The Evolution of Linguistic Meaning in Emergency Medicine

Owen Barfield: Verse and Imagination

In Owen Barfield’s classic work “Poetic Diction: A Study in Meaning”, initially published in 1928, Barfield describes a critical distinction between verse (poetry) and prose. He gives examples of prosaic verse and poetic verse followed by examples of prosaic prose and poetic prose. Leaving a deep dive into his fascinating ideas on poetry aside, I note that Barfield provides the following example for prosaic prose,

“I told the butcher to leave two and a half pounds of best topside.” (1)

He then gives the following example for poetic prose,

“Behold now this vast city, a city of refuge…” (2)

Clearly, by the examples alone, one can obtain an overall aesthetic sense of what Barfield means without any further expostulation. The one is a type of mundane declaratory statement that might be made in conversation on any given day while the other is an imaginative phrase that has poetic hues to it while not representing true verse.

One must only open any scientific textbook or journal to come into contact with reams of prosaic prose freighted with the added indignity of being written in the language of modern science. I have discovered that to read this type of prose, brimming with technical scientific jargon, is a far greater soporific than any pharmaceutical agent currently on the market.

Barfield then goes much further and develops a compelling theory about the history of linguistics in which there is a kind of evolutionary movement of language in which new poets dare to try and invent novel ways of expressing themselves. This novelty is often not recognized for the genius that it is until after the poet’s demise however he or she has changed the style (and therefore the culture of poetry) and moved the imaginative language and syntax of poetry forward. This style then becomes popular before inevitably becoming staid and overused in and of itself requiring the next generation of poets to push the envelope further still.

One of Barfield’s examples is Shelley’s poetic phrase, “My soul is an enchanted boat.” He writes,

…should the feeling and idea which these lines embody ever become sufficiently well-known and widespread, one can easily perceive how in a few hundred, or in a few thousand years, the word ‘boat’, or perhaps the phrase ‘enchanted boat’ might lose its present meaning and call up to the minds of our posterity, not a vessel, but the concept ‘soul’ as enriched by Shelley’s imagination. (3)

In this manner, over long periods of time, Barfield describes the evolutionary change in meaning that language undergoes. It seems to me that a similar thing can occur in multiple other realms of language, everything from medicine to law to simply our own cultural vernacular, and does so now over a far more compressed timeline. The Internet revolution and the era of high-speed communication and travel allows our language to move as fast as we do and as such the organic speed of the evolutionary change of language meaning is now orders of magnitude faster than it was in earlier times.

Consider the word epic. In the 16^th century it evolved from the French epique, from the Latin epicus and the Greek epikos, from epos meaning “a word; a tale, story; promise, prophecy, proverb; poetry in heroic verse.” It is thought to come from the Proto-Indo-European root ‘wekw”-to speak. (4) From a verb to a noun it moved to become an adjective in the vulgar vernacular, so well-known it is now utilized as a ski pass with the word representing something incredible or an activity that overcomes overwhelming odds. It is also the name of one of the most utilized electronic medical records in the United States. As such, in the present day, to be on Epic is to be using one of the more common electronic medical record systems in use in the country. How many users are aware that “Epic” refers to the Proto-Indo-European root ‘wekw’ or that utilizing the program, applying staid and unimaginative medicolegal language, a form of Barfield’s prosaic prose, in a patient’s chart, is the precise opposite of the meaning of the word. It is hard to imagine anything less epic than medical documentation.

And yet the terrible shame of it all is that each and every patient is an epic tale (in the modern adjectival sense of the word epic) told within the context of that specific patient’s life, and should be treated as such. However, that story, no matter how truly epic it might be, is converted into a language of billing and coding that distills the beauty of that particular patient into a miserable pastiche of billing codes and modern medicolegal jargon. The glory of the man becomes lost in the horrific ennui of the bureaucracy of medicine, and we chart it as such in a computer program with the ironic, and almost Orwellian, title of Epic.

Language within medicine, as elsewhere, therefore can evolve from a living entity in constant flux into a crystalline and brittle structure that takes on more of a legal and bureaucratic function than a human one. Consider the phrase “currant jelly stools”. This phrase was once used to describe the character of bloody stool in children suffering from a condition called intussusception in which the intestine can transiently slide into an adjacent part of itself, like the way in which a telescope can be compacted within itself. This process, if not definitively managed, can cause significant colicky abdominal pain, nausea and vomiting, and rectal bleeding, classically described as “currant jelly stools”. Though rarely seen, this moniker of pathology is taught to a legion of medical students who have no idea what currant jelly is (a jam made of berries that generally grow in the northern hemisphere). As such, hematochezia came to replace this wonderfully descriptive phrase meaning bloody (hemato) stool (chezia, from the Greek, to defecate). However, over time, hematochezia too has become somewhat superannuated and the acronym BRBPR is now used (bright red blood per rectum). Unfortunately, BRBPR, though the established abbreviation in modern day documentation, may not convey the same connotation as “currant jelly stools”, the original pathognomonic moniker for intussusception, despite the fact that the vast majority of physicians today no longer have any experience with actual currant jelly.

Clearly, the phrase “currant jelly stools” has become crystallized, frozen in time, as a byword for intussusception within medical circles despite the vast majority of practitioners no longer really understanding the source of the metaphor. Meanwhile, the terribly dull acronym BRBPR has become the accepted term for rectal bleeding despite its generic utility and lack of specificity. Yet, currant jelly stools meant something to doctors. In fact, it still does. To hear that phrase is to hear the word intussusception. Much like the word “lethargy” means a very sick infant or the word “rigid” means a surgical abdomen. We still use the old 19^th century descriptors because they signify more than their 21^st century analogues. In other words, these simple phrases mean something to us still, even if we no longer understand the allusion. This fascinating fact speaks both to the power of the metaphor as well as the lack of imagination in our current nomenclature. Where are today’s gin blossoms, the bends, cherry hemangiomas, festinating gaits, quitter’s nails, clubbing, or geographic tongues, just to name a few? In that earlier time, language was a moving target; a beauty in and of itself that contained a kind of hidden, metaphorical depth that conveyed so much information to the astute clinician. Today’s unfortunate acronyms (ARDS, DJD, BKA, CABG, etc.) cannot compete with such poetic prose-even if the billing has become more streamlined.

For medicine is a study of the human being and it is therefore, when done well, a poetic science. It should be, I would contend, imaginative and creative by its very nature-on account of the complex and beautiful subject which it studies. Within the human being there lies a deep and recondite soul, complex and iconoclastic by its very nature. Should the study of such an entity be any less complex than the subject under consideration? Given this, metaphor is one imaginative way in which physicians may begin to both describe and understand their patients. I worry that our current lack of imagination, a general dearth of new descriptors and poignant observations of the human condition in our current age, represents a terrible loss for the modern physician. For with the loss of our imagination, so goes our humanity. We treat men as robots or as automobiles, as mechanical problems for which there is a mechanical remedy, when often it is the touch of a hand or the simple ear that listens that is needed most. I would argue that the physician who has lost the use of metaphor, the art of imagination, is not practicing medicine so much as engaged in a mere technical science.

Language that becomes crystallized and is unable to develop further becomes, like much of our scientific literature, dogmatic and terribly difficult to wade through without a harsh cup of black coffee at hand. Perhaps “currant jelly stools” needs a 21^st century update (I shall leave it to the reader to consider an appropriate metaphorical alternative) however its current replacement, BRBPR, is a generic acronym that may fail to flow for future physicians and become as unfamiliar to the medical student of 2075 as the meaning of AM (ante meridiem) or even AD (anno domini) to today’s. The philosopher Sir Roger Scruton noted a similar problem in the world of philosophy with a hope that philosophers might remember how to write “so as to express the problems of the head in the language of the heart.” (4) To do this well, to write poetic prose, is a dying art, both in philosophy and in medicine, and yet the ability to connect with the reader, both lay and specialist, will undoubtedly be enhanced by writing not just to make a technical point but to do so clearly and with beauty.

To underscore the point further, documenting a medical chart in a way that paints the patient as a living and breathing human being who has a story to tell requires a certain amount of imagination. This narrative skill endows the patient with the humanity that he or she deserves and allows the physician, the author of the chart, to think of the patient in this most critical of ways-within the context of their lives. An example may be of assistance here. Consider the following two hypothetical emergency medicine charts.

Chart 1

An 85 year-old female with a history of coronary artery disease, on blood thinners, presents to the emergency department after being found by her daughter on the ground. She complained of right hip pain after falling in the bathroom. It was unclear if she hit her head. The patient is not sure if she was knocked unconscious. EMS was called and noted a blood sugar of 52 mg/dL. She was given some orange juice and her sugar is 88 mg/dL on arrival. She was afebrile and hemodynamically stable on arrival. She complained primarily of right hip pain and was unable to walk. She was noted to have a right periorbital hematoma. Her right leg is 2 inches shorter than her left and is externally rotated. She has pain with palpation over her right lateral hip. She had an unrevealing exam otherwise but was noted to have a 2+ dorsalis pedis pulse in the right foot with normal sensation. Imaging revealed a right intertrochanteric hip fracture. Her head CT showed a small subdural hematoma at the right parietal region without contrecoup injury and without midline shift or herniation. Warfarin was reversed and the patient received 1 mg of hydromorphone for pain and was admitted to the neuro ICU with orthopedics following along for likely operative management this week. The level 5 caveat is a broken hip and subdural hemorrhage. I spent 40 minutes of critical care time with this patient.

Chart 2

Mrs. Smith is an 85-year-old female with a history of coronary artery disease, on warfarin, diabetes, depression, and suspected early-onset dementia who lives in a separate mother-in-law unit attached to her daughter’s house who was found on the tile floor in her bathroom. She reports feeling profoundly weak after developing diarrhea three days ago that feels very similar to her previous Clostridium difficile infection from 2 years ago. She hasn’t been eating and drinking well today and felt fatigued with a fever as high as 101 degrees Fahrenheit. She reports using the bathroom more than ten times today without hematochezia or melena noted. She threw up twice as well. Her daughter found her moaning on the ground when she didn’t show up for dinner. She contacted EMS who noted a blood sugar of 52 mg/dL. They had difficulty establishing a line but gave her some orange juice with improvement in her blood sugar and sensorium. Her most recent blood sugar on arrival was 88 mg/dL. She arrived with a BP of 85/50 and a heart rate of 115 beats per minute but without a fever. Her exam is notable for an ill-appearing woman with dry lips and a dry tongue. She prefers to lay on the stretcher and answers few questions. Her daughter answers most questions. She has a significant right periorbital hematoma but equal pupils to light without other evidence of globe trauma. She has no pain along her neck and back with palpation. She moves all four extremities however her right leg is 2 inches shorter than her right and externally rotated. She has a 2+ DP pulse and normal sensation in all four extremities. She has exquisite tenderness over the right lateral hip and with any attempt at passive range of motion. She has pale conjunctiva. She has equal and clear lung sounds bilaterally. She is tachycardic with a regular rhythm and without murmurs, rubs, or gallops. Her abdomen is diffusely but mildly tender and her pain does not localize to any one specific area. There is no rigidity, organomegaly, rebound tenderness, or significant guarding appreciated. Given her clinical appearance, we obtained labs and established an IV. She received a liter of crystalloid and was found to have a suspected acute kidney injury with a creatinine of 3.1 and a BUN of 60. Her Na was a little low at 131 and her white count was 16 with a hemoglobin of 9-down from 12 two months ago. Her Hemoccult was positive and we discussed the case with GI who agreed with admission on Protonix and they would follow along. She remains on contact precautions. Her head CT showed a small right parietal subdural hematoma and we will reverse her warfarin for now and discuss the case with neurosurgery. Orthopedics is aware of her right intertronchanteric hip fracture. We will admit to the neuro ICU service on contact precautions for presumed clostridium difficile colitis resulting in weakness, a fall, a subdural hematoma on blood thinners and a right intertrochanteric hip fracture. A stool culture is pending. Her family is aware and considering both her DNR status and potential surgery once she is improved from her other acute medical problems today.

The difference in these two charts regarding the same patient should be fairly obvious. One chart noted her fall, her hip fracture, and her traumatic brain injury. The other chart noted her likely recurrent diarrheal illness, need to be on contact precautions in the ER, acute kidney injury and dehydration, likely GI bleed, and subsequent neurosurgical and GI consultations in conjunction with her hospitalist admission and orthopedic consultation, as well as discussions with family about her Do-Not-Resuscitate Status, an important conversation to have in this critically ill elderly patient.

These are two fictitious charts for the same patient however one tells a much broader, and frankly, more interesting narrative. The latter chart is a story and as such the reader becomes wrapped up in the narrative. One knows what happened with this patient almost as if they were there themselves. It shows that the physician was deeply involved in the patient’s case and discussed it with multiple subspecialists, with the patient, with EMS, and with her family. The next physician reading that chart will have a much easier understanding of what happened because one tells a story whereas the other merely reports facts. One provides a vivid chronicle that anyone with an active imagination might enjoy, even without a medical degree, while the other provides very little but the science described, which even a reader with a medical background would find rather dull. One is more like a snapshot in time and the other hints at dynamic movement-like a narrative in real time. The second chart notes more than just the fall, the hip fracture, and the head injury but all those things plus a reason for falling (diarrheal illness, a possible GI bleed, dehydration, and AKI) that will require multiple other subspecialists and coordination of care, as well as elements of family concerns with the DNR question. One documents the injuries in a patient; the other describes a human being en soi, within oneself. The first reads almost like a list of injuries while the second describes the unfortunate last few hours of a fellow traveler. One is more prosaic prose; the other (slightly more) poetic.

It seems clear to me then that the physician’s imagination is a critical component of the art of medicine, however it is not a skill that is formally taught. Perhaps it is considered to be enjoined with a high GPA and a personal letter that describes its author as a person of high moral rectitude. Indeed, both these things may be true however neither would ensure the art of the moral imagination. To understand and interact with our fellow human beings is not contingent on one’s ability to describe the Krebs Cycle or relative to time reported to be spent at the local homeless shelter in a personal letter (though this might help). I suspect that it is rather some combination of natural inclination and learned ability. One can only hope that a formal education today does not drive out the former while failing to inculcate the latter and that our best future physicians may cling to that which cannot be easily taught while learning the necessary science that must be instilled.

1) Barfield, O. Poetic Diction: A Study in Meaning. Middletown, CT, USA. Wesleyan University Press, 1973. Ch. IX. pg. 146.

2) Ibid., pg. 146.

3) Barfield, O. Poetic Diction: A Study in Meaning. Middletown, CT, USA. Wesleyan University Press, 1973. Ch III. Pg. 66.

4) https://www.etymonline.com/word/epic

5) Scruton, R. Modern Philosophy: An Introduction and Survey. London, UK. Penguin Books Ltd, 1994. pg. IX.