The Normal, and the Perils of the Sylleptic Argument

Edmond A. Murphy

Perspectives in Biology and Medicine, Volume 15, Number 4, Summer 1972,

pp. 566-582 (Article)

Published by Johns Hopkins University Press

DOI: https://doi.org/10.1353/pbm.1972.0003

For additional information about this article

https://muse.jhu.edu/article/404580/summary

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THE NORMAL, AND THE PERILS OF THE
SYLLEPTIC ARGUMENT

EDMOND A. MURPHY, M.D., ScD*

The basic notion of syllepsis can be simply represented. Two

attributes separately predicated of two quantities may be confused
and make it appear that the two quantities have an attribute in com-
mon. Algebraically we might say that A is predicated of B and A*
of B*; confusion of the quantities A and A* may make it appear that
B and B* have the attribute A in common. Syllepsis is widely used
for literary effect. For example in Mrs. Packletide's Tiger the heroine
wishes to shoot a tiger so that she can give a party to gloat over her
friends with the "tiger-skin rug occupying most of the background
and all of the conversation" [I]. Here the word "occupied" is being
applied to the words "background" and "conversation"—in the for-
mer in a literal sense, in the latter as a metaphor.
Syllepsis may be carried over into the field of argumentation. In
Molière's Le bourgeois gentilhomme (act 1, sc. 2) the dancing master
argues that the diplomat should learn dancing because the errors of
diplomacy are false steps, and that the best prophylactic against tak-
ing false steps is to know how to dance. There is little danger of error
from such transparent cases. But this kind of absurdity is often per-
petrated quite unconsciously with words which have many meanings.
A brief classification of such words is given in table 1 . A typical mis-
use in an argument, which it seems appropriate to call the "sylleptic
syllogism," is provided at the top of table 1. Here the same word,
"fitness," is used in two different senses in the two premises: in a
medical sense in the first, in a genetic sense in the second.
The attendant problems are admirably illustrated in the use of
the word "normal." Doubtless many different meanings can be at-
tached to the word, but at least seven are sufficiently different to in-
volve some peril of syllepsis (table 2). From top to bottom of table 2
* Division of Medical Genetics, Department of Medicine, The Johns Hopkins Uni-
versity School of Medicine, Baltimore, Maryland 21205.

566 j Edmond A. Murphy · Perils of Sylleptic Argument

 TABLE 1
Proper and Sylleptic Syllogisms

Proper Syllogism Sylleptic Syllogism*

A implies B ........ A implies B.

A is true .......... A* is true.
Therefore B is true . Therefore B is true.

Examples

All men are mortal ......... Fitness is always desirable.

Socrates is a man ........... Fitness implies having many healthy children.
Therefore Socrates is mortal . Therefore it is always desirable to have many
healthy children.

* Some classes of words which lead to sylleptic arguments: (1) Words which refer tointrinsically
human acts (love, responsibility, consent, faith). (2) Words involving value judgment (good,
true, beautiful, scientific, democratic). (3) Common words inadequately focused (normal, gene,
lawful, the ether, democracy). (4) Words with a common meaning adopted in a specialized sense
(random, fit, measurable, probability) or in a generalized sense (bias, myth, disease). (5) Technical
words misappropriated by the laity (hysteria, allergic, fractured, tumor, abortion, assault, libel,
replica). (6) Euphemisms (malnutrition, promiscuous, privilege). (7) Words which have been
watered down, perhaps deliberately (libido, homosexual, education, freedom, home).

TABLE 2
Seven Meanings of the Word "Normal"

Paraphrase Domains of Use Preferable Term

1. Having probability density function

'<^-K(^)']
(predicated of a metrical character) . Statistics Gaussian
2. Most representative of its class. Descriptive science Average, median,
(biology, etc.) modal
3.Commonly encountered in its class. Descriptive science Habitual
4.Most suited to survival and
reproduction .................... Genetics, operations re- Optimal or
search, quality control, "fittest"
etc.
5. Carrying no penalty Clinical medicine Innocuous or
harmless
6.Commonly aspired to. . . Politics, sociology, etc. Conventional
7.Most perfect of its class. Metaphysics, esthetics, Ideal
morals, etc.

there is increasing loss of simplicity and objectivity and increase in

complexity and subjectivity. For each sense there are spheres of study
in which the term is so used, and for each an alternative term is sug-
gested which is preferable because it is less ambiguous.
1. The word "normal" may mean that it is a metrical variate with

Perspectives in Biology and Medicine · Summer 1972 | 567

a particular probability density function which is better described
by some such term as "Gaussian." Why the term "normal" ever be-
came applied to it is not clear, but there is no reason for thinking
that it has anything whatsoever to do with the word normal in any
other sense. There is no reason at all why an attribute of "normal"
people should have this distribution: indeed it is usually impossible
for it to do so, since this distribution has no limits, and most variables
in man (height, weight, blood sugar, etc.) cannot assume negative
values. Nevertheless this use of "normal" is a constant source of
confusion. The statistician commonly asks, "Is it reasonable to sup-
pose that the data are normally distributed?" The investigator often
mistakes the sense, and because he has examined these people himself
and considered them normal, he is liable to say that it is a reason-
able assumption. In fact, the use of methods based on at least ap-
proximate normality must be justified either by serious mathematical
theory or by analysis of empirical data. There are several other uses
of "normal" in mathematics (for example, in geometry and in mea-
sure theory) which are of little interest to the biologist and will be
ignored.
2.Then normality may be used in the sense of simple descriptive
statistics. The man in the street asked what the normal height of a
giraffe is might reply, "Ten feet." This figure may be wrong, but at
least what he is trying to do is to give the most representative height
of a giraffe from his own knowledge. The most representative value
which he is trying to guess might be the mean or (for the size of a
mouse litter) the mode.
3.A more sophisticated witness might feel that some kind of a
range of values would be more appropriate, and might reply, "Nine
to 14 feet." What he means by this, it would be hard to say exactly;
but in some undefined sense he considers that this encompasses the
values habitually encountered in these animals. It implies that if he
saw one 2 inches high he would experience genuine difficulty in call-
ing it a giraffe. Attempts have been made to formalize this kind of
statement by defining a "normal range," which is "the mean plus or
minus two standard deviations" (see below).
But these three ways of looking at normality are of a neutral char-
acter. They are in some sense descriptive of what happens without
regard to effects.
4.A more practical but also less objective way of using the term
"normal" is to consider it in relationship to some kind of criterion
568 [ Edmond A. Murphy · Perils of Sylleptic Argument
of fitness. Here, of course, the trouble starts because value judgments
have been introduced. Geneticists take the ability to reproduce as a
mark of excellence. This statement requires some qualification be-
cause the production of a large number of sterile offspring would
not be evidence of fitness. Perhaps the best definition would be that
the fitness of a genetic line is the probability that the line will not
become extinct. A technologist or an expert in operations research
would use a somewhat similar criterion—the probability that the
instrument used will continue to function and to function well. But
whereas there would be little doubt as to what a good function in
an automobile tire would be, it is much more difficult to see that
mere fecundity is a satisfactory criterion of normality in an organism.
It can be, and indeed is, widely used in this sense. But then the word
"fitness" itself must be used in syllogisms with circumspection.
5.A further rather loose usage of the term "normal" to describe
a characteristic is to imply that it carries a trivial burden with it. A
pediatrician consulted by a mother who complains that her child is
a somnambulist may tell her that this is "normal," not because it is
common but because the ill consequences are trivial. Here, perhaps
the preferred term would be "innocuous" or "harmless." This cri-
terion implies the methods of the decision theorist.
6.Normality may be used in a still more subjective sense, and
then even definition of the criterion, however arbitrary, becomes
difficult. There is the "democratic" criterion of conforming to the
consensus. The politician is acutely sensitive to the aspirations of the
"common man" and projects the corresponding image. The sociolo-
gist's notion of the normal would be somewhat similar: he is not
concerned with the outlier but with the typical man. But the form of
the consensus becomes progressively less rational as the characteristic
under consideration becomes more and more personal. Society might
reason with some force that in the interests of self-protection, and the
design of clothes, furniture, houses, and so forth, it is desirable that
there should not be too much variation in body size. But in the psy-
chological sphere judgments of this kind look more arbitrary than
ever. What is normal behavior and what psychotic is a particularly
sensitive matter. Herbert writes [2, chap. H]: "It's normal to share
the delusions of one's society. . . . It's abnormal to develop private
delusions," which probably has a certain justification in that at least
such a policy is not disruptive. But there is also a widespread ap-
Perspectives in Biology and Medicine · Summer 1972 \ 569
proach to madness which does not even put on the trappings of a
principle: "For to define true madness, what is it but to be nothing
else but mad?" (Hamlet, act 2, sc. 2, line 93), which (it need hardly
be pointed out) says nothing at all and leaves the whole matter prey
to the bias of minds which are themselves part of the system being
judged.
7. If there is any reference standard outside of mere convention,
then the consensus may bear little relation to it. Pi cannot be made
equal to three by a legislative body, though the task has been at-
tempted. It may be politically dangerous to say so, but it is neverthe-
less true that the aspirations of the common man call for guidance
by the reformer and the visionary. It seems clear that the normal man
should be the ideal man, and the study of the nature of the ideal
man falls within the various branches of philosophy. Needless to say,
this is the most controversial and the most subjective way in which
to define the normal. But such a criterion, even if consensus is im-
possible, seems better than an unambiguous definition based on a
narrow viewpoint.
But it is important to distinguish personal prejudices from arbi-
trary usages. If an investigator takes as normal "the mean plus or
minus two standard deviations," then we know what he means by
the term, and in any argument he constructs about the normal,
wherever the word occurs it can, and perhaps should, be replaced by
his definition. Such arguments may have a trivial character, but at
least they will not mislead if the rules of logic are followed. But if,
for instance, he pushes his argument to mean that people not within
this range should be exterminated or should be admitted to mental
hospitals or require thorough medical investigation, then he is guilty
of syllepsis. A hundred years ago he would doubtless have joined
forces with the fifth group in observing with approbation the "laud-
able pus" which was present after all the best surgical operations.
A Synthetic Approach
The approach to the problem so far has been cautionary: it sug-
gests that in current usage great ambiguity exists. It might be more
helpful to start at the other end of the problem to see what use is to
be made of the notion of normality and then consider how it is to
be formulated. To this end it will be advantageous to consider three
questions at increasing levels of epistemological difficulty.

570 I Edmond A. Murphy · Perils of Sylleptic Argument

 1 . WHAT IS THE BEST METHOD OF DISTINGUISHING BETWEEN A NORMAL
AND AN ABNORMAL GROUP?

Of course, some criterion of "best" is needed, perhaps that which

minimizes the cost of the process. A decision is to be made on the
basis of a set of measurements or attributes; the criterion may be a
complicated one because the various measurements will provide dif-
ferent amounts of information but will not, in general, be indepen-
dent. Thus, impaired intelligence is a more secure sign of phenyl-
ketonuria than blond hair [3]. But in principle, at least, all the
pieces of information going into the decision can be reduced to a
single quantity or index. Thus, by dealing with the interpretation
of a single value we lose nothing in generality. This consideration
should meet the common criticism that the following kind of argu-
ment oversimplifies the nature of diagnosis.
In simple fashion, suppose that a false positive is just as unde-
sirable as a false negative. Then it is an easy matter to find a dividing
point which will minimize the total misclassification. One such in-
stance which we have worked out in detail elsewhere [4] is the diag-
nostic value of the lipoprotein fraction Sf 0-12 in coronary artery
disease.
To make this method pertinent to real life, factors other than the
probability density of the curves must be taken into account. First,
the relative frequencies of the normal and abnormal states should
be considered. So also should the effect of bias of ascertainment. For
example, in coronary disease the family physician is liable to see all
manner of cases, whereas the hospital resident will see disproportion-
ately few of the trivial cases and of the cases producing sudden death.
The two physicians will be sampling from different populations,
and the best cutoff points between the normal and the abnormal they
should use will differ. Again, it is said that the very mildest and the
totally incapacitating errors of refraction do not cause headache, that
it is the intermediate cases which do and which come to the attention
of the neurologist. If so, the notions of what the neurologist and the
oculist consider normal will likely be different.
Further, the results must take account of the cost of misdiagnosis.
A satisfactory formulation of "cost" may be hard to give, but in prin-
ciple the point is clear enough. Where cost of the false negative is
high, the diagnosis will be made on slighter grounds. The adjustment

Perspectives in Biology and Medicine · Summer 1972 | 571

is achieved by introducing a "cost function." The details may be
found elsewhere [4, 5].
Now, how exactly we construct these decision schemes depends,
among other things, on the alternative to normality under consid-
eration.
This seems to show that any attempt to cut the Gordian knot of
diagnosis by any such simple device as "the mean plus or minus two
standard deviations" will inevitably fail.
The other fact to be borne in mind is that the decision is not often
made between the normal and one disease state only, but between
the normal and a variety of alternatives.
2. HOW IS A DISEASED GROUP TO BE DEFINED?
This is a more fundamental and a more difficult question. There
are really two problems here.
If there were some external reference on the basis of which to
group the cases, it would be easy by discriminant analysis to find the
best set of decision rules [6]. This method is used if the objective
is to replace a definitive but costly, and perhaps dangerous, proce-
dure (such as an exploratory craniotomy) by cheap, simple, and
harmless tests such as X-ray of the skull.
But much more commonly—and this is a major problem in modern
epidemiology—not only is there no external reference on the basis
of which to minimize the cost, but there is no very clear idea of what
is being sought. There is a vague idea that atherosclerosis is bad be-
cause it leads to high morbidity and mortality, but it is very far from
clear what is really meant by this term. Is a fatty streak atherosclero-
sis? Is an organized thrombus atherosclerosis? What is the difference
between a thrombus and a hemostatic plug? These are by no means
trivial or impractical questions, and an appeal to the state of con-
fusion of the field after vast expenditure of time and money on basic
research gives support to the claim that at least part of the problem
rests on these fundamentally semantic questions.
Fortunately—or unfortunately, it is difficult to say which since
nothing succeeds like success but also nothing misleads more than
success—not all problems are of this kind. Some Mendelian charac-
ters at least separate the subjects into unambiguous groups, not quite
so perfectly as the categorical geneticist thinks but well enough for
any possible practical purpose. The matter of defining discrete enti-

572 I Edmond A. Murphy · Perils of Sylleptic Argument

ties and the methods and criteria for doing so are discussed in some
detail by McKusick [7].
There are other conditions which segregate into somewhat less
secure groups, such as certain infectious diseases or intoxications.
The common run of measurable characteristics, however, do not
behave in this way, especially in higher organisms. Height, which in
the pea segregates as a Mendelian character, in man shows no evi-
dence of grouping (ignoring a number of genetic diseases causing
dwarfism, all of them rare). There are, in fact, good arguments from
population dynamics why characteristics tend to be multilocal, espe-
cially where disease is concerned [8].
Where there is incomplete separation into groups, analysis is a
much more difficult matter and probably cannot be solved except by
putting arbitrary constraints on the parameters. If the task set is to
find the description which conforms most closely to the data, it tran-
spires that the best way is to put each individual in its own class.
Now the whole scientific endeavor implies that the number of terms
required to describe the universe is less than the number of data to
be obtained from it. A classification which yields as many classes as
there are data points is useless. So to start with it must be supposed
that the number of classes is small, and known. But even then the
problem is difficult and in certain cases still gives absurd results [9].
But then there is the other half of the question. Suppose that two
groups of people are demonstrated, how can we decide which is the
normal and which the diseased? Obviously, neither might be dis-
eased. There is grouping with respect to handedness, and there is no
reason to believe that either is diseased. There is no doubt which
should be regarded as the disease, the hemophilic or the nonhemo-
philic state. In the case of sickle trait, we could give a reasonably
sure answer if the environmental conditions were specified. Such
answers could be defended in terms of morbidity and mortality. But
in many cases who is to say? The old proverb that the creaking gate
lasts the longest implies that there is survival value in not always
feeling on the top of one's form. A previous generation used to de-
scribe some members of society as "delicate" or "not very strong,"
and it is impossible to discover any discernible meaning in the term.
Many such persons lived to very advanced ages.
But in making judgments, however obvious they may appear, our
prejudices, conscious or unconscious, get in the way. Rightly or

Perspectives in Biology and Medicine · Summer 1972 | 573

wrongly we are appalled at an eighteenth-century society which sent
a child of six to the gallows for the crime of stealing sixpence. Right-
ly or wrongly they would have been appalled at our society, which
tolerates abortion of a fetus. The tendency is to think that their
standards are only conditionally true whereas ours are absolutely
true.1 McKusick has remarked that we think it reasonable to study
the height of Pigmies, whom we regard as dwarfs; but we would
think it unreasonable that Pigmies study the height of Americans,
whom they would consider giants. Yet one would be hard put to
think of any reason we could plead before a cosmic court as to which
of the two attitudes is correct.
Curiously enough, the problem is easier for the multifactorial
trait. Where a large number of environmental factors and genetic
loci operate independently with about equal influence to determine
some characteristic, the value it assumes should follow a Gaussian
distribution approximately, or at least should be bell-shaped. The
peak depends basically on the various gene frequencies, which are in
turn determined in large part by selection. Thus, an exquisite feed-
back system is operating: if the peak of the curve does not conform
to the optimal for the type of environment, then under selection,
gene frequencies will readjust, and a new peak will be established
representing that state which is most suited to the environment. This
mechanism presumably provides the justification for senses 2 and 3 of
the word "normal" and sets up a relationship to sense 4. The argu-
ment is sound if two assumptions can be accepted: that the yardstick
of normality is biologic (or genetic) fitness and that the present
condition of the distribution curve represents a final or steady state.
The former point will be ignored, since it is almost certainly not a
scientific question at all; the latter raises considerable difficulties.
In steady state the rate at which genes are entering the popula-
tion (for the most part by mutation) is exactly balanced by the rate
at which they are leaving it (mostly by selection)—which may in part
be the result of a struggle among the members of the population
themselves. It might be fairly easy to demonstrate a steady state in a
population with a short generation time under controlled and ob-
served environmental conditions. But in human populations, gener-
i These examples are not quoted to start a controversy. They are merely intended to
suggest that "being appalled" is neither evidence nor rational argument. In exploring
the theory of his judgments a man with a disciplined mind should be able to identify his
prejudices and the prejudices of his age.

574 I Edmond A. Murphy · Perils of Sylleptic Argument

ation time is long relative to the life of an observer, and what is
known about environment in the past is based on inference from
indirect evidence, which, while highly imaginative, is rarely coercive.
It is thus difficult to establish that a steady state exists, and therefore
the argument from central tendency (in any sense other than 2 and 3)
is specious. For one thing mutation rate and selection have doubtless
changed over the centuries. But besides, it is very far from evident
that the human species will not continue to change in the future.
Even if it were true that no further evolution will occur, the fact
that man has devised so many recording devices and hence can ac-
cumulate scientific and cultural information will ensure that his en-
vironment will continue to change. Moreover, man is self-conscious
and hence will tend to provide his own feedback mechanisms and
artificial selection. It has been argued that various chronic diseases
represent the results of the time lag between, on the one hand, the
environment and the selection it imposes and, on the other, the
genetic composition of the population to which it leads [10].
There is one curious logical consequence of the notion of a steady
state which seems to have been almost entirely overlooked. If the
peak occurs in the distribution at the optimal state, then there must
be relatively greater selection against all alternative values. It is
freely accepted that people with unusually high blood pressure,
weight, or serum cholesterol or glucose have a considerably lower
expectation of life than those near the mean. Why does not the force
of selection drive down gene frequencies to the point where the re-
sulting phenotypes will almost all lie within the "safe" range? I can
think of only two possible answers. First, it may not be possible for
a system to be constructed in which, for example, the blood cho-
lesterol or blood pressure does not rise with age, any more than it is
possible to devise a machine which will not wear out. This answer
seems to be belied by the fact that there are classes of people in whom
no rise in blood pressure with age occurs [H]. The other interpre-
tation is that there is also a selection against the low values. Now
surely this is a hypothesis which could be very easily tested? Of
course blood pressure may be low as a result of Addison's disease or
sodium-losing nephritis, and serum cholesterol may be low because
of malabsorptive disease; and these conditions lead to low fitness. But
that is not the point. If high blood pressure is selected against, in its
own right (and not simply because it is a manifestation of something

Perspectives in Biology and Medicine · Summer 1972 | 575

more important), low blood pressure should also be selected against
in its own right. The standard textbooks emphatically reject "idio-
pathic hypotension" as a disease. Harrison's textbook [12], for in-
stance, states: "Chronic hypotension is not a disease. . . . Thus, per-
sistent low blood pressure should never be treated as such." If this
means that prognosis is good in low blood pressure unassociated with
disease, it would be of value to know whether this viewpoint has
been formally verified or is based on "common sense" or on vague
clinical impressions. Unfortunately the claims are undocumented.
Should it prove to be true, then the argument from central tendency
would be in peril.
3. WHAT REASON IS THERE TO BELIEVE THAT NATURAL GROUPINGS
OCCUR?
This is at once the most fundamental and the most difficult of the
questions. Every entity is in some sense unique; classification is a
convenience of thought and invariably falsifies to some extent. An
exact description of anything would not allow it to be put into any
category.
For the most part, of course, subjects are not looked at in their
entirety but from the standpoint of one characteristic. Sometimes
measurement of the characteristic shows incontrovertible grouping.
Almost invariably, however, even for well-established Mendelian
characters, there is some scattering within groups. Whether this scat-
ter should be ignored clearly depends on what its genesis may be. If
it merely represents "noise"—that is, irrelevant variation such as ex-
perimental error, or variation due to the time of day at which the
study is done—it is appropriate to discard it. But if it is due to the
action of modifying genes, or to some habit of life, or to some en-
vironmental hazard, much may be learned from analyzing it. It is
rarely easy to distinguish with confidence between the relevant and
the irrelevant, and when in doubt, it is usually wise to retain the
pristine data.
Categorization even as an arbitrary device has its advantages, and
indeed in certain situations it may be indispensible. For example,
how can the effect of war on the sex of newborn children be deter-
mined? A simple approach (and there is no virtue in making the
problem gratuitously complicated) is to compare the percentage of
male children in time of peace with that in time of war. But this

576 I Edmond A. Murphy · Perils of Sylleptic Argument

whole method supposes that the division of children into "male" and
"female" is possible.
There is a further matter, one of convenience. Suppose it is true
that all cases of cancer or schizophrenia or congenital heart disease
could be divided into a number of classes and an exact prognosis
worked out for each. It seems evident that as the number of cate-
gories goes up, the greater the burden on the memory of the physi-
cian; but also the price for greater homogeneity within the categories
is smaller samples and therefore larger standard errors of the esti-
mates [13].
But this is an oversimplification. Not all members of a category
may behave in exactly the same way. But if the variance within cate-
gories is small compared with that among categories, lumping them
together may mean little loss of information and great gain in sim-
plicity. In such cases the dividing point between cases can be chosen
such that a shift in either direction makes very little difference in the
classification of actual cases. If the upper limit of one class is five
arbitrary units and the lower of the other is twenty, it does not matter
whether the dividing point is chosen as ten or fifteen. By contrast,
blood pressure does not show this kind of partition of variance.
Wherever the dividing line is between normal and abnormal, it will
not be true that most of variance is concentrated between groups.
Moreover, a small shift in the dividing line will produce a dispro-
portionately larger difference in the allocation of cases.
We might then take as a kind of joint index of the usefulness of
a classification of a variable the simplicity which results and the pro-
portion of the variance which is distributed among categories. The
more categories, the larger the proportion of the variance taken by
the differences among them.
Consider the following imaginary data points: 117, 121, 129, 131,
139, 140, 156, and 163. They might represent height in centimeters
in some rare form of dwarfism. A common clinical problem is to
decide into how many groups these values would fall naturally. They
can be grouped in various numbers of categories so that the largest
part of the total variation is distributed among categories (table 3).
If the "best" split into two categories is used (so that the maximum
proportion of the total variance is between categories), about three-
quarters of the total variation is attributable to differences between
the two groups. For three categories the variation among groups in-

Perspectives in Biology and Medicine · Summer 1972 | 577

 TABLE 3

Relationship of Homogeneity to The

Number of Groups

Percentage of
Classes Breakdown Total Variation
among Groups

None 0.0000
1-6, 7-8 74.7508
1-2, 3-6, 7-8 93.0648
1-2, 3-4, 5-6, 7-8 98.0620
1-2, 3-4, 5-6, 7, 8 99.4186
1, 2, 3-4, 5-6, 7, 8 99.8616
1,2,3,4,5-6,7,8 99.9723
100.0000

creases to about 93 percent of the total. By the time eight categories

are used, all the variation is between categories and none within.
Clearly if the only criterion is homogeneity within classes, eight cate-
gories will achieve it. However, it might be felt that with grouping
into, say, four categories the loss of homogeneity within groups is
trivial.

An Alternative Scheme
It might seem, then, that for this problem there is no cure which
will work in the general case. If things fall neatly into categories,
widely separated from each other, well and good; if they do not, the
problem is insoluble, except by unwieldy methods.
Now this is an unduly pessimistic viewpoint. The problem as
stated is not in general soluble, but it is largely a gratuitous problem.
It arises from a confusion between dimensionality and cardinality.
A line has an uncountable number of points, and its cardinal num-
ber is therefore infinite. Thus it would seem to require an uncount-
able number of facts to describe it. But this is not so. The line can
be described by specifying that it is straight and giving the positions
of its ends each of which can be defined by three space coordinates.
A distant colleague could reconstruct the line from these seven facts
alone. The information can be coded in a seven-dimensional vector.
Quite elaborate-looking curves can be unambiguously reconstructed
from a comparatively small number of facts.
A fair example is given in table 4. For a simple rectangular co-
ordinate system with measurements in inches, a set of data on arcs
of circles is given: the extremities for each arc, the radius of curva-

578 I Edmond A. Murphy · Perils of Sylleptic Argument

 TABLE 4
The Information in a Diagram

Figure IjI Figuhe IB

Radius Radius
Start End (in Inches) Start End (in Inches)

(0.00,0.00). (1.50,1.30) 2.15 (7.45,1.40). (9.40,0.00) - 2.15

(2.70,1.55) 5.00 (9.40,4.35) +10.00
(3.20,1.80) 2.20 (8.50,8.40) + 10.00
(4.05,5.20) 3.00 (7.70,9.20) + 2.90
(4.30,7.70) OO
(5.45,0.60) + 1.50
(4.20,9.00) + 3.30 (5.50,7.20) - 4.40
(2.90,9.60) + 1.50 (5.70,6.35) - 0.90
(1.00,8.00) + 2.50 (6.65,4.65) -10.00
(0.15,4.55) + 9.50 (6.65,4.65). (7.45,1.40) - 3.30
(0.15,4.55). (0.00,0.00) + 10.00

Note.—By convention, a positive radius means that the arc is concave to the center of the figure; i.e., a line
connecting the terminals will separate the arc from the center of the figure. The opposite applies to negative cur-
vature.

ture, and whether the curvature is positive or negative (defined in

an arbitrary manner). These data were then given to a mathematical
colleague who reconstructed the diagram shown in figure 1. He did
not identify it, but the physician will recognize the silhouette of a
heart and lung field. In fact the reconstruction agrees to within 0.5
percent of the original X-ray. To these tolerances and from the point
of view of heart size, the dimensionality of the X-ray is something
like forty: a modest content of information.
In interpreting the X-ray the radiologist would of course be con-
cerned with other information—for instance the vascular markings.

Fig. !.—Silhouette of heart and lung fields

Perspectives in Biology and Medicine · Summer 1972 | 579

But they would not contain any information about the size of the
heart.
It then seems evident that any purpose to which a classification is to
be put could be dealt with by using a continuous mathematical func-
tion with little increase in complexity (indeed often quite the re-
verse) and considerable gain in accuracy. Why, for instance, does the
clinician try to set up categories of "hypertensive" and "normoten-
sive"? The answer seems to be because he will use it as a basis for
deciding what to do in the way of investigation, what he can say in
prognosis, and how he will treat. The matter of investigating cases
represents a complex decision procedure which it would not be prac-
ticable to pursue here. As for a five-year prognosis, he would have to
remember two pieces of information, one for each group. But sup-
pose (for instance) that the five-year mortality rate increases ten per
thousand for every 10 mm rise in diastolic pressure: he would still
have to remember two facts: what the rate is for the average and the
gradient of risk. But this scheme would surely be more helpful than
trying to pretend that all cases above 100 mm Hg have an equal prog-
nosis. No sensible physician would attempt to defend this latter
policy, but why categorize at all if the same and better results could
be obtained from the same number of facts? Both are two-dimension-
al representations of a set of facts of infinite cardinality. The former
distorts. The latter does not.
As to treatment, the matter is even more clear. Reputable practice
in the treatment of most diseases considers the objective as a restor-
ing of values to the optimum. The vigor with which weight reduc-
tion is encouraged depends on the degree of obesity; other things
being equal, the higher the blood pressure, the more powerful the
drugs used and the greater the dosage; insulin or thyroid or adrenal
hormones are titrated to a nicety against response. The same is true
of the use of most effective drugs.
Whitehead [14, p. 43] points out that much of the habit of classi-
fying in science is to be traced to the preoccupations of medieval
philosophers with categories, an idea derived ultimately from Aris-
totle, whose attitudes of mind perhaps reflect the fact that he was the
son of a physician. Plato, on the other hand, was a mathematician.
Had he gained the hegemony in Western thought, our scientific
habits, particularly in medicine, might have been different and,
Whitehead believes, better.

580 I Edmond A. Murphy · Perils of Sylleptic Argument

 At the present time at least, it is difficult to think of disease as
other than an intimate interaction between the organism (with its
genetic endowment and accumulated experiences) and perturbations
in the environment. It has been suggested elsewhere [15] that the
word "disease" is used in at least three distinct senses:
1.The manifestations of the body's attempt to maintain a normal
interior milieu despite the effects of environmental change. The fea-
tures of food poisoning (diarrhea and vomiting, which tend to elimi-
nate toxin) might be thought of as an example. In this sense disease
is closely allied to homeostasis.
2.Perversion of a normal homeostatic process, which in some cases
may conceivably be a compensating process. Hypertension behaves in
this fashion. Attempts to lower the pressure (although they would
reduce the risk of serious complications) are nevertheless strenuously
combated by the body. The hypertension which accompanies raised
intracranial tension is presumably a compensating mechanism to
maintain cerebral blood flow against outside compression.
3.A completely anarchical state in no way directed to serving the
economy of the body. Cancer is the prime example.
In the first sense, good clinical practice is directed to aiding the
process. In the second it consists of adjusting the settings of the
homeostatic mechanisms. In the third it is a matter of destroying
the anarchical system.
In all three cases the object is to pursue the optimal. But it is
clearly desirable that the physician should know what is optimal
before he attempts to pursue it. In this decision he must seek the
opinions and the support of society. Who knows how much misery
has been produced by the arbitrary decree that left-handedness is an
abnormality which must be eradicated?
But if the optimal can be defined, then it should be pursued as
well as possible. The ideal doctor would concern himself with the
task of making his patients ever more healthy. And if he did, he
could with advantage forget about the word "normal" altogether.
REFERENCES

1.H.H. Munro. The short stories of Saki. New York: Modern Library, 1958.
2.F. Herbert. The Santaroga Barrier. New York: Berkley, 1968.
3.L. S. Penrose. An introduction to human biochemical genetics. Eugen. Lab.
Mem., vol. 37. London: Cambridge Univ. Press, 1955.
4.E. A. Murphy and H. Abbey. J. Chronic Dis., 20:79, 1967.
5.H. Chernoff and L. E. Moses. Elementary decision theory. New York: Wiley,
1959.

Perspectives in Biology and Medicine · Summer 1972 | 581

6.C. R. Rao. Advanced statistical methods in biometrie research. New York:
Wiley, 1952.
7.V. A. McKusick. Perspect. Biol. Med., 12:298, 1969.
8.E. A. Murphy. Perspect. Biol. Med., 9:333, 1966.
9.E. A. Murphy and D. R. Bollino. Amer. T. Hum. Genet., 19:322, 1967.
10.J. V. Neel. Amer. J. Hum. Genet., 14:353, 1962.
11.R. J. Jorgenson, D. R. Bolling, O. C. Yoder, and E. A. Murphy. Blood pres-
sure studies in the Amish. In preparation.
12.A. Blalock and T. R. Harrison. In: T. R. Harrison et al. (eds.). Principles of
internal medicine, article 135. 5th ed. New" York: McGraw-Hill, 1966.
13.J. Truett, J. Cornfield, and W. Kannel. J. Chronic Dis., 20:511, 1967.
14.A. N. Whitehead. Science and the modern world. New York: Macmillan, 1925.
15.E. A. Murphy. Linacre Quart., 36:158, 1969.

SUMMER NIGHT

Here and now, past midnight's hour, alone,

Unsettled thoughts seek out profound expression,
Find only languor, the pen upended by a smile.

And the city sleeps without anticipation,

Sleeps and dreams in incongruous scenes,
These thousands set somehow at cross purposes.

We know no more this summer night than ever,

And yet we read the world with ease and smile,
While gray clouds muster in the firmament,
Prepare to wash our souls with summer rain.
Jay Cohen

582 I Edmond A. Murphy · Perils of Sylleptic Argument