together with the appearance of adiposity in several of the adult animals, suggests that the cases in which an hypophyseal tumor has been found in common with symptoms of adiposity and either a persistence of infantilism or a secondary sexual degeneration, point toward the lowering of hypophyseal activity as the explanation of the clinical syndrome" (8). Wrong science. Too many words. Clumsy sentence structure. Bad grammar. Repetitious. Productive of obscurity. As for the pressure to publish, everyone knows it exists. Grant support is dwindling, but the number of papers submitted to journals continues to rise; new journals keep appearing. The papers are being written by somebody-by "committees," hastily, for bad motives, by "word processors"-verbal Cuisinarts. The results? More shoddy prose, more obscurity. One usage that makes prose shoddy and obscure is ritual addiction to the passive voice. A survey of the matter is reported here. Three journals were sampled: the July, 1979 issue of the Journal of Clinical Investigation, the Journal of Clinical Endocrinology and Metabolism, and the American Journal of Medicine. Occurrence of the official passive in the first sentence of the "Methods and Materials" section of every paper was counted. A few desultorily-not-randomly-chosen articles from 50 years ago, were, in an effort to evaluate for comparison the frequency of the passive in scientific prose of one to two generations back, read. Nowand a half century ago-the overall prevalence of the passive voice in
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starting "Methods" was found to be 90.42%. The passive tended not to be used in a) case reports, and b) papers that were written by foreign scientists. Further, it was observed that the passive construction fostered the interposition of many modifying words and phrases between subject and verb. Word-clumps or number-clumps containing 10 to 30 items were often identified. In one sentence, 66 words were contained in the clump. Up to 13 identically constructed passive sentences in a row were common, giving out a rhythmic if halting syncopated beat, like a tom-tom, with the numbing effect of a tom-tom. Various methods were encountered which had been used-or employed-to break the monotony: one method was occasionally to substitute "were employed" for "were used", as in: "Four random-bred dogs were employed in the study .. ." (9). Nothing is said about how the dogs came to be employed, what were the terms of employment (9). In summary, the passive is inactive, leaden, impersonal, general, wordy, hard to follow-the reader has usually forgotten the subject by the time he (at last) reaches the verb. The passive is monotonous and obscure. To return to the original question: is language the dress of thought? No. As we have seen, it is often the cover of thought in medical as in other kinds of prose. Johnson, criticizing Cowley's diction understood this: "Truth indeed is always truth and reason is always reason; they have an intrinsic and unalterable value, and constitute that intellectual gold which defies destruction: but gold may be so concealed in baser matter that only a chemist can recover it; sense may be so hidden ... that none but philosophers can distinguish it; and both may be so buried in impurities as not to pay the cost of their extraction" (1). Before the work of modern philosophers and linguists, it would have been enough to dispose of the creative and stylistic problems of obscurity by sticking to the maxims of rhetoricians through the ages, from Aristotle to E. B. White: "A good style is first of all clear"; "Express yourself in a plain, easy manner"; "No word or phrase should be ambiguous"; "Use definite, specific, concrete language ... Omit needless words ... Be clear ... Clarity, clarity, clarity." The studies of the philosopher, Ludwig Wittgenstein (Fig. 2), Noam Chomsky, the professor of linguistics, and many others demand that we do more. Start with the premise that the relation of mind to language is not known. The relation of thought to language is unknown (10, 11). "Man (has) the ability to construct languages capable of expressing every sense, without having any idea how each word has meaning or what its meaning is" (10), writes Wittgenstein. Says Chomsky: "The normal use of language" is a creative act, "is innovative, in fact, infinite in its variety" (11). Thought may be verbal or wordless. Yet, we intuitively sense that thought and language are connected-tightly and intricately. Wittgen-
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FIG. 2. Ludwig Josef Johann Wittgenstein (1889-1951), Vienna-born logician who taught philosophy at Cambridge from 1929 until his death. He influenced Alfred North Whitehead and Bertrand Russell; the one book he published during his lifetime (10) abetted the development of logical positivism. Wittgenstein's pertinence to this paper is based on the importance of his work to modemn linguistic analysis and semantics. For Wittgenstein, philosophy is a clarification of the logical process through a critique of language. (See also his posthumously published Philosophical Investigations, English translation, 1953; New York, N.Y., the Macmillan Company, Inc., 1958).
stein again: "Everyday language is a part of the human organism and is no less complicated than it" (10). Still, as he says elsewhere, "Everything that can be thought at all can be thought clearly. Everything that can be put into words can be put clearly" (10). But, getting back to our question about the "dress of thought" (1), Wittgenstein states: "Language disguises thought. So much so, that from the outward form of the clothing [the "dress of thought" (1)] it is impossible to infer the thought beneath it,
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because the outward form of the clothing is not designed to reveal the form of the body, but for entirely different purposes" (10). He does not say what purposes, but from looking at medical language, we have seen some of the purposes, overt and hidden: mostly to do with disguise, concealment, evasion, escape (6, 7). George Orwell (Fig. 3), in his essay, "Politics and the English Language" (1946) characterizes the inflated style-like that of medical writing-as a "kind of euphemism" (12). Again, concealment, evasion and escape. In urging plain English "as an instrument for expressing and not for concealing or preventing thought," Orwell perceives that "if thought corrupts language, language can also corrupt thought," not only in the listener or reader-through tradition and imitation-but in the speaker or writer himself. Using inflated or flat, conventional language just because it is the "going" idiom, softens and blunts the thinking process (7): "unless you make a conscious effort to prevent it, the existing dialect [e.g., the passive voice!] will come rushing in and do the job for you, at the expense of blurring or even changing your meaning" (12).
FIG. 3. George Orwell (Eric Arthur Blair, 1903-1950) at about the age of forty.
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Is all the complaint about obscure language worth the bother? Orwell and many others have believed so. "The great enemy of clear language is insincerity" (12), he said, speaking of the influence obfuscatory language has on political behavior. Max Beerbohm (1953) went further-what he thought also applies to science: "Already one discerns a debasement of English; and other debasements will follow that. With the blunting of precision in language ... comes muddiness in political policy, in morality, and in conduct" (13). The relation of language to morality and conduct becomes plain when a Speaker of the AMA's House of Delegates casuistically equates medical ethics, i.e., medically ethical behavior with fee-forservice practice (14). Figure 4 shows Hans Christian Andersen's emperor's new clothes, that is, no clothes. The Emperor's subjects admired his absent dress because they were afraid to appear "out of it" or foolish. For the same reason, we now tolerate, imitate, make traditional the fustian language that overdresses thought, disguises it, hides it utterly. "What can be said at all can be said clearly" (10). The relation between thought and language is present, but its nature is unknown, and language is arbitrary but with an agreed-upon arbitrariness; the user of language who sincerely (12) wishes to communicate will put as few linguistic obstacles as possible between what he thinks is the thought and its expression. Some day, there may be a naked human language, in which thought and language are one; the
FIG. 4. The emperor's new clothes (Hans Christian Andersen).
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bare thought will then be communicated pristine and intact. Then also, like the subjects of the naked Emperor, but for better reasons, we may as Andersen puts it-"praise the stuff we do not see": the transparent stuff, the transparent dress (1) through which we see the thought entire (Fig. 4). REFERENCES
1. JOHNSON, SAMUEL: Abraham Cowley In The Lives of the English Poets (1779-1781). Everyman's Library #770, London, J. M. Dent & Sons, Ltd., Volume 1, pp. 39-40. 2. DARWIN, CHARLES: The Descent of Man and Selection in Relation to Sex (1871). The Modern Library, New York, N.Y., Random House, n.d., p. 463. 3. ALBRIGHT, W. F., AND LAMBDIN, T. O.: The evidence of language. In The Cambridge Ancient History, Third Edition, Volume I, Part 1, 1970, p. 122. 4. JAYNES, J.: The Origin of Consciousness in the Breakdown of the Bicameral Mind. Boston, Mass., Houghton Mufflin Company, 1976, p. 129. 5. RICHARDS, D. W.: Medical priesthoods, past and present. Trans. Assoc. Am. Phys. 75: 1, 1962. 6. CHRISTY, N. P.: English is our second language. N. Engl. J. Med. 300: 979, 1979. Letters to the Editor: "MEDSPEAK". Ibid. 301: 506, 1979. 7. CHRISTY, N. P.: Silence always sounds well. Am. J. Med. 67: 550, 1979. 8. CUSHING, H.: The functions of the pituitary body. Am. J. Med. Sci. 139: 473, 1910. 9. PopovIc, W. J., BROWN, J. E., AND ADAMSON, J. W.: Modulation of in vitro erythropoiesis. J. Clin. Invest. 64: 56, 1979. 10. WITTGENSTEIN, LUDWIG: Tractatus Logico-Philosophicus (1921, 1922). London, Routledge & Kegan Paul, Ltd., 1961 (1974-1977). 11. CHOMSKY, NOAM: Language and the Mind I. Columbia Univ. Forum. 11: 5, 1968. 12. ORWELL, GEORGE: Politics and the English Language. In The Orwell Reader: Fiction, Essays, and Reportage by George Orwell. New York, N.Y., Harcourt Brace Jovanovich, Inc., 1956, p. 355. 13. BEHRMAN, S. N.: Portrait of Max: an Intimate Memoir of Sir Max Beerbohm. New York, N.Y., Random House, 1960, pp. 118-119. 14. ROTH, R. B.: Medicine's ethical responsibilities. JAMA 215: 1956, 1971.
DISCUSSION DR. MOHLER (Charlottesville): I certainly enjoyed your paper. I share your dismay about sloppy communications that occur in many areas both verbally and written as you've so well outlined. However, I think it is interesting that your paper followed such a splendid example of how to communicate properly in the wonderful way Dr. Nathans presented his paper. It's nice that we have had an example of how to do it right contrasting with the many examples of how it's done wrongly. DR. CHRISTY (Brooklyn): Thank you Dr. Mohler. I was noticing that. As you know it's a little hard to concentrate on someone's paper when you're the next person to speak, but I was able to absorb maybe 3 or 4% of what Dr. Nathans said. But I particularly noticed how he did it. The secret is plain-he used plain language.
"Language is the dress of thought," wrote Samuel Johnson (Figure 1) in the Lives of the Poets when assessing the diction of Abraham Cowley. The core of Johnson's idea here is typically 18th century-language is decoration: "... as the noblest mien ... would be degraded by (the) garb ... of rustics ... ., so the most splended ideas (will) drop their magnificence, if they are conveyed by words used commonly upon low and trivial occasions" (1). This is part of Johnson's view; the rest of it, less typically 18th century, we will see at the end of this essay, whose burden is: language is not the dress, but the costume, the disguise of thought, whereas language and thought should-ideally-be inseparable. These assertions lead to the question: what is the origin of language? Love, Charles Darwin believed. Love and music. In The Descent of Man, he surmises: "Language owes its origin to the imitation ... of various natural sounds ... primeval man probably first used his voice in producing true musical cadences, that is in singing ... this power would have been especially exerted during the courtship of the sexes,-would have expressed ... love, jealousy, triumph .. ." (2). Whatever was the origin, some kind of spoken language has existed for 100,000 years in Western Europe, and the oldest written language dates from about 4000 B.C. in Sumer (3). "In the beginning was the Word" (John i:1). Not likely. In the beginning, more likely, was the song or the grunt or the yell. When words became the coin of language, linguists agree that names came first; psychologists infer that things led to names, names led to new things, later, to ideas (4). In most historical periods, medicine and medical language have not been notably accessible or clear. Hermetic obscurity is more usual (5), despite what Aristotle laid down in the Rhetoric: "Language which does not convey a clear meaning fails to perform the very function of language" (6). For the sake of science, clarity is required to convey the names of things, processes, concepts. In aid of humanism, clear communication From the Brooklyn Veterans Administration Medical Center and the Department of Medicine, Downstate Medical Center, State University of New York, Brooklyn, New York. The work reported here was partly done during a sabbatical leave from Columbia University at the National Humanities Center, Research Triangle Park, North Carolina 27709, January-June, 1979. Requests for reprints should be addressed to Nicholas P. Christy, M.D., Chief of Staff, Brooklyn Veterans Administration Medical Center, 800 Poly Place, Brooklyn, New York, 11209.
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FIG. 1. Samuel Johnson (1709-1784). This portrait is by Sir Joshua Reynolds and was done at about the time (1782-1784) Johnson wrote the Lives of the Poets (1779-1781).
with patients is a mandatory "function of language." Yet clarity is a rarity (6, 7). Let us see what are the aims and functions of our famously obscure medical language here and now. We may learn to what extent medical language is the dress of medical thought. In a recent report on spoken medical English-the language of rounds, MEDSPEAK-I suggested that the communication accomplished thereby is limited and offered four reasons for MEDSPEAK's obscurity: a need to appear learned-big words when small ones will do; a need to be brief and condensed through acrostic abbreviations*-forms of short* Some abbreviations are hard to decode: NPBAH for "no psittacine birds at home," ADL for "activities of daily living," SMO for "laboratory slips made out." Some are ambiguous: HNP for "herniated nucleus pulposus" or "human neurophysin," LAP for the
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hand, literally, SHORTMOUTH; the need to hide, to avoid making a commitment or decision by the use of vague, ambiguous, and sometimes mendacious qualifiers like "essentially"t; and the need for hangman's humor to allay feelings of distress on the part of the doctor confronted by critically ill patients (6). A fifth need is to be perceived as a member of the club, of the cult, of the priesthood (5). The common result of these five needs is a jargon which puts distance between the speaker on one side, and, on the other, the patient, the disease, and any other listener. In turn, the effect of this distance is dimness, obscurity, some of it unconscious, some conscious and deliberate. The topic is not elucidated, but clothed-hidden in words (1, 6). The bad state of written medical English has also become a popular whipping boy. Besides the willful obfuscation that Crichton has detected, Ingelfinger and others have blamed poor school and college education in reading and writing, failure of doctor-authors to expose themselves to good English style by reading decent literature, authorship "by committee," and the overgrowth of jargon brought on by a fast-growing technology (7). Elsewhere, I have suggested that the causes lie deeper: indistinct thought, a defect not peculiar to doctors; and the pressure to publish in order to advance one's career. These two afflictions also lend obscurity
(7). "Most men think indistinctly and therefore cannot (write) with exactness," said Johnson (1755), recognizing the close relationship between thought and expression (Fig. 1). Indistinct thought has many causes. There is double-talk, often found in patients' charts: "Not suicidal but may harm self if left unattended," that is, "Yes, but no." There is stating the obvious, found everywhere; the prevailing style must influence medical writing. Ten years ago, the AEC comments on radioactivity in the drinking water of a nuclear plant, found to be due to a hose connecting the drinking water supply to a tank 3f radioactive waste: "The coupling of a contaminated system with a potable water system is considered poor practice ...". In 1979, the Chairman of the Federal Reserve Board top of the thighs when you sit down or "leukocyte alkaline phosphatase." Some serve more than one purpose; this one is impenetrable and inappropriately breezy at the same time: "stool for BOP" means "stool for blood, ova and parasites." t "Essentially" has a peculiar property: it can drain the meaning out of any sentence (6). Example: "The patient was essentially afebrile before admission." The range of interpretations is wide. "The patient had no fever." "The patient had a little fever but I don't know how much." "The patient felt feverish but didn't take her temperature." "The patient had a low grade fever for 7-10 days before she came in" or "She had a high fever but for only 1-2 days." "Her temperature was not much above 101'F. for less than two weeks before admission." And so on. This illustrates Bloomfield's Second Law of Linguistics: "if a sentence has many meanings it has no meaning."
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remarks on inflation: "If we do not control inflation, I do not think our economic system will be able to work efficiently...". This kind of writing in the public press cannot help but influence medical prose. Instructions for the emergency room treatment of rape contain this first sentence: "In general, rape is a traumatic experience for women." Published scientific articles tell us that cigar smoke is as irritating to the bronchi as cigarette smoke (7). There is adherence to Thurber's Rule: "Don't get it right, just get it written" (7). Leaving out as unfair game the chess or bridge columns of any newspaper, here is a commentary about the string quartets of Bela Bartok from a 1949 program note: "Subtle shifts of sonorous balance serve to delineate phrase structure in a texture where cadential articulation, no matter how tangentially and sparingly used, can easily create sonorous inconsistency.... Unique timbral characteristics serve to endow an ambiguous harmonic aggregate with an individuality which makes it possible for it to function referentially in the role of a 'tonic sonority'." That is Milton Babbitt, composer and a Professor of Music at Princeton. Here is a comparable specimen of Harvey Cushing (1910), by some deemed a masterly medical writer: "The persistence of the characteristics of infantilism in a number of our puppies subjected to a partial hypophysectomy, and the occasional evidence of secondary atrophy of the sexual organs, together with the appearance of adiposity in several of the adult animals, suggests that the cases in which an hypophyseal tumor has been found in common with symptoms of adiposity and either a persistence of infantilism or a secondary sexual degeneration, point toward the lowering of hypophyseal activity as the explanation of the clinical syndrome" (8). Wrong science. Too many words. Clumsy sentence structure. Bad grammar. Repetitious. Productive of obscurity. As for the pressure to publish, everyone knows it exists. Grant support is dwindling, but the number of papers submitted to journals continues to rise; new journals keep appearing. The papers are being written by somebody-by "committees," hastily, for bad motives, by "word processors"-verbal Cuisinarts. The results? More shoddy prose, more obscurity. One usage that makes prose shoddy and obscure is ritual addiction to the passive voice. A survey of the matter is reported here. Three journals were sampled: the July, 1979 issue of the Journal of Clinical Investigation, the Journal of Clinical Endocrinology and Metabolism, and the American Journal of Medicine. Occurrence of the official passive in the first sentence of the "Methods and Materials" section of every paper was counted. A few desultorily-not-randomly-chosen articles from 50 years ago, were, in an effort to evaluate for comparison the frequency of the passive in scientific prose of one to two generations back, read. Nowand a half century ago-the overall prevalence of the passive voice in
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starting "Methods" was found to be 90.42%. The passive tended not to be used in a) case reports, and b) papers that were written by foreign scientists. Further, it was observed that the passive construction fostered the interposition of many modifying words and phrases between subject and verb. Word-clumps or number-clumps containing 10 to 30 items were often identified. In one sentence, 66 words were contained in the clump. Up to 13 identically constructed passive sentences in a row were common, giving out a rhythmic if halting syncopated beat, like a tom-tom, with the numbing effect of a tom-tom. Various methods were encountered which had been used-or employed-to break the monotony: one method was occasionally to substitute "were employed" for "were used", as in: "Four random-bred dogs were employed in the study .. ." (9). Nothing is said about how the dogs came to be employed, what were the terms of employment (9). In summary, the passive is inactive, leaden, impersonal, general, wordy, hard to follow-the reader has usually forgotten the subject by the time he (at last) reaches the verb. The passive is monotonous and obscure. To return to the original question: is language the dress of thought? No. As we have seen, it is often the cover of thought in medical as in other kinds of prose. Johnson, criticizing Cowley's diction understood this: "Truth indeed is always truth and reason is always reason; they have an intrinsic and unalterable value, and constitute that intellectual gold which defies destruction: but gold may be so concealed in baser matter that only a chemist can recover it; sense may be so hidden ... that none but philosophers can distinguish it; and both may be so buried in impurities as not to pay the cost of their extraction" (1). Before the work of modern philosophers and linguists, it would have been enough to dispose of the creative and stylistic problems of obscurity by sticking to the maxims of rhetoricians through the ages, from Aristotle to E. B. White: "A good style is first of all clear"; "Express yourself in a plain, easy manner"; "No word or phrase should be ambiguous"; "Use definite, specific, concrete language ... Omit needless words ... Be clear ... Clarity, clarity, clarity." The studies of the philosopher, Ludwig Wittgenstein (Fig. 2), Noam Chomsky, the professor of linguistics, and many others demand that we do more. Start with the premise that the relation of mind to language is not known. The relation of thought to language is unknown (10, 11). "Man (has) the ability to construct languages capable of expressing every sense, without having any idea how each word has meaning or what its meaning is" (10), writes Wittgenstein. Says Chomsky: "The normal use of language" is a creative act, "is innovative, in fact, infinite in its variety" (11). Thought may be verbal or wordless. Yet, we intuitively sense that thought and language are connected-tightly and intricately. Wittgen-
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FIG. 2. Ludwig Josef Johann Wittgenstein (1889-1951), Vienna-born logician who taught philosophy at Cambridge from 1929 until his death. He influenced Alfred North Whitehead and Bertrand Russell; the one book he published during his lifetime (10) abetted the development of logical positivism. Wittgenstein's pertinence to this paper is based on the importance of his work to modemn linguistic analysis and semantics. For Wittgenstein, philosophy is a clarification of the logical process through a critique of language. (See also his posthumously published Philosophical Investigations, English translation, 1953; New York, N.Y., the Macmillan Company, Inc., 1958).
stein again: "Everyday language is a part of the human organism and is no less complicated than it" (10). Still, as he says elsewhere, "Everything that can be thought at all can be thought clearly. Everything that can be put into words can be put clearly" (10). But, getting back to our question about the "dress of thought" (1), Wittgenstein states: "Language disguises thought. So much so, that from the outward form of the clothing [the "dress of thought" (1)] it is impossible to infer the thought beneath it,
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because the outward form of the clothing is not designed to reveal the form of the body, but for entirely different purposes" (10). He does not say what purposes, but from looking at medical language, we have seen some of the purposes, overt and hidden: mostly to do with disguise, concealment, evasion, escape (6, 7). George Orwell (Fig. 3), in his essay, "Politics and the English Language" (1946) characterizes the inflated style-like that of medical writing-as a "kind of euphemism" (12). Again, concealment, evasion and escape. In urging plain English "as an instrument for expressing and not for concealing or preventing thought," Orwell perceives that "if thought corrupts language, language can also corrupt thought," not only in the listener or reader-through tradition and imitation-but in the speaker or writer himself. Using inflated or flat, conventional language just because it is the "going" idiom, softens and blunts the thinking process (7): "unless you make a conscious effort to prevent it, the existing dialect [e.g., the passive voice!] will come rushing in and do the job for you, at the expense of blurring or even changing your meaning" (12).
FIG. 3. George Orwell (Eric Arthur Blair, 1903-1950) at about the age of forty.
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Is all the complaint about obscure language worth the bother? Orwell and many others have believed so. "The great enemy of clear language is insincerity" (12), he said, speaking of the influence obfuscatory language has on political behavior. Max Beerbohm (1953) went further-what he thought also applies to science: "Already one discerns a debasement of English; and other debasements will follow that. With the blunting of precision in language ... comes muddiness in political policy, in morality, and in conduct" (13). The relation of language to morality and conduct becomes plain when a Speaker of the AMA's House of Delegates casuistically equates medical ethics, i.e., medically ethical behavior with fee-forservice practice (14). Figure 4 shows Hans Christian Andersen's emperor's new clothes, that is, no clothes. The Emperor's subjects admired his absent dress because they were afraid to appear "out of it" or foolish. For the same reason, we now tolerate, imitate, make traditional the fustian language that overdresses thought, disguises it, hides it utterly. "What can be said at all can be said clearly" (10). The relation between thought and language is present, but its nature is unknown, and language is arbitrary but with an agreed-upon arbitrariness; the user of language who sincerely (12) wishes to communicate will put as few linguistic obstacles as possible between what he thinks is the thought and its expression. Some day, there may be a naked human language, in which thought and language are one; the
FIG. 4. The emperor's new clothes (Hans Christian Andersen).
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bare thought will then be communicated pristine and intact. Then also, like the subjects of the naked Emperor, but for better reasons, we may as Andersen puts it-"praise the stuff we do not see": the transparent stuff, the transparent dress (1) through which we see the thought entire (Fig. 4). REFERENCES
1. JOHNSON, SAMUEL: Abraham Cowley In The Lives of the English Poets (1779-1781). Everyman's Library #770, London, J. M. Dent & Sons, Ltd., Volume 1, pp. 39-40. 2. DARWIN, CHARLES: The Descent of Man and Selection in Relation to Sex (1871). The Modern Library, New York, N.Y., Random House, n.d., p. 463. 3. ALBRIGHT, W. F., AND LAMBDIN, T. O.: The evidence of language. In The Cambridge Ancient History, Third Edition, Volume I, Part 1, 1970, p. 122. 4. JAYNES, J.: The Origin of Consciousness in the Breakdown of the Bicameral Mind. Boston, Mass., Houghton Mufflin Company, 1976, p. 129. 5. RICHARDS, D. W.: Medical priesthoods, past and present. Trans. Assoc. Am. Phys. 75: 1, 1962. 6. CHRISTY, N. P.: English is our second language. N. Engl. J. Med. 300: 979, 1979. Letters to the Editor: "MEDSPEAK". Ibid. 301: 506, 1979. 7. CHRISTY, N. P.: Silence always sounds well. Am. J. Med. 67: 550, 1979. 8. CUSHING, H.: The functions of the pituitary body. Am. J. Med. Sci. 139: 473, 1910. 9. PopovIc, W. J., BROWN, J. E., AND ADAMSON, J. W.: Modulation of in vitro erythropoiesis. J. Clin. Invest. 64: 56, 1979. 10. WITTGENSTEIN, LUDWIG: Tractatus Logico-Philosophicus (1921, 1922). London, Routledge & Kegan Paul, Ltd., 1961 (1974-1977). 11. CHOMSKY, NOAM: Language and the Mind I. Columbia Univ. Forum. 11: 5, 1968. 12. ORWELL, GEORGE: Politics and the English Language. In The Orwell Reader: Fiction, Essays, and Reportage by George Orwell. New York, N.Y., Harcourt Brace Jovanovich, Inc., 1956, p. 355. 13. BEHRMAN, S. N.: Portrait of Max: an Intimate Memoir of Sir Max Beerbohm. New York, N.Y., Random House, 1960, pp. 118-119. 14. ROTH, R. B.: Medicine's ethical responsibilities. JAMA 215: 1956, 1971.
DISCUSSION DR. MOHLER (Charlottesville): I certainly enjoyed your paper. I share your dismay about sloppy communications that occur in many areas both verbally and written as you've so well outlined. However, I think it is interesting that your paper followed such a splendid example of how to communicate properly in the wonderful way Dr. Nathans presented his paper. It's nice that we have had an example of how to do it right contrasting with the many examples of how it's done wrongly. DR. CHRISTY (Brooklyn): Thank you Dr. Mohler. I was noticing that. As you know it's a little hard to concentrate on someone's paper when you're the next person to speak, but I was able to absorb maybe 3 or 4% of what Dr. Nathans said. But I particularly noticed how he did it. The secret is plain-he used plain language.
