1. JOHN NESSA
A B O U T SIGNS A N D S Y M P T O M S : C A N S E M I O T I C S E X P A N D T H E
VIEW OF CLINICAL MEDICINE?
ABSTRACT. Semiotics, the theory of sign and meaning, may help physicians complement
the project of interpreting signs and symptoms into diagnoses. A sign stands for something.
We communicate indirectly through signs, and make sense of our world by interpreting
signs into meaning. Thus, through association and inference, we transform flowers into love,
Othello into jealousy, and chest pain into heart attack. Medical semiotics is part of general
semiotics, which means the study of life of signs within society. With special reference
to a case story, elements from general semiotics, together with two theoreticians of equal
importance, the Swiss linguist Ferdinand de Saussure and the American logician Charles
Sanders Peirce, are presented. Two different modes of understanding clinical medicine are
contrasted to illustrate tile external link between what we believe or suggest, on the one
hand, and the external reality on the other hand.
KEY WORDS: The theory of signs, symptoms and signs, diagnostic interpretation,
structural linguistics, Ferdinand de Saussure, Charles Sanders Peirce, medical semiotics,
scientific mode of understanding, henneneutic mode of understanding
1. I N T R O D U C T I O N
Even though the expression "signs and s y m p t o m s " tends to c o m e out in a
single breath, as a unit, the two concepts are often discussed seperately in
the medical literature. According to Lester King,1 s y m p t o m s are subjective,
or intersubjective, verbally expressed sensations, presented in the medical
consultation. A sign is more objective. It unravels a disease when perceived
and interpreted by a skilled clinician. A clinical symptom is, unlike a sign,
transient and volatile, without substantial information.
T h e distinction between signs and symptoms is one o f the consequences
o f biomedicine having b e c o m e part o f the natural sciences during the last
century. In the Hippocratic tradition, a symptom had its own status, giving
information for medical observations. A s y m p t o m was three-dimentional,
in the sense o f pointing to the past (anamnesis), present (diagnosis) and
future (prognosis). 2 The Galenic tradition, which was the only authoritative
medicine o f the Middle Ages, embodied theoretical medical knowledge in
texts called Institutes o f Medicine. 3 S e m i o l o g y (from G r e e k s e m a - s i g n )
was one o f the five segments o f these texts.
Theoretical Medicine 17: 363-377, 1996.
(~) 1996 Ktuwer Academic Publishers. Printed in the Netherlands.

2. 364 JOHN NESSA
Sign
Interpretation Reference
(into meaning) (to an object)
Figure 1. Different aspects of the message.
A medical consultation often starts with the patient presenting a symp-
tom, a bodily sensation of some kind. The common assumption is that the
symptom may express bodily or emotional pathology. A healthy person has
no symptom. The problem is, however, that even in patients presenting with
one or more symptoms we often cannot identify any significant pathology;
we have no physical findings, all tests are normal .4 The patient nevertheless
usually wants an explanation for his or her sufferings, which biomedicine
in many cases cannot give. And traditional explanations, such as somati-
zation, hypochondriacal symptoms or functional overlay, are insufficient,
pejorative and theoretically inadequate for both doctor and patient. 5
2. SEMIOTICS
The word "semeion" stems from the Greek noun "sema", which means
"sign, signal, mark, token". The term "semiotics" is understood as the
theory of sign and meaning, and has been given various definitions. I
use the Saussurian term "the study of life of signs within society". 6 The
subject matter of semiotics is messages, any messages whatsoever, and
their relation to interpretation, meaning and reference (Figure 1). Meaning
and reference are not identical terms. The meaning of a message is given
by what the receiver understands by the message, literally how the message
is interpreted. The reference of a message concerns the relation between
the message and the object in the world the message is referring to. The
difference between the terms may be illustrated by a clinical example:
A patient complains of abdominal pain. The surgeon, interpreting it as
appendicitis, decides on an operation. The peroperative finding is a pale
appendix and enlarged nodes. Hence, the meaning of the sign "abdominal

3. SEMIOTICS AND CLINICAL MEDICINE 365
pain" for the surgeon becomes "a suspected appendicitis". But its reference,
namely the source, the object of the pain, is unknown, or perhaps, a viral
infection giving enlarged lymph nodes and abdominal pain.
Semiotics contains theories and models about linguistic signs (words)
as well as gestures and other signals which are perceived and interpreted
as part of the interaction between man and the world around him.
In this article, my aim is to show if and how the theory of semiotics
can be used to expand the view of clinical medicine. Theories of signs
will be used as key concepts for understanding medical symptoms and
their pragmatic and clinical function. Special emphasis will be put on the
Swiss linguist Ferdinand de Saussure and the American logician Charles
Sanders Peirce, two theoreticans of equal importance to the development
of modern semiotics. A clinical vignette will be used as a heuristic device,
to illustrate the relevance of semiotics to clinical medicine.
3. CASE HISTORY
A case history presented by Cecil G. Helman may be well known to many
physicians: A man in his forties consulted his general practitioner during
a busy practice day for two episodes of pain on the left side of his chest. 7
He was afraid that the pain had "something to do with my heart". He
was a busy man, and admitted to his doctor that he had been "under a lot
of stress recently". He was briefly examined by the general practitioner,
who found no physical abnormality, concluding "it's just due to strain, but
we'd better be sure and run a few tests". He was sent to a hospital, told
by a doctor there that he had had a small heart attack, "probably anginal
in origin". The patient asked for a second opinion by a cardiologist, who
found no abnormalities whatsoever, and told the patient that his "tension"
in his daily life was responsible for his "hyperventilation".
4. LANGUAGE AS SEMIOTICS: FERDINAND DE SAUSSURE
Ferdinand de Saussure (1857-1913) was a Swiss professor in linguistics.
His theories, also called structural linguistics and semiology, in addition to
the widely accepted term semiotics, is primarily a theory about language.
Essential in his theory is the term linguistic sign. A sign is, according to
Saussure, a dual entity. 8 It consists of both a noise and an idea, a sound
that signifies (= signifier) and a concept that corresponds to it (= signified).
"Signifier" and "thing signified" are inseparable, as are the two sides of
a coin or the inside and the outside of a circle. To have a sign that not

4. 366 JOHN NESSA
signifies anything is like having a coin with one side only. The meaning
of a sign is a concept to be interpreted according to an idea, not a thing
identified as an object (Figure 1).9 The relation between "signifier" and
"thing signified" is arbitrary and conventional. Therefore the same idea
can be called "stomach" in English and "Magen" in German.~°
Both medical symptoms and medical diagnoses are conceptualizations
of ideas, and hence linguistic signs. And so are the words "strain", "angina"
and "hyperventilation", the three different labelling diagnoses taken from
the case story. These words, as noise or as written signs, are in themselves
without meaning. They get their meaning in relation to an idea, a concept
about diseases. Hence, they convey a message about everyday life (strain),
cardiology (angina) and psychodynamics (hyperventilation), respectively.
The signs also refer to a physical object outside language, to the physical
world which the patient is part of. Maybe we could find later on, by
an angiographic examination, abnormalities (partly or fully) responsible
for his pain. Then we would find that the sign "chest pain" refers to
an identifiable extra-mental physical entity, an object in the world. But
the meaning of the sign, the "thing signified," is, according to Saussure,
independent of this. He regards language as a system independent of the
physical, extra-linguistic reality. 11 Language is not primarily a naming-
process of objects in the world. This does not mean that Saussure denies
the possibility of a connection between language and reality. But according
to his notion of a sign as a pure linguistic entity, he prefers to emphasize
the social and intersubjective character of all discourse. ~2 Language is
"a system of interdependent terms in which the value of each term results
solely from the simultaneous presence of the others". 13Words and concepts
are constituted as signs by their simultaneous differences from other signs.
A sign both tells what a concept is and what it isn't. By saying "strain",
"angina" or any other medical diagnosis, the words act as signs by their
simultaneous differences from other signs: It is "strain" that is implied,
"'not angina".
5. LOGIC AS SEMIOTICS: CHARLES SANDERS PEIRCE
In addition to structural linguistics, semantic theory was developed mainly
by Charles Sanders Peirce (1839-1914). Peirce defined a sign as "something
which stands to somebody for something in some respect or capacity. It
adresses somebody, that is creates in the mind of that person an equvivalent
sign, or perhaps a more developed sign. That sign which it creates I call the
interpretant of the first sign. The sign stands for something, its object".14,15

5. SEMIOTICS AND CLINICAL MEDICINE 367
This definition has three elements: The primary sign, the interpretant
and the object. The interpretant is a more developed sign giving the pri-
mary sign its meaning. According to Umberto Eco, the interpretant can be
conceived as the definition of the sign, and it is something that guarantees
the validity of the sign. 16,17 The object is what both the sign and the inter-
pretant are referring to. This is a three-dimensional definition of a sign,
the triadic relation of sign-object-interpretant is the irreducible character
of any sign that signifies.
This may be highly theoretical and difficult to grasp. But since the
human mind cannot function without signs, let us for a moment simply
replace sign, interpretant and object with the pronouns I, you and it: I speak
to you about something. I am the sign, you are the interpretant, and we
speak together about an object.
To grasp the Peircian way of thinking in a clinical context, we have to
start with the following situation: A doctor (A) is talking to another doctor
(B) about a third matter (C). Let us further suggest that A is a general
practitioner talking to a cardiologist B about what may be the patient's
sufferings, his "real disease" C. As in the case story, by presenting the
episodes as chest pain the doctor is producing a sign which the cardiolo-
gist may interpret as angina pectoris. For the cardiologist, theories about
ischaemic heart disease give the sign its meaning as angina pectoris. A
has produced one sign, B has produced an equivalent; but yet another sign
corresponding to the first one. But what they really are talking about, what
the signs "chest pain" and "angina pectoris" are referring to in the physical
world, may be quite different. Let us again imagine that the patient had an
unrecognized tumor that caused his pain. Then this tumor is the object for
the sign - his pain - and hence its reference.
Peirce's triadic relation corresponds well with the clinical situation
exemplified above (Figure 2). It has also its parallel in the triadic clinical
relation symptom-diagnosis-disease. The patient "is" the symptom, the
doctor interprets it as a diagnosis, and they both refer to an object which is
a disease.
Life is, according to Peirce, a process of continuous signification, semi-
osis. Hence the interpretant of a sign in a sign-object-interpretant relation
becomes a sign in a new triadic relation, and so on (Figure 3). Generally, the
process of interpretation and signification has also to be called the coding
process of the sign. A code is a system, a set of formally structured oppo-
sites and differences, and hence a set of signs. 18 A system of cardiologicat
concepts is a code category, as is a system of psychodynamics.

6. 368 JOHN NESSA
Person A Matter C
/
Person B
The clinical model:
Symptom Disease
/
Diagnosis
The semiotic structure:
Sign Reference
/
Meaning
The Peircian semiotic:
Sign Object
/
Interpretant
Figure 2. Four parallel triadic relations.

7. SEMIOTICS AND CLINICAL MEDICINE 369
Sign 1 Object 1
/
Interpretant 1
Sign 2 Object 2
(= Interpretant i) (= Sign 2 object)
"x/
Interpretant 2
I
and so on, endlessly ....
Figure 3. The process of continuoussignification.
5.1. Symbolic, Indexical and Iconic Signs
Both sign, object and interpretant are complex entities. Peirce states that
philosophy would do well "to provide itself with a vocabulary so out-
landish that loose thinkers shall not be tempted to borrow its words", m
(Maybe he has not succeeded since I am trying to apply his scemata and
vocabulary to a medical setting.) Of special interest in medicine is the rela-
tion between signs of disease and the disease itself, which is considered as
the object of the sign. Between the sign and its object, Peirce differenti-
ates signs into three categories: symbolic signs, indexical signs and iconic
signs. Human language is a paradigmatic example of symbolic signs, as
are the arab numbers 1,2, 3 etc. The connection between signs and objects
is artificial and conventional as one has to know the code and master the
language to interpret the signs. Communicative approaches to psychia-
try and psychosomatics regard symptoms as arbitrary symbolic signs, as

8. 370 JOHNNZSSA
does psychoanalytic theory. 20-23 In everyday medicine, history taking is
primarily a collection of symbolic signs.
The indexical sign is causally related to its object. 24 It has some exis-
tential relation to that object, and shows to its object by being a footprint,
a track of what it m e a n s Y Smoke means fire, knocking on the door means
that somebody is asking for the door to be opened. Bodily gestures, "body
language" have strong indexical attitudes. Indexical medical signs are
explored mainly through the physical examination.
An icon is a sign that has "some character in itself", showing what it is,
like a line drawing, a sketch or a traffic sign. 26 X-rays or other technological
visualizations are medical examples of iconic signs. 27
The distinction between symbolic signs, indexical signs and iconic
signs is arbitrary and not exact. Hence Peirce himself states that it would
be difficult, if not impossible, to find an absolutely pure index, or to
find any sign absolutely devoid of the indexical quality. 28 In the realm
of medical semiotics these difficulties are seen especially regarding the
symbolic and indexical sign pain. Even though the symptom of feeling
- and expressing - pain has the same name for different diseases, it is a
significant clinical difference between a patient, in a relaxed atmosphere,
telling about instances of abdominal pain or headache, respectively, and
a patient showing his pain by rolling around on the floor screaming for
help.
5.2. Saussure and Peirce: Two Different Approaches
Independent of, and unknown to each other, Saussure and Peirce developed
their respective theories of signs. The differences between their approaches
are obvious: Saussure defines the sign as a dual entity, Peirce as a triadic
one. Saussure has a linguistic approach, his theory is about human lan-
guage. Peirce, on the other hand, has a much wider approach. Language is
only a part of his semiotics, but he gives us ideas about the relation between
signs and the physical reality. Saussure has a very profound knowledge and
understanding of human language in general. But he lacks terms and vocab-
ulary for an extensive use of his semiotics on extra-linguistic subjects.
Peirce, on the other hand, has a more technical approach than Saussure.
Both are essential to medical semiotics. King - without himself explicitly
commenting on it - uses a Saussurian concept when analyzing signs and
symptoms29 Marja-Liisa Honkasalo, who teaches medical semiotics in the
Department of Public Health at the University of Helsinki, uses a Peircian
perspective. 3°

9. SEMIOTICS AND CLINICAL MEDICINE 371
6. APPLYING SEMIOTICS TO A CLINICAL CASE
The clinical vignette may illustrate how we as clinicians structure our
thinking, and give meaning to patients' symptoms. None of the applied
diagnoses depend on certain clinical signs. Rather, all physicians have by
their respective interpretations produced different diagnoses. They are cre-
ators of meaning when they conclude that the patient's symptoms means
strain, angina and hyperventilation, respectively. All the diagnoses are, in
the Peircian sense, different interpretions of the sign "chest pain". The
diagnoses may also illustrate the Saussurian sign: because the physicians
are proclaiming that the patient has muscular strain, angina and the hyper-
ventilation syndrome, the patient, in a way, "has" these diseases. The
diagnoses depend heavily on the doctors' interpretations, since diagnos-
ing is naming, structuring of reality. None of the diagnoses are in essence
facts belonging to the external world, but linguistic and cognitive struc-
turings of reality, ways of interpreting experiences and perceptions. Even
though the patient might have ischaemic heart disease, angina as a diagno-
sis explaining a specific episode of chest pain is in fact an interpretation,
a "reflexive construct", a way of grouping experience into objects in the
world. 31 According to Thomas Kuhn, an essential part of scientific research
is regrouping of objects in the world. 32,33 It is to produce significant differ-
ences creating knowledge. Both diagnoses can be regarded as regroupings
of knowledge different from other possible explanations. The presented
case displays very clearly that more than one theoretical construction can
be utilized to explain a given collection of data. 34
7. MEDICAL SEMIOTICS
A medical student didn't pass an examination because on studying a blood
smear under the microscope he stated "I see only dots". What he should
have seen, after having studied haematology, was lymphocytes. It was
not incorrect to see dots. It was, however, an insufficient and inadequate
medical interpretation of the smear.
This example may illustrate the Kantian philosophical statement that
we have no direct access to the world. In everyday life as well as in
medical settings, the only way to grasp reality is to perceive signs and
interpret them through inferences. To see something is always to see it a s
something. Using the case story about the man with chest pain, I will now
try to characterize the process of interpreting signs to understand what we
do when we attend to patients.

10. 372 JOHN NESSA
First, I have to repeat that the diagnoses are not primarily facts belonging
to the real world, but interpretations, ways of structuring reality, hypotheses
and conjectures. This of course does not mean that a "real world" does not
exist, or that we cannot speak about such a world. On the contrary, scientific
medicine is based on an assumption about objectivism, truth, reality and
methodology. There is supposed to be a physical reality behind the chest
pain. And this reality is one and the same even though three different
doctors make three different interpretations. This reality is what Peirce calls
the object of the sign. The problem arises: What is the relationship between
the interpretation of the sign, namely the diagnoses, on the one hand, and
reality on the other hand. This is a problem about modes of understanding
in clinical medicine, a notion which is discussed in a clarifying way by
Allan B. Chinen. 35
7.1. Modes of Understanding
According to Chinen, modes of understanding provide the external link
between thought or belief, on the hand, and reality, on the other. 36 We
can define a mode of understanding in the Peircian semiotic term as the
relationship between a sign, such as a proposition ("chest pain") and the
object the sign refers to, e.g. a situation in the real world. Different modes
of understanding involve different kinds of relationships between the sign
and the referent.
7.2. The Scientific Mode of Understanding
The diagnosis angina pectoris represents a scientific mode of understand-
ing. Angina represents ischaemic heart disease, which is claimed to exist as
an empirical, biological fact. The diagnosis is correct or incorrect, depend-
ing on objective findings following a specific methodology to unravel
coronary heart disease.
The scientific attitude constitutes a distinctive mode of understanding.
In this mode subjective beliefs are distinguished from objective situations,
and it is acknowledged that our beliefs can be wrong or incomplete. 37 To
apply a scientific attitude to the case story is to narrow the sign "chest
pain" down to a question about somatic disease only.
7.3. The Hermeneutic Mode of Understanding
However, as physicians, we use other modes besides the scientific one.
The reason is obvious. Human medicine is, unlike veterinarian medicine,
an enterprise where the object is a an individual, a person, not a biological
being only. To understand a man is to understand a being who under-
stands himself. This acknowledgement requires empathic communication

11. SEMIOTICS AND CLINICAL MEDICINE 373
and interaction with the patient. 38 In the case of clinical medicine, these
exchanges involve deeply personal values and meanings, on the part of
patient and physician alike, whether explicitly discussed or not. The study
of meaning in philosophy is called hermeneutics, a term which covers
semiotics as well. The hermeneutic mode includes both personal and inter-
personal dimensions of meaning - the patient's or physician's own values
and viewpoints on the one hand, and their communication with each other
on the other hand. 39
The main difference between the scientific mode of understanding and
the hermeneutic one is, according to Chinen, that in the hermeneutic mode,
subjective experience and interpretations take precedence over objective
facts. That is, the normal reference from subjective belief to objective sit-
uation is temporarily suspended, and attention is focused on the subjective
side. 4°
This does not mean that no reference, no object exist. Above, I discussed
the diagnosis of strain. Strain is just as real as ischaemic heart disease. But
it is a reality on another level, not belonging to the physical, but the intra-
(or inter-) personal mental world.
The three diagnoses all represent different modes of understanding,
different ways of interpreting the same sign and relating it to different
realities. Different combinations of interpretations are possible, the patient
may or may not feel strain, may or may not have angina, may or may not
have hyperventilated. In what particular interpretation to rely on in a clini-
cal situation depends on many factors. The everyday clinical interpretation
depends on previous experience and on bias of the individual physician as
well as on risk factors, the situation and its context, and is due to the art of
medicine rather than science.
7.4. Semiotics: Science or hermeneutics?
The aim of medical semiotics is to narrow the gap of uncertainity and give
a fuller understanding of the process of clinical work. 41 All symptoms
and all clinical signs need an interpretation. Sometimes, this interpretation
is due to routine practice. A bleeding wound in the forehead needs no
hermeneutic interpretation for medical care. For a patient with a heart
arrest, it is meaningless to ask what he could have meant by that. In terms
of semiotics, sign and meaning coincide, and a scientific- biological way of
understanding takes precedence over a hermeneutic o n e . 42 But this is not
the rule. Rather, in clinical medicine, very often we cannot be quite sure.
We seldom are immediately certain about a diagnostic problem. In such
cases, we have to reason and decide what information is most relevant to
solve a pragmatic clinical problem.

12. 374 JOHN NESSA
8. DISCUSSION
All clinicians are familiar with history taking, listening to the patient's
symptoms which lead us to physical findings and give us a diagnosis. The
ensuing treatment follows routine standards. A number of physical symp-
toms, however, such as abdominal pain, dyspepsia, headache, backache,
joint pain, chest pain, palpitations and fatigue lack a satisfactory analytical
t e r m . 43 It makes no sense to say that these symptoms are not real. They
are just as real as the patient is. To accept utterances at face value is a pre-
requisite for all human communication. So also in medicine. But of course
it make sense to ask what kind of reality the symptoms reflect. The clinical
challenge emerges when the symptom does not correlate with an identi-
fiable pathology, probably because such a pathology often does not exist.
The symptom is not always what Galenos learned, "the shadow behind the
disease". 44,45 The signs delivered by the patient may be regarded as a text,
a story embedded in a body language. The patient is both telling and show-
ing what is his or her sufferings and agenda. Hence, we perceive the sum
total of the patient's signs by both listening to, seeing, feeling, touching
and tasting the complex message from the patient. Symptoms experienced
and expressed can also be regarded as cultural and communicative acts,
attempts to translate subjective sensations into signs that are understood in
the medical consultation. 46,47
The symptom is a verbal or physical sign experienced by the patient, the
symptom presentation represents a "handing-over" of experience. Being a
human being requires to organize life linguistically as well as expressing
oneself to other human beings in a symbolic way. 48 Man is, according to
Ernst Cassirer, the symbolic animal. 49 This is also what Peirce is express-
ing, insisting on the idea that man is the sum total of the words or signs
that man use. 5°
The patient with chest pain got three different diagnoses. None of
the diagnoses are in themselves objective physical findings, rather they
are interpretations of symptoms and signs. The three different physicians
recognize three different things, just as two observers may see two dif-
ferent animals in the well-known duck-and-rabbit example, often used in
psychology textbooks (Figure 4). To interpret a symptom expressed as a
diagnosis necessitates a cognitive structure, a code-set. The general prac-
titioner chooses an everyday code, the hospital doctor a somatic code and
the cardiologist a psychodynamic one. All the codes are meaningful, but
none of them are expressing the whole truth. Understood as a semiotic sign
production, the shift from the symptomatic attacks to the three different
diagnoses is a shift from one sign to three different signs. The doctors are

13. SEMIOTICS AND CLINICAL MEDICINE 375
I IIIII .
%__
C__ II I
Figure 4. The duck-and-rabbitfigure(From Jastrow: Fact and Fable in Psychology).
thus creators of meaning, and the diagnoses get their value as signs of
meaning in the interaction between doctor and patient. 51
To interpret medical symptoms is normally to interpret verbal expres-
sions. 52,53 Hence this procedure might be comprehended by means of
linguistics. 54 Semiotic interpretations put scientific medicine in a wider
context. Semiotics analyzes and interprets what happens with man as a
social being, interacting with other persons in an intersubjective way.
The interpreting process is endless. The diagnosing is, as a linguistic and
pragmatic activity, part of this process. This process is also an integral part
of being a doctor, regardless of the physical findings we make.
ACKNOWLEDGEMENTS
I am grateful to Kirsti Malterud of the University of Bergen for her combi-
nation of radical critisism and encouragement during many earlier drafts of
this paper, to Anders Seim, 1464 Fagerstrand, and to Rolf Wynn, Univer-
sity of Troms0, who both have corrected and commented on my different
versions.
NOTES
I King L. Medical Thinking. A ttistorical Preface. New Jersey: Princetown University
Press, 1982.
2 HonkasaloM. Medicalsymptoms:A challengefor semiotic research. Semiotica, t991;
87:251-268.
3 King: 77.

14. 376 JOHN NESSA
4 Mayou R. Medically unexplained physical symptoms. Do not overinvestigate. Brit Med
J, 1991; 302: 534-535.
5 Ibid: 534.
6 Innis RE. Semiotics. An Introductory Reader. London: Hutchinson University Library,
1988.
7 Helman CG. Disease and pseudo-disease: A case history of pseudo-angina. In: Hahn RA,
Gaines AD, eds. Physicians of Western medicine. Anthropological Approaches to Theory
and Practice. Dordrecht: D. Reidel Publishing Company, 1985.
8 Saussure E Course in General Linguistics. New York: McGraw-Hill paperbacks, 1966.
9 Psaty BM, Inui TS. The place of human values in the language of science: Kuhn, Saussure
and structuralism. Theor Med, 1991; 12: 345-358.
10 Saussure: 67.
11 Psaty: 350.
12 Ibid: 351.
13 Saussure: 114.
14 SheriffJK. The Fate of Meaning. Charles Peirce, Structuralism and Literature. Prince-
ton, New Jersey: Princeton University Press, 1989.
15 Hartshorne C, Weiss R The collected papers of Charles Sanders Peirce, volumes I & II.
Cambridge: The Belknap Press of Harvard University Press, 1960.
16 Eco U. A Theory of Semiotics. Bloomington: Indiana University Press, 1976.
iv Honkasolo: 253.
18 Sebeok T. Zoosemiotic components of human communication. In: Innis R, ed. Semiotics.
An Introductory Reader. London: Hutchinson University Library, 1988.
19 Sheriff: 55.
2o Shands HC. Semiotic Approaches to Psychiatry. The Hague: Mouton, 1970.
21 Szasz T. The Myth of Mental Illness. London and Toronto: Granada, 1972.
22 yon Uexktill T. Semiotics and medicine. Semiotica, 1982; 38: 205-215.
23 Honkasolo: 256.
24 Ibid: 255.
25 Sheriff: 67.
26 Ibid: 67.
27 Innis: 11.
28 Ibid: 13.
29 King: 74.
30 Honkasolo: 252.
31 M~seide P. Interactional Aspects of Patient Care. Thesis. Bergen: Department of Soci-
ology, University of Bergen, 1987.
32 Psaty: 353.
33 Kuhn T. The Structure of Scientific Revolutions. Chicago: University of Chicago Press,
1970.
34 Psaty: 346.
35 Chinen AB. Modes of understanding and mindfulness in clinical medicine. Theor Med
1988; 9: 45-71.
36 Ibid: 47.
37 Ibid: 48.
38 Ibid: 52.
39 Ibid: 50.
4o Ibid: 51.

15. SEMIOTICS AND CLINICALMEDICINE 377
41 Bumum JE Medical diagnosis through semiotics. Giving meaning to the sign. Ann
InternalMed, 1993; 119: 934-923.
42 Ibid: 941.
43 Mayou: 534.
44 King: 78.
45 Whitbeck C. What is diagnosis? Some critical reflections. Metamedicine, 1981; 2:319-
329.
46 Daniel S. The patient as text: A model of clinical hermeneutics. Theor Med, 1986; 7:
195-210.
47 Psaty BM. Literature and medicine as a critical discourse. Literature and Medicine,
1987; 6: 13-34.
48 Budd MA, Zimmermann ME. The potentiating clinician: Combining scientific and
linguistic competence. Advances, 1986; 3: 40-55.
49 Cassirer E. An Essay on Man. London: Yale University Press, 1964.
50 Innis: 2.
51 Baer E. The medical symptom. In: Deely J, Williams B, Kruse FE, eds. Frontiers in
Semiotics. Bloomington: Indiana University Press 1986: 140-152.
52 Malterud K. Allmennpraktikerens mote med kvinnelige pasienter (The encounter between
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Department o f Public Health JOHN NESSA
& Primary Health Care
Division f o r General Practice
University o f Bergen
Ulriksdal 8c, N-5009 Bergen
Norway