Difference between revisions of "The logic of medical language - de"

Unlike the formal languages of mathematics, logic and computer programming (which are artificial systems of signs with precise rules of syntax and semantics), most scientific languages develop as a simple expansion of natural language with a mix of some technical terms. The medical language belongs to this intermediate category. It emerges from natural and everyday language by adding terms such as 'neuropathic pain', 'Temporomandibular Disorders', 'demyelination', 'allodynia', etc. This is why it has no specific and semantic syntax beyond the one it takes from natural language. For example, let's consider the term 'disease' referring to the patient Mary Poppins: this is a term that indicates the fundamental concept of medicine, disease at the base of nosology and clinical research and practice. It is expected to be a well-defined technical term, yet it is still an indefinite term.

Nobody knows what it means precisely and, apart from some philosophers of medicine, nobody is interested in its exact meaning. For example, does 'disease' concern the subject/patient or the System (as a living organism)? And consequently: can a patient who is not sick in time <math>t_n</math>  live together with a system already in a state of structural damage in time <math>t_{i,-1}</math>?

''The term languishes without any semantics as if it were irrelevant or gratuitous and its derivatives share the same semantic obscurity with it.''<ref>{{cita libro

;In short,

* is the patient Mary Poppins sick, or is the chewing System damaged?

* Is it instead a 'System' disease considering the masticatory System in its entirety consisting of subsets such as receptors, peripheral and central nervous tissue, maxillary bones, teeth, tongue, skin, etc.,?

* Or, is it an 'organ' disease involving in this specific case the temporomandibular joint (TMJ)?

These brief notes demonstrate how the inaccuracies and peculiarities of natural language enter medicine through its syntactic and semantically underdeveloped form. We should deal with some of these peculiarities with concrete clinical examples.

 

 

 

<center>

== Clinical approach==

(hover over the images)

File:Spasmo emimasticatorio.jpg|'''<!--46-->Figure 1:''' Patient reporting 'orofacial pain' in the right hemilateral face

File:Spasmo emimasticatorio ATM.jpg|'''<!--48-->Figure 2:''' <!--49-->Patient’s TMJ stratigraphy showing signs of condylar flattening and osteophyte

File:Atm1 sclerodermia.jpg|'''<!--50-->Figure 3:''' <!--51-->Computed tomography of the TMJ which confirms the stratigraphy in figure 2

==What does a medical term mean==

Let us ask ourselves what "meaning" means.

The Cambridge Dictionary says that "''The meaning of something is what it expresses or represents''"<ref>[https://dictionary.cambridge.org/dictionary/english/meaning Cambridge Dictionary online]</ref>. As simple as it may seem, the notion of "meaning" is rather generic and vague; there is still no commonly accepted answer to the question 'what does "meaning" mean?' Controversial theories of meaning have been advanced, and each has its advantages and shortcomings<ref>{{cita libro  

Traditionally, a term is displayed as a linguistic label meaning an object in a world, concrete or abstract. The term is thought to stand in the language as a representative for that object, e.g. ‘apple’ for the famous fruit. This term ‘apple’ will have the same meaning for the American child, the European adult or the Chinese elder, while the meaning ‘Orofacial Pain’ will have an intention for the neurologist, one for the dentist, and its own essence the unfortunate Mary Poppins.

Such expressions do not derive their meaning from representing something in the world out there, but how they relate to other terms within one’s world or context.

The meaning of ''pain'' for Mary Poppins is concerning what it can mean to her, to her conscience, and not about the external world: actually, asking the patient to attribute a numerical value to his pain, say from 0 to 10, makes no sense, has no meaning, because there isn't any internal normalizing reference to one's world or context. <br>

The same is true for the neurologist who will give sense to the term 'pain in the right half face' solely in his/her context based on synapses, axons, ion channels, action potentials, neuropeptides etc.<br>

The dentist will do the same, based on his/her context consisting mainly of teeth, temporomandibular joint, masticatory muscles, occlusion etc.

Concepts should not be neglected when it comes to '<nowiki/>'''differential diagnosis'''', because they could be sources of clinical errors. For this reason, we should reflect on the modern philosophy of 'Meaning', which began with Gottlob Frege<ref>[[:wikipedia:Gottlob_Frege|Wikipedia entry]]</ref>, as a compound of "extension" and "intention" of a term that expresses a concept.

The concept has its '''extension''' (it includes all beings with the same quality) and 'understanding' (a complex of markers referred to the idea). For example, the concept of ''pain'' refers to many human beings, but it is more generic (great extension, but little understanding). If we consider the pain in patients who receive, for example, dental implants, in patients with ongoing inflammatory dental pulpitis and patients with neuropathic pain (atypical odontalgia)<ref>{{cita libro

| titolo = Pain from Dental Implant Placement, Inflammatory Pulpitis Pain, and Neuropathic Pain Present Different Somatosensory Profiles

}}</ref> we'll have:

# Increases in the mechanical perception threshold and the sensory perception threshold related to C fibres' activation.

# Somatosensory abnormalities such as allodynia, reduced mechanical perception and impaired pain modulation in patients with atypical odontalgia.

# No somatosensory alteration after implant insertion, although patients report mild pain in the treated region.

On ‘pain’ in general we can say that it has a wide extension and minimal understanding, but if we consider the type of pain mentioned above, for example in patients who receive dental implants, in patients with ongoing inflammatory dental pulpitis and in patients with neuropathic pain (atypical odontalgia), it becomes evident that the greater the understanding is, the smaller the extension.

The '''intension''' of a concept, on the other hand, is a set of aspects that distinguish it from the others. These are the characteristics that differentiate the generic term of "pain", which by articulating the intension of a concept automatically reduces its extension. Obviously, though, various generality scales can descend from a concept depending on which aspect of its intension is articulated. That is why we could conceptually distinguish pain in the TMJ from neuropathic pain.

We can conveniently say, therefore, that the meaning of a term ''<math>\mathrm{S}</math>'' with respect to a particular language <math>\mathrm{l}</math> is an ordered couple, consisting of extension and intension, in a world that we will now call ‘context’.

Precisely with reference to the '''context''' we must point out that:

#In the dental ‘context’, the term ''pain in the right half face'' represents a relatively large extension (so that it can be classified in an area that includes the ‘TMDs’) and an intension composed of a series of clinical characteristics perhaps supported by a series of instrumental radiological investigations, EMG, axiographic etc.

#In the neurological ‘context’, however, the term ''pain in the right half face'' represents a relatively wide ‘_nOP’ extension and an intension composed of a series of clinical features, perhaps supported by a series of instrumental radiological investigations, EMG, somatosensory evoked potentials, etc.

This brief but essential argument allows us to ascertain how the linguistic expression of a medical language is vulnerable for a series of reasons; among these, please note semantic incompleteness, as well as how a meaning can be so different in different contexts that the terms ‘_nOP’ or ' TMDs' become ambiguous with these premises<ref>{{cita libro  

==Ambiguity and Vagueness==

As said, beyond the language used, the meaning of a medical term also depends on the contexts from which it originates, and this can generate ‘ambiguity’ or ‘polysemy’ of the terms. A term is called ambiguous or polysemic if it has more than one meaning. Ambiguity and vagueness have been the subject of considerable attention in linguistics and philosophy<ref>{{cita libro  

  }}</ref>; but despite the significant detrimental effect of ambiguity and vagueness on adherence to and implementation of the Clinical Pratice Guideline (CPG)<ref>{{cita libro  

  }}</ref>, these concepts have not been explored and differentiated yet in a medical context.

Doctors' interpretation of vague terms varies greatly<ref>{{cita libro  

  }}</ref>, leading to a reduced grip and q greater practice variation from CPGs. Ambiguity is classified into syntactic, semantic and pragmatic types<ref>{{cita libro  

As previously described, the meaning of a simple linguistic expression referred to by Mary Poppins has at least three different meanings in three different contexts. The ambiguity and vagueness in the linguistic expression behind the term ‘orofacial pain’, which at the same time could be a source of diagnostic errors, mainly concerns the inefficiency of the medical language logic in decrypting the machine message that the System sends in real time to the exterior.

Let's spend a minute trying to describe this interesting topic of '''encrypted machine language''' from which the following chapters will be articulated.

Orofacial pain does not have a meaning in its most genuine lexical form, but rather in what it means in the context in which it exists: a whole series of domains referred to and generated by it such as clinical signs, related symptoms and interactions with other neuromotor, trigeminal, dental districts, etc. ''This machine language does not correspond to verbal language, but to an encrypted language built on its own alphabet'', that generates the message to be converted into verbal (natural) language. Now the problem shifts to the ''language logic used to decrypt the code''. In order to describe this concept in an understandable way, let’s contemplate a series of examples.

We are supposing that the unfortunate Mary Poppins is suffering from ‘orofacial pain’, and she is representing the following to the healthcare professionals to whom she relates:{{q2|<!--93-->Doc, 10 years ago I started with a widespread discomfort in the jaw, including episodes of bruxism; these worsened so much that I was accusing ‘diffuse facial pain’, in particular in the area of the right ‘TMJ’ with noises in the movements mandibular.<br><!--94-->During this period, ‘vesicular lesions’ formed on my skin, which were more evident in the right half of my face.<br>In this period, however, the pain became more intense and intermittent|}}

The healthcare worker, who may be a dermatologist, a dentist or a neurologist, picks up some verbal messages in Mary Poppins’ dialogue, such as ‘diffuse facial pain’ or ‘TMJ’ or ‘vescicular lesion’, and establishes a series of hypothetical diagnostic conclusions that have nothing to do with the encrypted language.

Here, however, we should abandon a little the acquired patterns and opinions to better follow the concept of ‘encrypted language’. Let's suppose, therefore, that the System is generating and sending the following encrypted message, for instance: '''Ephaptic'''.

Now, what has ‘Ephaptic’ to do with _nOP or TMDs?

Nothing and everything, as we will better verify at the end of the chapters about the logic of medical language; but by now we will dedicate some time to the concepts of ''encryption'' and ''decryption''. We have perhaps heard about them in spy movies or in information security, but they are important in medicine too, you'll see.

==Encryption==

Let us continue with our example:

Let us take a common encryption and decryption platform. In the following example we will report the results of an Italian platform but we can choose any platform because the results conceptually do not change:

You type your message in plain text, the machine converts it into something unreadable, but anyone knowing the "code" will be able to understand it.  

Let us suppose, then, that the same happens when the brain sends a message in its own machine language, made up of wave trains, packets of ionic fields and so on; and that carries a message with it to decrypt the ‘Ephaptic’ code.

This message from the Central Nervous System must first be transduced into verbal language, to allow the patient to give meaning to the linguistic expression and the doctor to interpret the verbal message. In this way, however, the machine message is polluted by the linguistic expression: both by the patient, who is unable to convert the encrypted message with the exact meaning (epistemic vagueness), and by the doctor, because he/she is conditioned by the specific context of his/her specialization.

The patient, actually, by reporting a symptomatology of orofacial pain in the region of the temporoandibular joint, virtually combines the set of ''extension'' and ''intention'' into a diagnostic concept that allows the dentist to formulate the diagnosis of orofacial pain from temporomandibular disorders. (TMDs).

Very often the message remains encrypted at least until the system is damaged to such an extent that clinical signs and symptoms emerge so striking that, obviously, they facilitate the diagnosis.

Understanding how the encryption works is quite simple (go to decryption platform chooses and to try it out):

#choose an encryption key among those selected;

#type a word;

#get a code corresponding to the chosen key and the typed word.

For example, if we insert the word ‘Ephaptic’ in the platform encryption system, we will have an encrypted code in the three different contexts (patient, dentist and neurologist) which correspond to the three different algorithmic keys indicated by the  program, for instance: the A key corresponds to the patient's algorithm, the B key to the dental context and the C key to the neurological context.

 

{{q4|<!--117-->Why do you say that the patient's "key" is defined as the REAL one?|<!--118-->difficult answer, but please observe the Gate Control phenomenon and you will understand}}

First of all: Only the patient is unconsciously aware of the disease that afflicts his own system, but he does not have the ability to transduce the signal from the machine language to the verbal language. The same procedure occurs in 'Systems Control Theory', in which a dynamic control procedure called ‘State Observer’ is designed to estimate the state of the system from output measurements. Matter of fact, in the control theory, observability is a measure of how much the internal state of a system can be deduced from the knowledge of its external outputs<ref>[[wikipedia:Observability|Osservability]] </ref>. While in the case of a biological system a ‘Stochastic Observability’ of linear dynamic systemsis preferred<ref>{{cita libro  

  }}</ref>, the Gramian matrices are used for the stochastic observability of nonlinear systems<ref>[[wikipedia:Controllability_Gramian|Controllability Gramian]]</ref><ref>{{cita libro  

This would already be enough to bring now our attention on an extraordinarily explanatory phenomenon called ''Gate Control''. If a child gets hit in the leg while playing soccer, in addition to crying, the first thing he does is to rub extensively the painful area so that the pain decreases. The child does not know the ‘Gate Control’, but unconsciously activates an action that, by stimulating the tactile receptors, closes the gate at the entrance of the nociceptive input of the C fibres, consequently decreasing the pain; the phenomenon was discovered only in 1965 by Ronald Melzack and Patrick Wall<ref>{{cita libro  

As much as in computers, encryption-decryption also takes place in biology. In fact, in a recent research the authors examined the influence of molecular mechanisms of the ‘long-term potentiation’ (LTP) phenomenon in the hippocampus on the functional importance of synaptic plasticity for storage of information and the development of neuronal connectivity. It is not yet clear if the activity modifies the strength of the single synapses in a digital ('''01''', all or nothing) or analog (graduated) way. In the study it emerges that individual synapses appear to have an 'all or nothing' enhancement, indicative of highly cooperative processes, but different thresholds for undergoing enhancement. These findings raise the possibility that some forms of synaptic memory may be digitally stored in the brain<ref>{{cite book