RSM papers

Royal Society of Medicine David Aldridge Collected Papers

Journal of the Royal Society of Medicine Volume 84 March 1991

147

Aesthetics and the individual in the practice of medical research: discussion paper

D Aldridge P ~ D Medizinische Fakultat, Universitat Witten Herdecke, Beckweg 4, D-5804 Herdecke (Ruhr), Germany Keywords: complementary medicine; research; clinical controlled

'Art does not reproduce the visible, rather it makes visible.

Formerly we used to represent things visible on earth, things we either liked to look a t or would have liked to see. Today we reveal that reality that is behind all living things, thus expressing the belief that the visible world is merely a n isolated case in relation to the universal, and there are many more latent realities' Paul Kleel

Introduction There is a demand made of practitioners of complementary medicine by the wider community that they validate their work with clinical studies. This is often countered by complementary practitioners with the argument that scientific methods are often inappropriate to the study of these forms of medicine.

A similar cry is also heard in orthodox medicine that the strict methodology of science is often found wanting when applied to the study of human behaviour. This has stimulated calls for innovation in clinical medical research2. What we may need then in clinical research is to facilitate the emergence of a discipline which seeks to discover what media are available for expressing clinical change. These media may be as much aesthetic as they are scientific thereby emphasizing the a r t of healing in parallel with the science of healing. As Langer3 writes: 'The function of art is to acquaint the beholder with something he has not known before' (p 22).

Both science and art are activities which attempt to bring certain contents of the world into cognition.

The contention of this paper is that when we study human behaviour, and in particular what it means to be sick, to become well again or to live through the process of dying then both forms of acquaintance are necessary for the practice of research in medicine.

In medical research most of the modern initiatives for that research have come from the field of natural science. Such research when applied to the study of human behaviour is partial and neglects the important creative elements in the process, and practice of healing. This is not to deny the scientific, rather to emphasize the aesthetic such that both may be considered together. Unfortunately the tension of understanding both elements of human understanding results in one or the other being denied. Such is the current situation in modern medicine. However, the continuing problems of chronic illness and human suffering urge us to go beyond our partisan beliefs and look again at how we know as well as what we know.

This is literally the a r t of re-search.

The problem facing the clinician is that he must often mediate between the personal needs of the patient and the health needs of the community. These needs are informed by differing epistemologies.

Similarly there is often a split in medical science between researchers and clinicians. One group seeing themselves as rational and rigorous in their thinking and others as sentimental and biased which in turn elicits comments about inhuman treatment and reductionist thinking. Neither of these stances alone is true, each perspective has something to offer the other. However, the predominating ideas in published medical research are those of natural science as informed by statistical data.

Historical context The science of statistics developed in 18th century France as part of the centralized apparatus of the State. 'Statistics' as the science of state was the empirical numerical representation of the resources available to the State and formed the components of a new power rationality. Health care became, as it is now, a political objective, as well as a personal objective. Health, from this perspective, is seen as the duty of each member of society and the objective of all. Individual needs are subsumed within the goals of the collective, the private ethic is informed by the public ethic and objective empirical data are the means by which goals are assessed (see Table 1). These data are related to the economic regulation of health care delivery (health as commodity); public order (the regulation of deviance), and hygiene (the quality of food, water and the environment).

From this viewpoint we have the notion of health care, and knowledge about that health care, which is Table 1 . Comparative and complementary perspectives on health research Scientific perspective

Individual perspective

State regulation of health

Personal regulation of health

Constancy predictability and Creative irrationality: being control: the future is based on and becoming past data Technology of the body: Techniques of the self: music, observations, examinations art, personal narratives and and case reports poetry Objective statistical reality Subjective and symbolic realbased on instrumentally ity based on the senses and monitored data human consciousness The health of the body is a n Self maintains its own imperative of the State identity Scientific

Aesthetic

Time as chronos

Time as kairos

0141-07681911 030147-041$02.0010 C3 1991 The Royal Society of Medicine

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regulated by the State. The objects of that health care (patients), the practitioners of that health care (clinicians), and the providers of that health care (health and State insurance) are informed by the same epistemology. Such was the strength of modern science, it offered a replicable body of knowledge in the face of the ever increasing solipsism of metaphysics in the 18th century.

From a modern scientific stance the body is to be manipulated as an object of the State to whose ends it serves. Such manipulation is served by the processes of classification and normalization. People are observed, classified and analysed as 'cases' according to their deviance from a given norm.

Disease becomes a category like any other rather than the unique experience which it is.

The epistemology of this normative process is that of natural science which emphasizes reason, constancy and predictability. In the face of death and disruption the imperative of health is to maintain continuity and control. It is a philosophical assumption that the positive instance of an hypothesis will give ground for further instances. However, there is no logical necessity which will safeguard our passage from past to future experiences.

It is also ironical that modern statistical methods were developed by the agriculturalist Fisher. It was possible in his work to develop hybrid strains of plants which produced identical, albeit sterile, specimens which could be grown in large numbers for statistical comparison. However, for our purposes human beings cannot be reared like cabbages.

A critique of scientific methodology Implicit in much criticism of complementary medical research is the notion that there are 'right' premises for doing science. The implication is that there is a common map of the territory of healing, with particular co-ordinates and given symbols, for finding our way around and that the orthodox map of scientific medicine is the only one. Any different map is seen as deviant, and any challenge to the construction of that map as heretical4.

Similarly, when we speak of scientific or experimental validity, that validity has to be conferred by a person or group of persons on the work or actions of another group. This is a 'political' process. With the obsession for 'objective truths' in the scientific community then other 'truths' are ignored. As clinicians we have many ways of knowing; by intuition, through experience and by observation. If we disregard these 'knowings' then we promote the idea that there is an objective definitive external truth which exists as 'tablets of stone' to which only we, the initiated, have access.

Methodological issues While clinical controlled trial methodology may appear to be scientifically sound a number of articles have questioned the scientific premises of such methods: (i) A random selection of trial subjects cannot be achieved because any group of patients comprises a highly selected non-random group. (ii) Group generalizations from research findings raise problems for the clinician who is faced with the individual person in his or her consulting room.

Individual variations are mocked by the group average5.

(iii) The reliability of our knowledge is only as good as the underpinning hypothesis. Inevitably the reliability of a trial when extended to a broader population is an act of induction6. (iv) Persons are not experimental units, nor are the measurements made on persons isolated sets of data.

While at times it may be necessary to make this split we must be aware that we are making the act of separating data from persons. (v) People do not live in isolation. Life is rather a messy laboratory and continually influences the subjects of our therapeutic and research endeavours.

Even more daunting is the fact that subjects influence themselves. (vi) There is no such thing as a purely 'physical' treatment7. Treatment always occurs in a psychosocial context. Medicine is a social as well as a natural science. The way people respond in situations is sometimes determined by the way in which they have understood the meaning of that situation.

The above criticisms reflect one of two fundamentally differing approaches to science. One is to develop precise and fixed procedures that yield a stable and definite empirical content. We have this in controlled trial methodology. The other approach to investigation depends upon careful and imaginative life studies which although lacking some of the precision of technical instruments have the virtue of continuing a close relationship with the natural social world of people. (vii) As clinicians the concern for the subject prevails over the interest of society at large and scientific medicine as an institution. Individual persons are not treated as a means to some collective end in clinical practice, although we may subscribe to a notion of community health. The Declaration of Helsinki States8: 'In any medical study, every patient - including those of the control group, if any - should be assured of the best proven diagnostic and therapeutic method'.

The clinical judgement of the doctor is on the side of the individual patient even if it means the corruption of a research project. When clinicians, who are bound by contracts for treatment, take part in clinical trials then the dilemma is revealed. Either they fulfil their individual contract for treatment with the patient, or they abdicate that contract and fulfil their obligations to the research contract which are concerned with group benefit. This raises further the conceptual issues for health care of whether 'health' is an individual or a societal concept. Are we as clinicians committed to improving the health of individuals we see, or are we directed to improving the health of the communities we serve?

Scientific medicine emphasizes one particular way of knowing and this seems to maintain the myth that to know anything we must be scientists. If we consider people who live in vast desert areas they find their way across those trackless terrains without any understandings of scientific geography. They also know the pattern of the weather without recourse to what we know as the science of meteorology. In a similar way people know about their own bodies and have understandings about their own lives. They may not confer the same meanings as we do, yet it is those meanings and particular belief about health to which we might best be guiding our research endeavours.

While as clinicians we may help to bring about a change in behaviour by technical means, it is the

Journal of the Royal Society of Medicine Volume 84 March 1991

person who we have to rely upon to describe the meanings and implications of that change. This also leaves out the burgeoning problem for us as scientists for explaining how a change in meaning can bring about a change in behaviour.

The art form presents the whole intelligible form as an intuitive recognition of inner knowledge projected as outer form: subjective is made objective but in the terms of the subject. In artistic expression we have the possibility of making perceptible an inner experience.

Art and science 'What it (art)does is to formulate our conceptions of feelings and our conceptions of visual, factual and audible reality together. It gives us forms of imagination and forms of feeling, inseparably; that is to say, that it clarifies and organizes intuition itself'. (p 397)3

Research from this standpoint is not science in that it has no generalizable reference. The importance of such work is in its particular subjective and unconventional reference. While the aesthetic may appear to occupy a pole opposite to the scientific, we may propose that both poles are necessary to express the life of human beings.

Both art and science bring an appreciation of form and the expression of meaning. Maps, traces and graphs are articulate forms of an inner reality. So are the objects of art. They exist as articulate forms; they have an internal structure which is given to perception. However, while the graph is a regularized form whereby the individual, as content, is charted upon given axes, the object of art is both the expression and the axes of that expression, ie form and content.

In expressive art sensory qualities are liberated from their usual meaning. While science requires the graph for regularity, art requires that forms are given a new embodiment; they can be set free to be recognized. In this way qualitative form can be set free and made wholly apparent in direct contrast to the questionnaire method where inner subjective realities are submitted to an external objective form.

This is not to deny the use of the questionnaire, rather to emphasize the possibility of considering expressive forms when we wish to discover what the quality of life is. Sensual qualities then become of vital import to the whole, not to be rated on a scale, but intrinsic to the total gestalt.

In this way of researching we are concerned with showing rather than saying.

Expression The artistic symbol negotiates insight not reference.

It expresses the feelings from whom it stems and is a total analogue of human life. The symbol and that which is symbolized have some common logical form, ie they are isomorphic.

Science negotiates reference not insight. That which is within the individual is placed within a context.

Music and art are concerned, not with the stimulation of feeling, but the expression of feeling. It may be more accurate to say here that feelings are not necessarily 'emotional state', more an expression of what the person knows as inner life, which may exceed the boundaries of conventional categorization.

By encouraging non-verbal forms of expression we can learn and utter ideas about human sensibility.

A reliance on verbal methods alone assumes that we can know and speak about all that we are. A reliance on machine expressions of our inner realities assumes that all that we are is measurable and material.

Conclusion A time has come when we can judge our research on 'whether it makes a powerful and important contribution to the cumulative e ~ i d e n c e on ' ~ a particular issue rather than whether or not it formally proves a point. This recognition of subjective data is occurring at a time when an emphasis is being placed on the 'whole' patient.

Balint showed us that it is not solely scientific skills which help us to fully understand the patient. It is possible to have a descriptive science of human behaviour which can be based upon the aesthetic. In this way we can ask of our research that it expresses what it is to be human, what it is to be well and what it is to fall sick.

As modern living provokes ever more anxiety then the present search for scientific solutions based upon predictability, and the attempted control of nature by technology continues. This retreat from the anxiety of dying and its emphasis on the material prevents us from understanding the true process of living. How can we then offer hope and comfort to the sick and the dyinglO? The politics of medicine, and the technology of modern medicine which serves it, places the existence of the individual in question. Personal means of health are concerned with a subjective reality which is symbolic. As human beings we are capable of selfregulation, and the foundations of this regulation are not confined to objective criteria. In many cases we are mysterious to ourselves. We have properties which are concerned with a created knowledge.

As clinicians and researchers then, how are we to face the problem of how to constitute an ethics of existence not solely founded on a scientific knowledge of the self which is comparative to group norms, but one in which the principal act is creative?

Our task is to ask of ourselves, and then of our patients, 'How can we create ourselves as a work of art?' ll.

The implications of this thinking for research practice is that we can encourage people to develop an articulacy of self based on their own expressive realizations. These may be expressed in the form of music, or pictures or stories. We can encourage people to document their journeys through life not as the accumulation of material quantities of flesh and blood but in sounds, words and pictures. The documentary of life's journey through a chronic illness may be realized in a series of case notes. However, it can also be possible to document that journey as a series of photographs which are far more eloquent for the travellers. The preservation of the values of humanity within our culture are as much in the hands of the cliniciadresearcher as artist as they are in the cliniciadresearcher as scientist.

Human behaviour cannot be studied from one point of view only. Within the total repertoire of medicine it is necessary to have different approaches to understanding the world: the scientific and the aesthetic. This position, of multiple understandings, offers an acceptance of orthodox clinical trials

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together with a promotion of new understandings12.

By doing so differing studies inform each other.

It is vital that we pursue academic rigour in our experimentation. But not by burying our heads in the sand. Rigour without imagination leads to stagnation just as imagination alone leads to anarchy. Modern clinical medical research can combine the two. A combination of rigour and imagination is necessary to meet the challenges of health care. Our intellectual endeavours should be astute enough to see that science can accommodate multiple viewpoints13-l5 and search for a reconciliation of difference within the framework of the scientific, which is Truth, and the aesthetic, which is Beauty.

References 1 Grohmann W . Klee. London: Thames and Hudson, 1987 2 Hart JT.Where is general practice going? New Doctor 1984;33:8-10 3 Langer S. Feeling and form: a theory of art. London: Routledge & Kegan Paul, 1953 4 Watzlawick P. The invented reality. New York: W W Norton & CO,1984 5 Barlow DH, Hersen M, Jackson M. Single-case experimental designs. Arch Gen Psychiatry 1973;29:319-25

6 Burkhardt R, Kienle G. Basic problems i n controlled trials. J Med Ethics 1983;9:80-4 7 Heron J. Critique of conventional research methodology.

Complementary Medicinal Research 1984;1:12-22 8 Declaration of Helsinki. Recommendations guiding doctors in biomedical research involving human subjects.

Adopted by the 18th World Medical Assembly, Helsinki, Finland, 1964, and as revised by the 29th World Medical Assembly, Tokyo, Japan, 1975 9 Pringle M . A minority interest: why? BMJ 1984; 289:163-4 10 Aldridge D. One body: a guide to healing in the Church London: S:P:C:K,1987 11 Rabinow P. The Foucault reader. London: Penguin, 1986 12 Touw-Otten F , Spreeuwenberg C. Multi-disciplinary research between natural and social sciences i n general medical practice. Fam Pract 1985;2:42-5 Howie JGR. Research i n general practice: pursuit of knowledge or defence of wisdom. BMJ 1984;289:1770-2 Rose AT. Chronic illness i n general practice. Fam Pract 1984;1:162-7 Freeling P. Health outcomes i n primary care: an approach to problems. Fam Pract 1985;2:177-81

(Accepted 25 April 1990)

22;

lournal of the Royal Society of Medicine Volume 80 April 1987

Clinical assessment of acupuncture in asthma therapy: discussion paper

D Aldridge P

~ D

P C Pietroni FRCGP MRCP Department of General Practice, St Mary's Hospital Medical

School, London Keywords: acupuncture, asthma, complementary therapy, controlled trials

This paper is concerned with reviewing the use of acupuncture for the relief of chronic bronchial asthma, for it is our intention to embark upon a controlled clinical trial of acupuncture therapy in the context of general medical practice. A secondary property of this paper is a discussion of clinical trial methodology as applied to a complementary therapy.

Acupuncture Acupuncture is a therapy which has gained some recognition both within the realms of popular practice and, perhaps more importantly, within the realm of medical practice. The practice of acupuncture is a collection of procedures which include the insertion of needles at specific points of the body for both the relief of pain and the treatment of disease, with moxibustion and cupping.

Traditional descriptions of acupuncture are concerned with the flow of vital energy, called ch'i, along fixed paths called meridians. These are linked together with each other and the organs of the body.

Flow of energy along these paths has a circadian rhythm, so that at times and season it may vary.

Energy in this context has a bipolar character; it can be positive called 'yang', and negative called 'yin'.

The energy within the body, ch'i, reflects both the vitality of the universe and society l.

For a body to be healthy in this system of description, the flow of ch'i in the meridians is normal and balanced. Essentially the process is one of maintaining balance, i.e. becoming healthy or losing health.

Diagnosis, too, is seen as a process and takes into account many factors. It includes a patient history of changes in behaviour, appetite and emotions. The state of the skin, eyes, breath and tongue are noted for colour, consistency and odour. There are also special techniques for the evaluation of the flow of energy in the 12 meridians, electrical measurements of skin resistance, and the palpation of skin subcutaneous tissue.

Although the mode of action of acupuncture is not known precisely, there are a number of suggestions which propose that the mechanism is linked with the secretion of endorphins2. Yu and Lee3 suggest that acupuncture relieves that part of the bronchoconstriction which does not arise from the constriction of smooth muscle as a result of chemical mediators.

The effect of acupuncture in asthma is mediated through modification of the reflex component of 0141-0768/87/ bronchoconstriction.

Other writers invoke the prox04022203,~0200/0 imity of the central nervous system projections of the @ 1987 acupuncture simulation site and the pain path as the The Royal rationale for the selection of treatment loci, humoralSociety of biochemcal mechanisms, neuromechanisms, and the Medicine

bioelectric mechanism1.It has been pointed out, however, that these descriptions are made by 'scientific apologists'1.

It is more likely that acupuncture represents many phenomena and that a primary difficulty, as discussed later, lies in a treatment modality that is underpinned by an Oriental philosophy being subjected to an explanation by the differing theoretical understanding of modern Western medicine.

Asthma Asthma is a condition characterized by symptoms which are present over long periods of a patients' life.

The number of people with asthma in the United Kingdom is estimated to be about two million - a number too great for the hospital services to provide continuing care. Although the condition is often mild and readily treated, for those persons with a chronic condition the illness is composed of recurrent crises and debilitation. Gregg4estimates that the incidence of asthma in the population is increasing, and in a form that is frequently more severe than in the past.

The general practitioner is in a position to identify the incidence of asthma, to be involved in preventive measures and to offer early treatment. Many persons seen in hospital outpatient departments could be managed just as easily in the context of the general practitioner clinic5.

Asthma is often refractory to pharmacotherapy, the side effects of which can be distressing. A low-risk form of treatment such as acupuncture could constitute an advancement in the management of asthma6, particularly if used in the context of general medical practice which utilizes elements of patient education and a self-care perspective.

Clinical controlled trials of asthma A literature search was carried out using the Medline database through St Mary's Hospital Medical School library. The criteria for the search were English language papers on 'asthma therapy' and 'acupuncture' published in the past ten years. Eight studies were discovered having a controlled trial methodology which used either a 'placebo' or 'no treatment' control group3v612.

Although these trials ostensibly used a controlled trial methodology, there were many inconsistencies.

First, most of the trials had few subjects; the largest trial had 111subjects but the rest had no more than 25. Second, there was a large disparity in the age ranges; in one trial the ages ranged from 6 to 71 years.

Third, the clinical entities were wide-ranging.

The predominant conclusion of the controlled trials was that at best acupuncture resulted in only

Journal of the Royal Society of Medicine Volume 80 April 1987

modest improvement in the 'objective' assessment of airways impedance. These objective measures were mainly concerned with expiratory flow rates, airway conductance and thoracic gas volume. A greater perception of symptom relief was made subjectively by the patients using self-report measures and diary techniques, a point that will be discussed further later in the paper.

Clinical evaluations Two t r i a l ~ were ~ ~ , essentially ~ ~ evaluations by clinicians of clinical practice. A range of symptoms associated with asthma were covered, the treatment approach being varied according to the presenting symptoms. The number of treatment sessions was not standardized but varied according to the symptoms and symptomatic improvement.

The criteria for improvement were subjective and included the assessments of both practitioner and patient. Cioppa13 found that 67% of the patients improved with acupuncture treatment. The conclusions of this research were that acupuncture appears to: (a) relieve muscle spasm; (b) be useful in subacute onditions; (c) be something other than hypnosis; (d) acilitate manipulation; (e) have an immediate effect; (/) give complete remission - not only palliation - in many cases; (g) give a sense of well being; (h) be a valuable adjunct to standard practice. Fuller14 also considered acupuncture to be effective in treating chronic asthma and recommended its use.

The remaining papers were a collection of miscellaneous reports and letters about the clinical application of acupuncture, the relationship to general medical practice, and replies to letters15z1.

Hossrizzdescribed the use of acupuncture massage for the relief of asthma in children. This entails a number of techniques using pressure a t acupuncture sites, friction and manipulation. Hossri also used hypnosis in combination with these techniques.

Acupressure, the substitute of digital pressure for needling at specific sites, has been used in medicine and dentistry both for the relief of pain and tensionz3- 2 5 .

K

R'

iscussion here is a disparity between the claims of acupuncturists as to positive clinical benefit, and the findings of the clinical trials research, which demonstrates little 'objective' change but does emphasize 'subjective' change. Such difficulties bedevil the assessment of alternative or complementary therapies, particularly since there is a confusion between different levels of measurement - i.e. between that which is measurable in terms of quantity such as gas volume, and that which cannot be readily subjected to such quantification such as 'feeling better'.

A more serious critique concerns the controlled trial methodology itself. The trials studied here failed to provide a sample size with sufficient power to make any valid conclusions from the statisticsz6.Furthermore, the trials really did not investigate 'acupuncture'. The process of standardizing the treatment approach removed from the practice itself that which is the essence of the treatment. By restricting needling sites to specific loci, limiting the number of treatment sessions and abdicating the use of traditional diagnostic practices, the trials were really reduced to testing the insertion of needles a t particular points. It is therefore not surprising that needling as 'acupunc-

ture' in these trials differed from needling as a 'placebo' or 'sham' acupuncture. What the trials failed to do was realize that even though methodology can be applied, if it is applied without understanding simply as a formula then no significant findings emerge. To do this abdicates both responsibility in science and real discovery. Science is not methodology;methodology serves science.

How can we as scientists say that we have subjected a practice to adequate investigation when we remove from the process that which is essential?

When applied rigidly, clinical trials remove the interaction between the subject and the researcher. It is this very interaction which is at the very heart of clinical practice, and which cannot be removed no matter how impersonal we may wish to be. The separation of the disease from the person loses those very qualities which we need to understand. Diseases may be treated as aggregates and submitted to statistical analysis, but it is individual persons in whom those diseases are located and who confront us in our surgeries.

Another feature of the clinical trial methodology was that asthma was seen as a homogeneous clinical entity. There was no consideration that the symptoms were located within persons who perceived their symptoms differentially, or that asthma in a 6-year-old is qualitatively different from that in a 71-year-old.

Asthma appears to be tractable to acupuncture when treated by committed clinicians who use traditional techniques. The clinical trials have not investigated acupuncture as a treatment modality, but 'needling techniques'. The challenge for clinicians and researchers is to examine rigorously the practical effects of acupuncture treatment but from a perspective which involves the whole person and the totality of the treatment process.

The way forward It is our intention to carry out a pilot study of acupucture treatment and education classes in the management of chronic asthma. Our referrals will be taken from hospital outpatients where the patients will be assessed by an external researcher, who will also carry out the post-trial blind assessment. Of 150 patients who will be recruited to the study, 50 will be randomly allocated to an acupuncture treatment; another 50 oatients will be allocated to education classes; and the third group of 50 patients will be offered continuing general practitioner contact only.

All groups will be asked to complete a diary for the eight-week treatment period, and a t a later follow-up period.

The acupuncture treatment method will be determined by the acupuncturist. There-willbe no definite fixed number of treatment sessions, but it is anticipated that the acupuncturist will attempt to keep within the eight-week timescale. The acupuncture sites will not be controlled, and it is expected that the acupuncturist will use a traditional pulse diagnosis.

The data collected will cover a broad spectrum of information concerned both with the symptoms and illness behaviour, as follows: (1) impact of asthma upon health (using the Nottingham Health P r ~ f i l e ~ and ' * ~ life ~ style data (Social Problem Q~estionnaire*~), and locus of control30;

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(2) diary recording of events3133,asthma attacks, use of medication/bronchodilator, night-time disturbance, time off work, crisis consultations, GP home visits and scores for wheeze, breathlessness, chest tightness and cough; (3) qualitative measures of practitioner, patient and family satisfaction; (4) knowledge and skills of patient about the management of asthma; (5) peak expiratory flow.

The education classes will consist of direct teaching about allergens and triggers of asthma (physical, psychological and relational); the correct use of medication, where appropriate, and the bronchodilator; and what asthma is in terms of airway impedance. Building on this basis there will be an opportunity for each person to identify through the diaries their own particular triggers.

A number of complementary strategies will be introduced, including dietary understandings, specific breathing technique, the use of relaxation techniques and stress management. It is anticipated that the people involved in this project will be able to personalize these strategies according to their own lifestyles and the contexts in which they become symptomatic.

This pilot study will attempt to meet our earlier criticisms of controlled trials. Acupuncture will not be restricted solely to needling, and a range of data will be collected which will include the physical, the psychological, the relational and the familial.

Acknowledgment: This research is funded by the Wates Foundation.

References Millman BS. Acupuncture: Context and critique. Ann Rev Med 1977;28:223-34 Guillemin R, Vargo T, Rossier J. Beta endorphin and adrenicorticotrophin are secreted concomitantly by the pituitary gland. Science 1977;197:1367 Yu DYC, Lee SP. Effect of acupuncture on bronchial asthma. d i n Sci Molec Med 1976;51:503-9 Gregg I . The quality of asthma in general practice - a challenge for the future. Family Practice 1985;2:94-100 Arnold AG, Lane DJ, Zapata E. Acute severe asthma: Factors that influence hospital referral by the general practitioner and self referral by the patient. Br J Dis Chest 1983;77:51-9 Dias PLR, Subramanian S, Lionel NDW. Effects of acupuncture in bronchial asthma: a preliminary communication. J R Soc Med 1982;75:245-8 Shao JM, Ding YD. Clinical observation of 111 cases of asthma treated by acupuncture and moxibustion.

Journal of Traditional Chinese Medicine 1985;5:23-5 Christensen PA, Laurensen LC, Taudorf E, Sorensen SC, Weeke B. Acupuncture and bronchial asthma.

Allergy 1984;39:379-85 Berger D, Nolte D. Acupuncture in bronchial asthma: body plethysmographic measurements of acute bronchospamolytic effects. Comparative Medicine East and West 1977;5:265-9

10 Tashkin DP, Bresler DE, Kroenig, RJ, Kerschner H, Katz RL, Coulson A. Comparison of real and simulated acupuncture and isoprotenerol in metacholine-induced asthma. Ann Allergy 1977;39:379-87 11 Tashkin DP, Kroenig RJ, Bresler DE, Simmons M, Coulson AH, Kerschnar H. A control trial of real and simulated acupuncture in the management of chronic asthma. J Allergy Clin Immunol1985;76:855-64 12 Takishima T, Mue S, Tamura G, Ishihara T, Watanabe K. The bronchodilating effect of acupuncture in patients with acute asthma. Ann Allergy 1982;48:44-9 13 Cioppa FJ. Clinical evaluation of acupuncture in 129 patients. Diseases of the Nervous System 1976;37:639-43 14 Fuller JA. Acupuncture. Med JAust 1974;ii:340-l 15 Alien M. Activity generated endorphins: a review of their role in sports science. Can J Appl Sport Sci 1983;8:115-33 16 Rebuck AS. The outpatient management of asthma.

Ann Allergy 1985;55:507-10 17 Donnelly WJ, Spyykerboer JE, Thong YH. Are patients who use alternative medicine dissatisfied with orthodox medicine? Med JAust 1985;142:53941 18 Bodner G, Topilsky M, Greif J.Pneumothorax as a complication of acupuncture in the treatment of bronchial asthma. Ann Allergy 1983;51:401-3 19 Hayhoe S. Effects of acupuncture in bronchial asthma J R Soc Med 1982;75:917 20 Marcus P. Effects of acupuncture in bronchial asthma.

J R Soc Med 1982;75:670 21 Rosenthal RR, Wang KP, Norman PS. All that is asthma does not wheeze. N Engl J Med 1975;292:372 22 Hossri CM. The treatment of asthma in children through acupuncture massage. Journal of the American Society of Psychosomatic and Dental Medicine 1976; 23:3-16 23 Weaver T. Acupressure: An overview of theory and application. Nurse Practitioner 1985;10:38-42 24 Kurland D. Treatment of headache pain with autoacupressure. Diseases of the Nervous System 1976; 37:127-9 25 Penzer V. Acupressure in dental practice: Magic at the tips of your fingers. Journal of the Massachusetts Dental Society 1985;34:71-5 26 Lewith GT, Machin D. On the evaluation of the clinical effects of acupuncture. Pain 1983;16:111-27 27 Hunt SM, McEwen J , McKenna SP. Measuring health status: a new tool for clinicians. J R Coil Gen Prac 1985;35:185-8 28 Hunt SM, McEwen J, McKenna SP. Social inequaliti and perceived health. EffectiveHealthCare 1985;2:1514 29 Corney R, Clare AW. The construction, development and testing of a self report questionnaire to identify social problems - a pilot study. Psychol Med 1985; 15:637-49 30 Lefcourt HM. Locus of control. New Jersey: Lawrence Erlbaum, 1982 31 Barry DMJ, Marshal1 TH, Rothwell RPG. Asthma and diaryltreatment cards. NZ Med J 1985;98:556 32 Freer CB. Self care: a health diary study. Med Care 1980;18:853-61 33 Murray J. The use of health diaries in the field of psychiatric illness in general practice. Psychol Med 1985:15:82740

(I

(Accepted 9 September 1986)

Journal of the Royal Society of Medicine Volume 84 May 1991

249

Editorials

Military doctor

The late Major General William Officer said that he required his medical officers to give one hundred per cent as soldiers and one hundred per cent as doctors.

With the recent deployment of the medical services of the Armed Forces to support the British military effort in the Gulf it is worth examining this requirement to determine whether General Officer's criteria are appropriate and whether they can be met.

The first reaction is that the medical officer of the Armed Forces may be serving in the Royal Navy, the Army or the Royal Air Force. Each service has its own special requirements for medical support in times of war but it is essential that the management of casualties should follow a coordinated plan. The direction of the three medical services under a Surgeon General a t the Ministry of Defence has ensured that this is the case and that there is close cooperation between the three medical services at all levels from Forward Treatment Unit back to National Health Service Hospitals in the United Kingdom. It is essential that every medical officer understands the special requirements of his or her own service in the maintenance of the health of the Force, in appropriate deployment to their special tasks and the threats inherent in their deployment and in current military weapons technology.

In the Gulf area it can be readily appreciated that the climate imposes its own burdens which can be greatly added to by the threat of chemical weapons.

The vast areas of empty desert pose special dficulties in the collection, first aid, treatment and evacuation of casualties to base hospitals in Saudi Arabia and to hospital ships prior to evacuation by air to the United Kingdom. Ten years ago the military medical professors coordinated regular courses of instruction in war surgery and war medicine, held a t the Royal Army Medical College but involving participants from all three services and including reserve medical and nursing officers. Guest lecturers included senior doctors from the Middle East with recent combat experience.

These courses began before the Falklands Campaign (19821, which was a testing ground for all three medical services and the experience so gained was fed

Single-caseresearch designs for the clinician Introduction Single-case study d e ~ i g n s l -are ~ an attempt to formalize clinical stories. These designs take as their

back in to these instructional courses and also in to the Annual Field Exercises of forward Medical Units of the Regular and Reserve Forces.

The Armed Forces Medical Services in peace time cannot effectively employ the number of doctors and nurses required for operational support in war.

Fortunately the system of granting short service commissionsto doctors and nurses with an emphasis on training for their peace time and war time roles has provided a large pool of experienced medical and nursing staff on the regular reserve or serving with volunteer reserve units. Thus the reserve units are as well trained as their regular colleagues and the volunteers bring to their tasks an enthusiasm and commitment which is impressive to behold.

Medical resources on a battlefield will always be limited by the war environment. The enormous technical advances in surgery which have transformed the outlook for patients with congenital or degenerative conditions may not have immediate application on the battlefield but the developments in resuscitation, intensive care and anaesthesia which has accompanied them have greatly increased the chances of survival of the seriously injured. Surgery and medicine on the battlefield are aimed a t preserving life and minimizing disability1. By the time the patients reach base hospital they should be in a stable condition and ready for restorative treatments, convalescence and rehabilitation.

All medical and nursing disciplines can make a significant contribution to the medical care of our sailors, soldiers and airmen. From the medical support in the front line through the dramatic intervention of the surgical teams and the specialist support of the physicians to the psychiatric social worker back in the United Kingdom all have been trained and exercised in their role, and those of us who can only watch and wait are assured that they carry it out with the utmost professional dedication.

Major General Robert Scott Totnes, Devon Reference 1 Ryan JM,Cooper GJ, Haywood IR, et al. Field surgery on a future conventional battlefield: strategy and wound management. Ann R Coil Surg Engl 1991;73:13-20

basis the clinical process where the illness is assessed and diagnosed, a treatment is prescribed, the patient is monitored during the application of that treatment, and the success of the treatment is then evaluated.

However, the validity of this therapeutic 'success' is open to question. There may be a subjective bias influenced by the expectations of the clinician and the

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patient. Similarly, the patient may appear to improve through willingness to please the physician. In some cases, the disease may have run its course and improvement would have occurred without a therapeutic intervention. Finally, the initial assessment of the patient may have represented temporary extreme values which are lessened at a subsequent assessment; ie a 'regression towards the mean7.

The experimental approach attempts to accommodate these difficulties by systematically varying the management of the patient's illness during a series of treatment periods4using randomization of treatment periods and blind assessment. In the single case approach the patient is the source of his or her own statistic, randomized treatment and blind assessment may be incorporated within the therapeutic plan. The patient is not compared with a group norm, his or her progress is in accord with individual constitution, which is subject to statistical verification using the analysis of data trend^^-^.

Single-case research designs are not a unified approach. There are differing levels of formality and experimentation: ie randomized single-case study designs, often called N=I s t u d i e ~ ~ and , ~single-case *~ experimental designs2J0.A common feature of these designs is that they stay close to the practice of the clinician. An advantage is that there are no difficulties of recruiting large groups of patients, or having to collect and analyse large data sets.

A criticism of group designs is that they mask individual changell. Improvement or deterioration is not evident for particular patients. Furthermore, the results of large-scale trials are not always easy to translate into clinical terms for the practitioner.

Single-case designs highlight individual change in daily clinical practice. Furthermore the dilemma of clinical priorities or research priorities is minimized.

This type of research is applied as part of the clinical treatment and is relevant to both clinician and patient. In some cases patient and clinician are the researchers4.

The principal feature of single-case study designs is that they are feasible. The problems of recruitment are minimized, the study is cheap and the results are generally evident. Much research flounders because of the difficulties of finding large groups of patients with similar symptoms, a lack of resources (time, personnel and money) or an absence of clear statistical analysis which is often compounded by initial confusions in the methodological approach. In this approach each person serves as his or her own control.

Effective treatments are linked with specific patient characteristics which are immediately relevant to the clinician and the patient. Any decisions about the design of the trial, and the choice of outcome measures, can be made with the patient9. The primary focus of the research is upon the treatment benefit for the individual, whereas conventional studies are more concerned with changes in groups of patients. A weakness of single-case designs is that, while individual change is specific, it is difficult to argue for a general validity of the treatment. To overcome this problem it may be feasible for groups of co-operating practitioners to collect single case data according to a common format and then analyse that collected data as a group.

The first step in this approach is to identify the target behaviour. This can be a symptom or physical sign, a result of a test, or an indicator suggested by

the patient. This is negotiated with the patient and is understood by both clinician and patient as being appropriate and relevant to the patient's well-being or clinical improvement. A critical feature of this target behaviour is that it will be susceptible to rapid improvement when therapy begins. This target behaviour then becomes the baseline measure in an initial period of observation. The initial period of observation is sometimes called the 'A' phase. The intention of this phase is to enable a stable pattern or trend to emerge. This is based on the natural frequency of the symptoms. Any treatment effects can then be seen clearly in contrast to this baseline. It is important that the method of measuring the observed behaviour is specified accurately. There can of course be more than one form of assessment; the clinician may want to rely upon physiological, immunological or biochemical markers while the patient may devise a self-report index. Apart from its clinical value, the choice of measure has a secondary research value. If the case study is to be part of a systematic research approach the measure will need to be replicable. Similarly, if the research is also intended to speak to other practitioners it is important to develop a measure which they can validate.

The development of a specific evaluative index12, or battery of tests, is an important task which challenges the clinician to relate theory to clinical practice. The main requirement of such an index is that it will be sensitive to change over time and will include all the clinically important effects. It is important to be able to link those clinical changes to the treatment.

Once the baseline has been established then the agreed treatment variable is introduced. There can be multiple treatment courses during this period, and these can include placebo. In the randomized case design these treatment courses are randomly assigned. This design is strengthened by the possibility for the patient and the clinician to be blind to the treatment variable if a medicament is used. Where the patient and clinician cannot be blind to the treatment intervention an external assessor can be blind to the treatment period. Such an external assessor can also act as a monitor of the trial and halt the trial if it is in the best interests of the patient.

Where the treatment variables cannot be randomized, single-case experimental designs are used with an assessor blind to the treatment phase.

The initial baseline 'A' period is followed by a treatment period, 'B'. This is an improvement on the case history in that it offers comparative data in two clear phases. This design can be extended by an additional assessment 'A' phase. There are problems here in that a decision about when to stop treatment has to be made, and the treatment may not be continued to conclusion. This is compounded by the difficulty of ending on a 'no treatment' phase.

If a further treatment period is introduced, then an 'A B A B' design occurs. The intention in these designs is to keep the length of the treatment phases identical.

These designs can become quite complex and include composite treatments. Parts of the treatment can then be omitted or included systematically. For example; after the baseline data are gathered, 'A', then a composite treatment is administered 'BC'. This could be a treatment which included manipulation of the body and a medicament. In the following phase the medicament could be withdrawn, the 'B' phase. The

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next phase returns to the composite treatment. This then becomes an 'A BC B BC' design.

Multiple baseline designs have been used to test some psychological behaviour approaches1°J3The treatment variable stays the same, but there are multiple baseline target behaviours of differing duration. Ideally these target behaviours are specific and independent.

The patient diary can be part of an evaluative index.

In diary studies the principal collector of data is the patient. The use of subjects making their own assessments of symptomatology is not new14, and offers a non-intrusive means of gathering data.

The use of diaries in clinical practice has several advantages. First, there is the opportunity to provide a daily scoring which eliminates recall error and produces consistent reporting. Second, there is a comprehensive view of the person's health15. Third, symptoms are treated as episodes rather than solely static events16J7. Fourth, diffuse conditions are included which may not be disabling or necessitate intervention but which contribute to the profile of the patient's symptomatology.

In single-case designs there are possibilities for a statistical analysis of each single study1s9.However, the main appeal of working in this way is that daily measures are plotted on a chart and can be seen by eye. Clinical improvement can also be assessed by reports from the patient and various persons connected with the patient (spouses, relatives, experts) who can also suggest that the change is of applied significance.

Statistical analysis can be used where subtle significant changes occur in the data which are not immediately visually apparent, or where many variables are collected from an individual and need to be correlated one with another. If data are serially dependent then it is possible to perform a time series analysis of the data. This provides important information about the different characteristics of behaviour change across phases, and a statistic which indicates significant change5. Such time series analysis requires large samples of data points to select the processes within the series itself. This time series analysis of data has proved to be clinically relevant.

It has been demonstrated that the time series analysis of serum creatinine levels from renal transplant patients is sensitive enough to detect transplant rejection which precedes that of experienced clinicians6. Furthermore, time series analysis of trends in data can also be sensitive to the circadian rhythms of physiological processes and influence the administration of drug regimens7.

A difficulty which can arise in single-case studies is when they are used following a period of standard treatment which has not worked. Some general improvement may occur which is nothing to do with the treatment being used but is a 'regression towards the mean', ie the tendency of an extreme value when it is remeasured to be closer to the mean. This can be overcome by including a washout period between the treatments. Such a period would serve to establish the patient's eligibility for the trial. Following this there would be a set of measurements which would be considered as the baseline data. The consistent recording of longitudinal multiple data in these studies requires great perseverance on behalf of the collector and the patient. This is mitigated by the sample size of one.

Perhaps the major criteria for using a single-case design are that the treatment should exert its effect in a moderately short time, and the effect will be temporary and reversible once treatment is discontinued. If not, then a group design must be considered. These single-case methods are generally reliant upon a stable baseline period in the 'A' phase.

This means that they are not particularly relevant to acute or labile problems. They are appropriate for chronic problems, or patterns of recurring behaviour, which have become stable over time.

The advantages of these single-case research designs are their flexibility of approach and the opportunity to include differing levels of rigour.

Such designs are appropriate for practitioners wishing to introduce research into their own practice, and particularly for developing hypotheses which may be submitted for other methods of clinical validation at a later date. Furthermore, with the development of statistical methods suitable for the monitoring of subjective, rhythmic or episodic data, which is not dependent upon the collection of equally spaced recording, and which provides a method which can detect changes and also discriminate between those changes5, clinicians have an opportunity to validate their clinical finding.

This analysis is pertinent to the individual in that they are always compared to their own individual physiology.

D Aldridge Universitat WittedHerdecke Medizinische Fakultat Beckweg 4, D-5804 Herdecke, Germany

References 1 Aldridge DR. Single case research designs. Complementary Medical Research 1988;3:37-46 2 Barlow DH, Hersen M. Single case experimental designs: strategies for studying behaviour change. New York: Pergamon Press, 1984 3 Kazdin A. Single case research designs: methods for clinical and applied settings. New York: Oxford University Press, 1982 4 Guyatt G, Satchett D, Taylor D, Chong J, Roberts R, Pugsley S. Determining optimal therapy randomized trials in individual patients. New Engl J Med 1986; 314:889-92 5 Gordon K. The multi state Kalman filter in medical monitoring. Computer Methods and Programs in Biomedicine 1986;23:147-54 6 Smith A, West M, Gordon K, Knapp M, Trimble I. Monitoring kidney transplant patients. Statistician 1983;32:46-54 7 Kowanko I, Pownall R, Knapp S, Swannell A, Mahoney P. Time of day of prednisolone administration in rheumatoid arthritis. Ann Rheumatic Dis 1982; 41:447-52 8 Louis T,Lavori P, Bailar J, Polansky M. Cross-overand self-controlledtrials in clinical research. N Engl J Med 1984;310:24-31 9 McLeod R,Taylor D, Cohen Z, Cullen J. Single patient randomised clinical trials. Lancet 1986;29:726-8 10 Barlow D, Hersen M, Jackson M. Single-caseexperimental designs. Arch Gen Psychiatry 1973;23:319-25 11 Aldridge D, Pietroni P. Research trials in general practice towards a focus on clinical practice. Fam Pract 1987;4:311-15 12 Kirshner B, Guyatt G. A methodological framework for assessing health indices. J Chronic Dis 1985;38: 27-36

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13 Murphy R, Doughty N, Nunes D. Multi-elementdesigns: an alternativeto reversal and multi-element evaluative strategies. Mental Retardation 1979;17:23-7 14 Murray J. The use of health care diaries in the field of psychiatric illness in general practice. Psychol Med 1985;11:551-60 15 Monck E, Dobbs R. Measuring life events in an adolescent population: methodological issues

Community and asylum care: plus qa change

and related findings. Psychol Med 1985;15:84150 16 Aldridge D, Rossiter J. Difficult patients, intractable symptoms and spontaneous recovery in suicidal behaviour. J Systemic Strategic Ther 1985;4:6676 17 Aldridge D, Rossiter J. A strategic assessment of deliberate self harm. J Fam Ther 1984;6:119-32

physical environment of the asylum was significant.

Turner3 quotes Browne writing in the 1830s: 'Conceive a spacious building resembling the palace of a peer,

airy, and elevated and elegant . . . the sun and air are allowed

Controversy still surrounds the future of Britain's mental hospitals1 despite 15 years of consistent Government policy2. Little attention has been paid to the lessons of the past, despite parallels between contemporary developments and those of 150 years ago3. Common themes are therapeutic optimism, the expansion of the scope of cure and political economy.

The latter is made much of e l s e ~ h e r e ~The . ~ . 19th century-builtasylums are now seen as a bad thing, but this in itself is not new. What is different about this revolution in mental health is the absence of the wider societal changes which characterized the 19th century revolution7.The pressure for change has been directed a t stamping out organizational bad practice. The therapeutic revolution of rehabilitation and normalization can be seen as being more apparent than real.

Scull7 argues that the 'asylum' movement did represent a major shift in the way the insane were treated. This change was mirroring wider societal/philosophicalchanges which laid emphasis on individual responsibility and rationality. As the industrial revolution progressed and the system of feudal patronage broke down, the industrious poor came to be valued chiefly in terms of the marketability of their labour. Thus, it became increasingly important to distinguish the deserving poor (who were supposedly incapable of supporting themselves) from the undeserving poor (who were poor, but were supposedly capable of earning a wage and could therefore support themselves). The insane were seen as being part of the deserving poor and so were separated out. This was most efficiently done by bringing them together in one place.

However, the 'Reformers' (such as Tuke and Connolly) envisaged 'the model institution' where the patient might be returned to good health, not just warehoused. The treatment in these institutions ('moral treatment') identified the social environment as being the therapeutic agent, acting through the patient's mind8. Two aspects of the social environment were regarded as especially important. First, the attitudes and demeanour of the attendant staff, were significant. In Tuke's words 'treating the patient as much in the manner of a rationale being as the state of his mind will possibly allow . . . whatever tends to promote the happiness of the patient is therefore considered of the highest importance in a curative point of view' (Tuke 18139).Secondly, the

to enter at every window . . . the inmates all seem to be activated by the common purpose of enjoyment, all are busy and delighted by being so.'

However, the asylums quickly came to be perceived as falling far short of the ideals of the Reformers.

Mortimer Granville (quoted by Scull9),for example, in 1887 described the Middlesex County asylum at Colney Hatch (later to be called Friern Hospital) as a: 'colossal mistake . . . it combines and illustratesmore faults in construction and errors of arrangement than might have been supposed possible in a single effort of bewildered or misdirected ingenuity . . .the wards are long, narrow, gloomy and oppressive,the atmosphere of the place dingy, the halls huge and cheerless. The airing courts, although in some instances carefully planted, are uninviting and prison-like.'

The Reformers plans for achieving more cures thus depended on the virtues of staff morality and landscape architecture. These plans for 'moral cure' seemed to be destroyed by: (1) Increasing numbers of the insane, few of whom seemed to be curable. They soon filled up the existing services defying the reformers notion that people would return to good mental health and the community.

(2) The pressure to economize in the light of the demise of Britain's international competitiveness a t the end of the 19th century.

(3) The medical profession's keenness to monopolize the care of the mentally il19J1,required them to have large hospitals like those of their medical colleagues.

Scull7 argues that 'there was a change in the cultural meaning of madness' in the 19th century.

This involved a change in perspective consistent with an increasingly technological age, when people came to be seen as less 'god given'. They were seen as rational beings, internally motivated and regulated by rules internalized from the environment. Similarly, the insane came to be seen as rational beings, capable of being influenced by the same forces as those acting upon sane people. Previously the insane were seen as having lost entirely the human features of reason, and o141~07681911 were left in a state of 'animality'lO. These changes 050352031S020010 helped fuel 'the moral outrage which did so much to 001 ---animate the lunacy reformers . . .' of the 19th ~h~ ~~~~l century7.Today there is no equivalent radical change Society of in the perception of the mentally ill. On the contrary Medicine

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Music, communication and medicine: discussion paper

D Aldridge RID

Medical Faculty, Uniuersitat Witten Herdecke, Beckweg 4 D-5804 Herdeke (Ruhr), FRG

Keywords: music therapy; physiology; communication; child development; rhythm entrainment

'The body of the speaker dances in time with his speech.

Further, the body of the listener dances in rhythm with that of the speaker!'

(Condon and Ogston, p 338)

In our work as a department of music therapy within the faculty of medicine in a West German teaching hospital we have begun to explore links between the playing of improvized music as therapy and the practice of medicine. Music therapists work with physicians within the hospital as complementary practitioners. We have attempted to develop a common language by which patients are described.

This language calls upon the art of medicine as much as it does upon the science of medicine. Our contention is that human beings have a personal identity which is musical1. When we search for a metaphor which informs the way we describe ourselves then we can say that we are symphonic, rather than mechanic, beings.

The main argument of this paper is that musical components are the fundamentals of communication; and that rhythm, in particular, is the musical aspect of communication fundamental to the way in which we relate to ourselves and to others.

Communication in this sense is not solely restricted to the transmission of information, but is also concerned with the establishment and management of relationships2.

If this argument is true then music is a powerful and subtle medium of communication which is isomorphic with the process of living3y4 and music therapy can be a powerful therapeutic medium for promoting communication.

The focus for understanding communication is how the human being can maintain a coherent identity in a personal and interpersonal milieu. This continually maintained coherence is a creative act. None of us as human beings are islands isolated in the universe. We are organisms which act and interact with the environment. We experience the world and attempt to influence it. Communication is the process by which we interact with our environment which includes the interpersonal milieux of our friends, colleagues and lovers. It is the medium by which we negotiate our self image in those relationships and integrate ourselves with others.

Dialogue and exchange of information, the regulation of interpersonal distance and personal boundary, the mutual expression of human emotion and the sharing of ideas are based upon communication.

These are located within a matrix of time which is not static. Sequence, order and phrasing, the fundamentals of musical form are vital elements in maintaining coherence whether in physiological systems, personal development or interpersonal relationships.

Physiology and communication At the molecular level the immune system and nervous system communicate with each other. Psychological stress and social stress influences the immune system, sometimes adversely. The relationship between neuroendocrine and immune systems is one of mutual comm~nication~,~.

Our bodies are engaged in a continuing communicative process out of the range of conscious awareness. These communications are vital for life. We can, as Rossi5 says

'. . . conceptualize a fairly complete channel of information transduction between mind as it is experientially encoded in the limbic-hypothalamic system filter, and the autonomic endocrine, immune, and neuropeptide systems that transmit their "messenger" molecules to the organs and tissues and to the cellular, genetic, and ultimately molecular levels'.

(P 52) In this approach mind and body are united within a rhythmic context of communication which enables healing to take place. At the core of this work is the idea that the suprachiasmatic nucleus of the hypothalamus is a regulator of the ultradian (within a day) rhythms7 responsible for autonomic system regulation and cerebral dominance5.When the normal periodicity of these rhythms is disturbed by stress then psychosomatic reactions may occur. The restoration of an integrated rhythmic hypothalamic response should be an important factor in the process of healing. It is feasible then that music therapy is an ideal medium for promoting such integration and regulation through rhythm.

Synchrony, rhythm and communication 'Curative chronobiotics may be visualized for disease such as certain emotional disorders or rheumatoid arthritis - if, and only if, rhythm alternation can be recognized to be etiologically significant" (p 487).

For communicationto occur there has to be an element of predictability by which events are structured. This communication occurs within a matrix of time and is manifested as particular rhythms. These may be the circadian rhythms (literally about a day) of temperature and sleep in humans, the shorter ultradian (within a day) rhythms of autonomic system regulation and metabolic processes, or the shorter periodicities of respiration, peristalsis and heart rate7-9.These are the regulatory mechanisms by which self synchrony is maintained as a process of internal communication.

The work of C ~ n d o n ~ O clearly - ~ ~ shows the integration in terms of verbal behaviour, including silence, and bodily gestures. There is a self sync o n o u s organization to h and movement which is essentially rhythmic. Rhythm provides the means by which behaviour is organized.

However, Condon12goes on to write that as human beings we also communicate with other people. This

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he calls 'interactional' synchrony. We are active participants in communication. When we listen we move synchronously with the articulatory structure of the speaker's speech. As the speaker moves with his own speech, then so does the listener too. What is 'sent' and 'received' are inseparable in the ordered context of communication. This gives additional support to the idea, to which some music therapists refer, when they say that therapist and patient are 'united in the music'. In Condon's words12 'But what flows through them is a similar order; so that what is sent and what is received are understood and shared by both speaker and listener. What all aspects of this process have in common is the propagation and reception of order.

There is no "between" in the continuum of order.' (p 56).

As rhythms are entrained, or synchronized, within the individual, then the listener will entrain with the emergent rhythmic structure of the speaker, singer or player. By watching the movement of the listeners body as well as by observing the way in which the listener plays it is possible to glean some ideas about their perceptual involvement.

Phrasing A central feature of both musical and biological form is phrasing. When we speak in dialogues then we must know when a phrase is ending, and how to begin another. This occurs in speech by accented differences in a rhythmic context. When we listen we give a continuous feedback by small motions and gestures of our heads and bodies, and vocalizations. When a phrase is coming to an end there is an increase or change in such activity13.

Interactional synchrony between people, and the coordination of phrasing in communication, cannot be explained as reaction or as a reflex response to sound or movement. Synchronization is achieved by a shared interaction in a rhythmic context known to both participants. The basis of such mutual knowledge is both physiological, in that we share common physiologies, and cultural14. The forces which bind us together, which are the essence of our mutuality, are musical.

Non-verbal communication and relationship As the preceding paragraphs suggest, communication occurs in a context of relationship. Peggy Perm2writes that 'All emotions are an indication of how someone else is to behave' (p 17). All too often when we consider communication in the context of therapy we concentrate on the semantic bases of communication when it is the relational aspects of the interaction which are primary.

Language and non-verbal behaviours are powerful organizers of personal and social actions2J4. In studying communication the role of verbal behaviour is often over-emphasized, and the role of non-verbal behaviour neglected. This places a n emphasis on the 'what' of communication (ie the content of communication)rather than the 'how' of communication (ie the regulation of that communication). The non-verbal aspects of communication indicate how the content is to be received. Watzlawick et al. l5 call this process 'metacommunication'; a communication about a communication. For example; the comment 'Oh, very interesting' can have quite a different meaning according to the tone of voice and gesture used to deliver it.

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alone, or words themselves seem inadequate. The communication of passions, love, ecstasy or anger are rarely dependent solely on words. At such times vocalizations and gestures are far more subtle and 'meaningful' than words.

Child development and rhythmic interaction The development of language and socialization in the infant depends upon learning the rhythmic structure of synchronization13.From birth the infant has the genetic basis of an individually entrained physiology, ie a self synchronicity. The infant has its own time as 'kairos'. Yet, the process of socialization, and the use of language depends upon entraining those rhythms with those of another, ie an interactional synchrony as 'chronos'. This interactional synchrony could reflect those neural timing mechanisms which form the ground of communication where interactional cycles of attention and affect are entrained with homeostatic mechanisms in the nervous system16.

Lester et aZ.17 investigated the synchronization of neonatal movement and the speech sounds of the adult talking to the baby. They argued that the ability of the infant to attend to social stimuli was related to the infant's capacity for self regulation. Cycles of rhythmic interaction between infants and mothers, they argued, reflected an increasing ability by the infant to organize cognitive and affective experience within the rhythmic structure provided by the parent.

However, this was not a one-sided phenomenon.

Infants produce forms of expression and gesture that are not imitations of maternal behaviour18J9.Both baby and mother learn each others rhythmic structure and modify their own behaviour to fit that structure.

Arousal, affect and attention are learned within the rhythm of a relationship.

This is the method employed in music therapy. The rhythmic structure of the patient is discovered by the therapist, and the patient is then met within that rhythmic structure.

Stern et al.20studied the non-verbal behaviour of mothers and infants. They found two parallel modes of communication.

One form of communication was that of CO-action.

In this form both mother and infant vocalize together.

These authors suggest that coactional vocalizing is an early pattern of behaviour which is structurally and functionally similar to mutual gaze, posture sharing and rhythm sharing. It occurs during the highest levels of arousal and is indicative of emotional tone. In adults CO-active vocalizing occurs in situations of interpersonal arousal such as intense anger, sadness, joy or lovemaking.

The contrasting form is that of alternation. This mode of communicationis that found in conversationwhere speaker and listener alternately exchange roles. It is a dialogic pattern and valuable for the exchange of symbolic information. This alternative mode is valuable for the acquisition of language. It allows information to be sent by one person while being processed by the other. However, it is a separate pattern to that of CO-action.

CO-actionemphasizes the event of communication itself, rather than the content of the communication.

Simultaneous vocalization promotes mutual experience and may be essential to the process of bonding and feeling of relatedness. These two structurally different c---rt

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Journal of the Royal Society of Medicine Volume 82 December 1989

Communication and pathology If musical elements are essential to communication, then the improvized musical playing of people may make manifest both underlying pathology and possibilities for growth and change.

Condon and Ogston1Ă‚compared normal and pathological behaviour between patients and therapists using the medium of film. Human interaction was filmed. The films were then viewed repeatedly one frame a t a time, and analysed. Each frame was numbered and sequences of frames analysed according to speech and vocalization correlated with body movements. The authors call this the study of 'linguistics-kinesics'1Ă‚ (p 38).

When the same authors studied a chronic schizophrenic patient they found that there was a noticeable lack of head movements and rigidity of posture in the patient compared to the relatively free head movement of normal speakers. The expressive qualities of speech and movement were severely restricted. A selfdysynchrony also appeared in the schizophrenic patient where body movements appeared to be laterally separate.

In the micro-analysis of films of depressed patients

by Condon1Ă‚ prosodic features of pitch, stress, phrasing and timbre were found which seemed indicative of underlying pathology; 'A marked laxity of articulatory movements characterizedthe speech of these patients. With its sparing use of pitch and accent, their voice had a dead listless quality: changes of pitch covered a narrow tonal range and were predominantly stepwise rather than gliding; hovering tones appeared at the end of sentences, . . .intonations tended to occur in the same stereotyped patterns; and emphatic accents were either rare or absent entirely. Their speech gave an impression of being slow and halting because of the frequent appearance of hesitation pauses interrupting the flow of their phrases' (p 344).

It is evident from this description that these are also musical qualities, and if the improvized playing of a depressed patient was heard then a music therapist would be making similar comments.

Fraser et aLZ1showed similar discriminating linguistic profiles of schizophrenic and manic patients.

There was a continuum of linguistic degeneration across the psychotic spectrum. In an experimental control group 'normal' subjects produced fluent, complex and error free utterances. Schizophrenic patients produced dysfluent, simple and error ridden speech.

Interestingly, when these patients improved clinically sentences became more tightly constructed and pitch widened in range and became more melodically varied. Again clinical improvement can be heard in the musical (prosodic or suprasegmental) aspects of speech style.

Condonl1continued to develop this diagnostic work further studying the integration of body motion and speech across many dimensions, particularly in the field of autistic-like behaviour. His frame by frame filmed micro-analysis of patients with various syndromes like petit mal, Huntington's chorea, autism, stuttering, parkinsonism and aphasia, led him to believe that there may be some relationship between their problems and an underlying dysfunction in sound processing. Many of the behavioural mannerisms he observed in children appeared to be related to a multiple response to sound; there was both a n immediate response and a delayed response to a sound event, or 'dyssynchrony'.

This work resulted in Condon postulating a continuum of degrees of delayed response to sound with autistic-like behaviour at the severe end and learning disabilities a t the milder end. (While not evident as a motor abnormality during conversation, these children had difTiculty with reading and mathematics).

The observed children responded to an immediate actual sound but also appeared to respond again to that same sound with a delay 'by as much as % to a full second'll (p 47).

He gives the example of a 2% year old child throwing a block on a table. The block lands on the table and the child picks up another such block. The childs' hands suddenly move in a jerky and seemingly bizarre manner. Microanalysis of the film revealed that the child's body moved synchronously with the sound of the brick hitting the table. At a later time, 16 film frames, the jerky hand movements occurred.

These hand movements were isomorphic with the sound and movements which occurred 16 film frames earlier. (There were 24 film frames per second). By delaying the film sound to coincide with the movement the child was seen to move in precise synchrony.

It was possible to see and hear the occurrence of a sound on film and predict the occurrence of a bodily movement 16 frames later without any sound occurring at that time.

In children with a delayed response to sound their behaviour appeared to be dominated by that delay. Furthermore, these children often lacked a co-ordination between hearing a sound and visually locating that sound. These children were literally out of time with the sensory structure of their world.

The entrainment of vision and sound gives an important spatial location in the world. To communicate we need to be entrained both within ourselves and with our environment. A delay in sound processing can lead to estrangement from the world and personal incoherence.

Discussion The basic elements of human communication are musical. Physiological, psychological and social activity occur in a context of time which is dynamic and the structure of which is musical. At a fundamental level human activity is organized as a hierarchy of rhythmic entrainment; within the individual as selfsynchrony, and within relationships as interactional synchrony.

When the breakdown of this synchronous behaviour occurs then pathology is evident. The restriction of musical aspects of communication,pitch, stress, articulation, timbre and fluency, appear to be indicative of psychopathology. An improvement in these qualities appears to be evident in a return to health and the maintenance of a coherent identity.

It is possible to hypothesize that improvized music therapyzz is a powerful tool for promoting communication in terms of personal and interpersonal integration. Alternative creative dialogues may be encouraged within the person such that they are not estranged within themselves, or estranged from others. Furthermore, clinicians, no matter in which discipline they have their origins, may be advised to attend to the musical components of communication.

In this way the arts, as well as science, may inform the practice of medicine.

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References 1 Aldridge D. A phenomenonlogical comparison of the organization of music and the self. Arts in Psychotherapy 1989;16:(in press) 2 Penn P. Coalitions and binding interactions in families with chronic illness. Fam Systems Med 1983;1:16-26 3 Aldridge D. The development of a research strategy for music therapists in a hospital setting. Arts in Psychotherapy 1989;16:(in press) 4 Aldridge D. Physiological change, communication and the playing of improvised music. Arts in Psychotherapy 1989;16:(in press) 5 Rossi EL. From mind to molecule: A state-dependent memory, learning and behavior theory of mind-body healing. Advances 1987;4:46-60 6 Tee DE. Another look a t the interaction of psyche and soma. Complementary Med Res 1987;2:1-2 7 Moore-Ede MC, Czeisler CA, Richardson GS.Circadian timekeeping in health and disease. N Engl J Med 1983;309:469-79 8 Reinberg A, Halberg F. Circadian chronopharmacology.

Ann Rev Pharmacol1971;11:455-92 9 Johnson C, Woodland-Hastings J. The elusive mechanism of the circadian clock. Am Sci 1986;74:29-36 10 Condon WS, Ogston WD. Sound film analysis of normal and pathological behavior patterns. J Nerv Ment Dis 1966;14:338-47 11 Condon W. Multiple response to sound in dysfunctional children. JAutism Childhood Schizophrenia1975;5:37-56 12 Condon W. The relation of interactional synchrony to cognitive and emotional processes. In: Key MR, ed. The

relationship of verbal and non-verbal communication.

The Hague: Mouton, 1980:49-65 Kempton W. The rhythmic basis of interactional microsynchrony. In: Key MR. ed. The relationship of verbal and non-verbal communication. The Hague: Mouton, 1980:68-75 Key MR. The relationship of verbal and non-verbal communication. The Hague: Mouton, 1980 Watzlawick P, Beavin JH, Jackson DD. Pragmatics of human communication. New York: WW Norton, 1967 Linden W. A microanalysis of autonomic activity during human speech. Psychosom Med 1987;49:562-78 Lester BM, Hoffman J, Brazelton TB. The rhythmic structure of mother-infant interaction in term and proterm infants. Child Dev 1985;56:15-27 Murray L, Trevarthen C. The infant's role in mother-infant communications. J Child Long 1986; 1315-29 Trevarthen C. Facial expressions of emotion in motherinfant interaction. Human Neurobiol 1985;4:4-21 Stem DN, Jaffe J, Bebbe B, Bennett SL. Vocalizing in unison and in alternation: two modes of communication within the mother infant dyad. Ann NY Acad Sci 1975;263:89-100 Fraser WI, King K, Thomas P, Kendell RE. The diagnosis of schizophrenia by language analysis. Br J Pyschiatry 1986;148:275-8 Nordoff P, Bobbins C. Creative music therapy. New York: John Day, 1977 (Accepted 25 May 1989)

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Making and taking health care decisions: discussion paper

D Aldridge P ~ D Medizinische Fakultat, Uniuersitat Witten Herdecke, Beckweg 4, D-5804 Herdecke (Ruhr), FRG Keywords: illness behaviour; family; culture; health care decisions

'I want to say a sentence to you and then I want to interpret that sentence in about four different ways, all of which are related to what we are talking about. And the sentence is, "Each person is his own central metaphor".'

Mary Catherine Bateson1

Introduction The position taken in this paper is that when we make and take health care decisions they are based on multiple perceptions made by intimately related persons based on a shared reality that has been constructed by those persons.

In this way of understanding 'problems', when presented as illness or disease, are located within what we might call an 'ecology of ideas'. There is no one reality from which we can determine our understandings, only varying ways of fitting behaving and thinking together. This perspective moves away from the notion of an individual reality, 'I', and towards the notion of community and shared reality, 'You and I together'.

Meaning a n d implication: the semantics a n d politics of illness behaviour When we talk about illness, whether it is recognizing that we are 'ill' or making the decision to 'go home' from our work place, which is a step in managing the illness, then we are making statements about our own beliefs and experiences in the world. The punctuation of an episode from the ceaseless stream of life's events has both semantic and political implications.

Semantic in the sense that explanations invoke meanings from a given episode. Political in the sense that human behaviour is managed, obligations are suspended and actions are taken.

Both the semantic and the political are linked. Fay Fransella2 writes, 'As a society we construct the social world according to our interests and beliefs, as individuals we construct our beliefs to make sense of our own particular experience of the world.

So shared experiences and beliefs support each other - a t least for a good deal of the time'

When we offer descriptions of our own behaviour to others, ie 'I have a really sore throat and I think I must have a cold', we are entering a realm where our description of a current reality is open to validation by another person. The validation of one person's description by another person is a political act. While this may not have serious overtones in the context of a head cold there are powerful implications for those persons who wish to have their experience of pain validated when it is not supported by physiological evidence.

In the context of a therapist-patient relationship the patient offers up symptoms or descriptions which they believe entitles them to the legitimate status ' ~ i c k ' ~The . therapist or doctor may interpret those same symptoms and descriptions as an example of the patient malingering and therefore making an illegitimate claim to the status 'sick'. In this context of consultation the therapist invalidates the patient, nothing is shared and a common legitimate reality is not negotiated.

What counts a s illness If we take an episode of illness then there are a number of stages in that episode when meanings are offered to others for validation. Making sense of the world is just that, a 'making' of sense. When we make sense it is made in the context of a relationship. Cecil Helman4 reminds us that, 'Consultations between doctors and patients do not take place in a vacuum. Rather, they are embedded in a particular time and place, and in a particular physical, social or cultural setting. That is, each consultation is embedded in a particular context. These contexts are important, because they shape what is said in the consultation, how it is said, how it is interpreted, and how it is acted upon'

We can apply the same criteria of time and place to our personal relationships. Helman also goes on to distinguish internal and external contexts.

An internal context is the set of hidden assumptions and responses that each party brings to the relationship. These would include our past experiences of illness, the explanations for the origin of the illness and how symptoms should be treated.

An external context includes the setting in which the event takes place and also includes rules of conduct. In some ways an external context is a form of ritual; it is punctuated as being separate from 'everyday life' and governed by explicit and implicit rules of conduct about how people are to act, speak and dress and what they are to talk about.

At an obvious level we see this in public rituals like weddings and funerals (and conferences),but we also have ritualized ways of dealing with deference, greetings and l e a ~ i n g ~ - ~ .

At a more fundamental level we have our own internal rituals for recognizing 'stress' or 'no stress' which are based upon a highly complex immunological language which is more than a biochemical alphabet.

This language can be used to identify what is 'self7 and 'not self'. In such a way we are daily constituting ourselves. We make a sense of the world bodily.

However, as we all are aware, we also make sense of the world psychologically, socially and spiritually.

o141~0768~90~ no720~04/~02,00/ l---QCK)

~h~ Royal Society of Medicine

Journal of the Royal Society of Medicine Volume 83 November 1990

'Sometimes this bodily sense becomes evident in another realm of experience. When we experience pain then a message is being sent from one systemic level (somatic) to another (psychic). This message needs to be interpreted. It is not always immediately discernible what pain is a message about. For instance in the case of back pain is it about muscular distress, or is it a metaphor about distress in a different context, eg having too much to bear or a lack of support? In some recent research into the common cold9the researchers found that people with different representational styles (verbal,visual or enactive)had different ways of being ill. Verbalizers, people who use inner speech, were prone to mouth ulcers.

However, visualizers showed no particular propensity for any problems but there was a negative correlation with relaxation and resistance to infection. Somehow literally the way we see the world and represent it to ourselves is a health enhancing activity. Making sense is not only a passive process, but an active process we do to the world.

Rules for the making of sense A number of authors suggest that 'making sense' is rule-basedlO-13.These rules can be separated into two forms14. One, there are rules of constitution.

A constitutive rule would be invoked when we say this behaviour (a sore throat) counts as evidence of another state (having 'caught a cold').

Two, there are rules of regulation. A regulative rule would be invoked when we say if this behaviour (a sore throat) counts as evidence of a particular state (having a 'cold') then do a particular activity (go home to bed).

Constitutive rules then are generally concerned with meaning. Regulative rules are concerned with the politics of relationship and the linking of meaning and action.

This correspondsto the interrelated healing functions of the provision of meaning and the control of sickness which Kleinman15describes. He argues that modern professional health care attends solely to the control of sickness and neglects the understanding of meaning.

Furthermore; ' . . the biomedical education of physicians and other modern health professionals, while providing them with the knowledge to control sickness, systematically blinds them to the second of these core clinical functions (the understanding of meaning), which they learn neither to recognize or to treat'.

In an episode of illness there will be stages when behaviour is understood in terms of constitution, ie meaning, and in turn, regulation, ie control or management. These episodes have critical times when they are seen 'to start' and 'to end'. This is the process of 'punctuation'16 and is a selective structuring of reality. Punctuation is vital to interaction as it is a means of organizing behavioural events both in terms of meaning and process.

We see this when someone says 'He always starts an argument', or 'Her problems began when her husband died'. While such punctuations may be shared, they may also be the source of conflict. For instance some of us may recall situations where one person has said 'I was only trying to be helpful and support you', and their partner says 'You were interfering and undermining my ability'. In such an

exchange the two punctuations of the same behaviour helpfullinterfering are a characterization of the relationship.

In our modern Western culture the predominant focus to punctuate the start of an episode of illness appears to be one of recognizing symptoms which are validated in the context of a relationship whether it be familial, filial, or fraternal. In terms of 'catching a cold' the causative agent is seen as a viral infection and not open to a great deal of debate. However, in considering other forms of illness meanings are not so clear cut.

Symptoms can be employed as a 'language' within a group of people17, and in particular f a m i l i e ~ ~ ~ J ~ where other groups would use less pathological forms of communication. Symptoms become part of a vocabulary of distress. Pain then becomes an indicator not only of physiological distress but also a marker of existential despair, or personal 'hurt' or unwillingness to cooperate.

This medium for communication does not have to be invented, it exists within the subculture of the group or family. We see this when someone has a day off work regularly with a headache. If this should occur repeatedly a t times when their work is to be scrutinized by a superior then we might infer as a group that the headache is 'caused' by the imminent scrutiny. In this way we can be said to have shared meanings.

This process is reflected in our therapeutic systems.

We learn a set of shared meanings whereby symptoms located in particular contexts are understood in a particular way; ie the process of diagnosis. This would correspond to a set of 'constitutive rules'.

Acupuncturists will recognize disturbances in ch'i.

Neurolinguistic programmers will recognize maladaptive speech patterns. Structural family therapists will see family coalitions and permeable boundaries.

Transactional analysts will hear the child speaking.

A priest will recognize the sinner and the sin.

Similarly the process of diagnosis would lead to implications for what to do about those symptoms; ie the process of treatment. This would correspond to a set of 'regulative rules'. The acupuncturist will endeavour to restore balance, the neurolinguist will intervene by talking directly to the somatic system responsible for the problem, the family therapist will ask the family to change seats and move closer together, the transactional analyst will encourage the adult to speak to the adult, while the priest will confer absolution.

The challenge for the therapist or practitioner is that although the symptoms reported by the patient may fit the practitioner's set of rule-based understandings, those rules and corresponding understandings may be quite different to those of the patient and the patient's family. All too often patient and therapist can be a t odds because the important phase of negotiating common or shared meanings is missed out.

The implications for therapy are that we must be concerned with understanding what the symptoms constitute for the patient, and what the patient has previously done to regulate those symptoms. In a similar way, we must be aware that by the time a patient reaches the therapist or practitioner they have been through a process where their symptoms have been negotiated and validated in other contexts which may have far more significance for them as persons.

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What this paper is proposing is that sometimes, when we see people with persistent problems, it may well be that the personal meaning system of our patients, their sets of constitutive and regulative rules, have been invalidated in other relational contexts, and they too have invalidated the systems of meanings offered by significant others. When such a situation of mutual invalidation occurs, and symptoms appear as 'intractable', then we find that the patient is given a label of deviance or described as resistant rather than the therapist having failed to understand the patient. This too would be falling into a trap of blaming one person in the relationship rather than looking at the therapeutic process itself and the relationship between therapist and patient.

Conclusion Making and taking health care decisions is a process.

We become aware of events which make a difference.

Some of these are seen as symptoms and are seen as indicative of certain states. These constitutive rules are learned through experience and are validated in the context of families and friends. We rarely have to invoke these rules as they are habitual. In the context of illness behaviour they form a repertoire for the management of distress. Occasionally when we come into contact with other persons and other groups we find that those rules are questioned and that repertoire is inappropriate.

As these rules are learned in families they persist over time, and can be carried over from one generation to the next. In this way some particular forms of illness behaviour such as depression appear to be hereditary. However, we have not as yet identified the gene responsible for depression, and nor are we likely to. It could well be that depression is not hereditary but it does run in families. At certain times and in particular situations, faced with personal failure in a context of relational conflict, there may be constitutive and regulative rules which propose particular behaviours, eg 'become depressed'. These behaviours are learned in families and transmitted from one generation to the next.

At which level then do we choose to intervene, and at which point in the cycle do we choose to enter?

A challenge for us as practitioners and researchers is to elicit those cyclic patterns of behaviour with their underlying rule structures whereby physiological changes occur in response to personal and relational crises. There may well be rules operating which say that in a particular context (a marital row) a particular action (confronting the other) constitutes a threat and that is regulated by a particular behaviour (elevated heart rate, increase in perspiration, suppression of lymphocytes). While this may well be 'normal' behaviour (and the attribution of normality itself is rule dependent), if there were a set of rules which interpreted all interpersonal situations as threatening (to be regulated by an elevated heart rate or a suppression of lymphocytes)then we might speculate that there is an underlying disease or at least a maladaptive coping strategyz0.

In this sort of description then diseases are not fixed or immutable, they are open to change at different levels of intervention, eg a change in a constitutive rule would mean that some events would no longer count as crises, a change in regulative rule would mean a change in response. We do this in treatment where some of us look for underlying attitudes and

attempt to change these (the process of constitution), whereas some therapists will attempt to provoke changes in response to stimuli (the process of regulation).

My thesis is that these connections are rule-based.

It is important to remember the notion of rule is used here as a metaphor for what happens, not that there is literally a rule book in the head or the family.

These rules need not necessarily be cognitive. They may act solely at the level of physiology where there are physiological changes occurring in response to biochemical markers in the context of immunological stress. As stated earlier what we need to address ourselves to is the continuing problem of how the threat to a threshold at one level, ie the cognitive, brings about a response at another level, ie the physiological. A rules-based explanation addresses this by offering a means of description (but not a causal link) of what happens. By understanding the interaction between these levels we can intervene at differing levels.

From this perspective, the 'personal' view of health is located within the 'familial' which in turn is located within the 'cultural'. We see this reflected in our health care initiatives where health care initiatives are invoked at the personal level of self care and at the level of changing social conditions. What we need to look a t is the mediating context of the family for it may be those with whom we live, who significantly influence what sense we make of our lives and what endeavours we pursue to change that sense. It is they with whom we negotiate our health.

Similarly we must continue to be aware that healers and patients are not independent of the cultural context of clinical care, and the explanatory models we bring to bear on illness and healing are resident within this cultural context. In this way we will begin to understand the meaning of illness and the attendant implications for healing rather than the headlong pursuit into the management of disease.

This will change our clinical practice and more fundamentally our research endeavours.

However, we must be wary. The way we construct our meanings of problems particularly when presented by the people who come to see us for therapy may be a contribution to the way in which the problem is maintained rather than allowing change to happen.

The aphorism 'Psychoanalysis is the illness whose cure it considers itself to be' might well be heededz1 and applied to our own disciplines.

References 1 Bateson MC. Our own metaphor. New York:Alfred Knopf, 1972:285 2 Fransella F, Frost K . On being a woman: a review of research on how women see themselves. London: Tavistock, 1977:24 3 Parson T . The social system. New York: The Free Press, 1951 4 Helman C . The consultation in context. Holistic Medicine 1986;1:37-41 5 Geertz C . Ritual and social change. American Anthropologist 1957;59:32-54 6 Leach E . Culture and communication: the logic by which symbols are connected. London: Cambridge University Press, 1957 7 Rippere V . Depression, common sense and psychosocial evolution. Br J Med Psycho1 1981;54:379-87 8 Vogt EZ. On the concepts of structure and process in cultural anthropology. American Anthropologist 1960; 62:18-33

Journal of the Royal Society of Medicine Volume 83 November 1990 Aylwin SM, Durand MA, Wilson K. Thinking symptoms and the common cold. Paper presented to the Psychological Society of Ireland Annual Conference, Ennis, November 1985 Bateson G. Afterword in: Brockman J, ed. About Bateson. London: Wildwood House, 1978 Cushman D, Whiting G. A n approach to communication theory: towards consensus on rules. J Communication 1972;22:217-38 HoffmanL. Foundations of family therapy: a conceptual framework of systems change. New York: Basic Books, 1981 Harr6 R, Secord PF. The explanation of social behaviour.

Totowa, New Jersey: Littlefield and Adams, 1973 Pearce W B , Cronen V E . Communication, action and meaning: the creation of social realities. New York: Praeger Scientific, 1980

15 Kleinman A , Sung LH. W h y do indigenous practitioners successfully heal? Soc Sci Med 1979;13:7-26 16 Bateson G. Mind and nature. Glasgow: Fontana, 1979 17 Kreitman N , Smith P, Eng-Seong T . Attempted suicide in social networks. Br J Preventive Soc Med 1969; 23:116-23 18 Haley J. Leaving home. New York: McGraw-Hill 1980 19 Madanes C. Strategic family therapy. San Francisco: Jossey Bass, 1981 20 Nixon PGF, Al-Abbasi AH, King J, Freeman L. Hyperventilation i n cardiac rehabilitation. Holistic Med 1986;1:5-13 21 Watzlawick P. The invented reality. New York: WW Norton, 1984 (quoting Karl Kraus, p 66)

(Accepted 25 April 1990)

Some recent books

Obesity: Towards a Molecular Approach: UCLA Symposia on Molecular and Cellular Biology Series. G A Bray, D Ricquier & B M Spiegelman, eds (pp 307)ISBN 0-47156755-8, New York: Wiley-Liss 1990.

Biology & Biotechnology Adheresis: Progress in Clinical and Biological Research Series. G Rock, ed (pp 592, $170.00)ISBN 0-471-56746-9,New York: Wiley-Liss 1990.

Platelet Heterogeneity: Biology and Pathology. J Martin & A Trowbridge, eds (pp 270, £75.00ISBN 3-540-19602-1, London: Springer-Verlag 1990.

Bacterial Vaccines: Advances in Biotechnological Processes Series. A Mizrahi, ed (pp 317, $130.00) ISBN 0-471-56219-X, New York: Wiley-Liss 1990.

Progress in Comparative Endocrinology: Progress in Clinical and Biological Research Series. A Epple, C G Scanes & M H Stetson, eds (pp 752, $160.00) ISBN 0-471-56800-7,New York: Wiley-Liss 1990.

Biotechnology and Human Genetic Predisposition to Disease: UCLA Symposia on Molecular and Cellular Biology.

C R Cantor, C T Caskey, L E Hood, D Kamely & G S Omenn, eds (pp 241, $75.00)ISBN 0-471-56772-8,New York: WileyLiss 1990.

Cellular and Molecular Biology of Normal and Abnormal Erythroid Membranes: UCLA Symposia on Molecular and Cellular Biology. C M Cohen & J Palek, eds (pp 338, $99.00) ISBN 0-471-56750-7,New York: Wiley-Liss 1990.

Flow Cytometry and Sorting, 2nd Edition. M R Melamed, T Lindmo & M L Mendelsohn, eds (pp 824, $89.50) ISBN 0-471-56235-1,New York: Wiley-Liss 1990.

Inositol Metabolism i n Plants: Plant Biology Series. D J Morre, W F Boss & F A Loewus, eds (pp 393, $96.00) ISBN 0-471-56708-6,New York: Wiley-Liss 1990.

Membrane Transport and Information Storage: Advances in Membrane Fluidity Series. R C Aloia, C C Curtain & L M Gordon, eds (pp 260) ISBN 0-471-56209-2,New York: WileyLiss 1990.

Mutation and the Environment - Part A: Basic Mechanisms: Progress in Clinical and Biological Research Series. M L Mendelsohn & R J Albertini, eds (pp 426, $110.00) ISBN 0-471-56791-4,New York: Wiley-Liss 1990.

Mutation and the Environment - Part B: Metabolism, Testing Methods, and Chromosomes:Progress in Clinical and Biological Research. M L Mendelsohn & R J Albertini, eds (pp 426, $110.00) ISBN 0-471-56792-2,New York: Wiley-Liss 1990.

Mutation and the Environment - Part C: Somatic and Heritable Mutation, Adduction, and Epidemiology: Progress in Clinical and Biological Research. M L Mendelsohn & R J Albertini, eds (pp 426, $110.00) ISBN 0-471-56794-9,New York: Wiley-Liss 1990.

Mutation and the Environment - Part D: Carcinogenesis: Progress in Clinical and Biological Research. M L Mendelsohn & R J Albertini, eds (pp 403, $110.00)ISBN 0-471-56790-3, New York: Wiley-Liss 1990.

Mutation and the Environment - Part E: Environmental Genotoxicity, Risk, and Modulation: Progress i n Clinical and Biological Research. M L Mendelsohn & R J Albertini, eds (pp 385, $110.00) ISBN 0-471-56797-3,New York: Wiley-Liss 1990.

Nucleic Acid Methylation: UCLA Symposia on Molecular and Cellular Biology. A G Clawson, D B Willis, A Weissbach & P A Jones, eds (pp 425, $120.00) ISBN 0-471-56727-2,New York: Wiley-Liss 1990.

Structural and Organizational Aspects ofMetabolic Regulation: UCLA Symposia on Molecular and Cellular Biology.

P A Srere, M E Jones & C K Mathews, eds (pp 416, $130.00) ISBN 0-471-56748-5,New York: Wiley-Liss 1990.

The International Narcotics Research Conference (INRC) '89: Progress in Clinical and Biological Research Series. R Quirion, K Jhamandas & C Gianoulakis, eds (pp 558)ISBN 0-417-56689-6, New York: Wiley-Liss 1990.

Transgenic Models i n Medicine and Agriculture: UCLA Symposia on Molecular and Cellular Biology. R B Church, ed (pp 166, $55.00) ISBN 0-471-56780-9,New York: WileyLiss 1990.

Neurology A Great British Veterinarian Forgotten: James BeartSimonds 1810-1904. Ian Pattison (pp 168 £16.00ISBN 0-85131-491-0,London: J A Alien 1990.

Neurological Complications of Renal Disease. Charles F Bolton & G Bryan Young (pp256 £50.00 ISBN 0-409-95139-0,Stoneham: Butterworth Publishers 1990.

Neurology and Neurobiology Volume 55: Differentiation and Functions of Glial Cells. Giulio Levi, ed. (pp 429, $102.00) ISBN 0-471-56701-9,New York: Wiley-Liss 1990.

Neurology and Neurobiology Volume 56: Information Processing in Mammalian Auditory and Tactile Systems.

Mark Rowe and Lindsay Aitkin, eds (pp312) ISBN 0-471-56699-3,New York: Alan R Liss, 1990.

Pharmacology of Neuromuscular Function. William C Bowman (pp 316 £45.00ISBN 0-7236-09135, Sevenoaks: Wright (Butterworth Scientific Ltd) 1990.

Steroids i n Diseases of the Central Nervous System.

Rudy Capildeo, ed. (pp 306) ISBN 0-471-91959-4,Chichester: John Wiley & Sons 1989.

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well be able to prescribe dressings the need for a doctor's prescription for pharmacological agents is unlikely to change.

It is only after a considerable amount of further work, interest and enthusiasm has been shown for this subject that it is likely to produce an improvement in the standard of care offered to all patients. Although leg ulcers may not directly lead to the death of many patients they can certainly make the patient's life extremely miserable when they are present.

References 1 Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic leg ulceration; the extent of the problem and the provision of care. BMJ 1985;290:1855-6 2 Cornwall JV,Dore CJ, Lewis JD. Leg ulcers epidemiology and aetiology. Br J Surg 1986;73:694-6 3 Blair SD, Wright DDI, Backhouse CM, Riddle E, McCollum CM. Sustained compression and chronic venous ulcers. BMJ 1988;297:1159-61 4 Colgan MP, Dormandy JA, Jones PW, Schraibman IG, Shank DG, Young RAL. Oxpentifylline treatment of venous ulcers of the leg. BMJ 1990;300:972-5

K G Harding Director, Wound Healing Research Unit, Department of Surgery University of Wales College of Medicine Heath Park, Cardiff CF4 4 X N

Healing and medicine Within both church and medicine important changes have taken place. Issues related to health and well-being have been raised which question the fundamental practices of these institutions. Principally these issues are about the definition of health and who is to be involved in healing. These issues are not new.

It is the contention that such issues are raised at times of transformation when the old order, whether it be in church or medicine, is being challenged.

From the lay community there is a growing demand for involvement in health issues and for initiatives promoting a healthy life style. Within the church too there are demands by the laity to be actively involved in the life of the church and for lay ministries to be recognized. Communities are eager to make decisions about matters which affect their daily lives and are no longer willing to abdicate the sole process of decision making to licensed and expert professionals who may be far removed from them in terms of educational background, social class and experience.

This does not mean that there is a revolt against expert health from the health professional or the clergyman. What is proposed is that these experts become facilitators and informed advisers.

Such a participative approach provides a real opportunity to remove the apartheid between church and medicine in dealing with matters of our corporate health.

The natural science base of modern medicine. and the way in which it is delivered, often ignores many of the social and spiritual factors associated with illness. The over-riding concern of medical decisions is that of correct diagnosis. Such diagnoses are concerned to discover the hypothesized cause of the problem within the person. Health invariably becomes defined in anatomical or physiological terms.

In this way problems of living are translated into physical descriptions; and, more importantly, submitted to physical interventions. While this may give the sick a legitimate status and remove them from condemnation as sinners, this situation is

only temporary. A degree of personal responsibility is still demanded in those situations where the problem does not respond to treatment, where there are problems of mental health, chronic disease, family disorganization or sexually transmitted disease.

These behaviours are couched in psychological, social, ethical and legal terms. Perhaps none more so than by the new health and well being advocates. Rarely do we find diagnoses which include the relationship between the patient and their God. The descriptions we invoke have implications for the treatment strategies we suggest. Patience, grace, prayer, meditation, forgiveness and fellowship are as important in many of our health initiatives as medication, hospitalization, incarceration or surgery.

The spiritual elements of experience help us to rise above the matters at hand such that in the face of suffering we can find purpose, meaning and hope.

Medicine has a system of explanations for what it does. These are predominantly scientific, and it was this coherence of cogent ideas whiph was influential historically in the separation of scientific medicine from the influence of the church and metaphysical notions of healing.

The history of the spiritual in healing reflects the growth of scientific knowledge, demands for religious renewal and the continuing shift of understanding concerning what is health within a broader cultural context. Throughout the last 2000 years Christian healing, reviving vitalist theories and shifting away from Greek concepts of hygiene, survived under the threat of Roman persecution by inspiring followers by acts of healing and other inspirational gifts.

As Christianity gradually became accepted and established, healing, which depended upon individuals being inspired by the spirit as opposed to being licensed by law, was seen as a threat to the hierarchy of the church. Furthermore, physicians began to organize themselves into guilds and medicine itself began to form itself into a body of knowledge replicable in university centres throughout Europe.

Metaphysics became increasingly idiosyncratic and open to individual interpretation and sentimentality.

Christianity surrendered the sole authority to speak of life, birth and death to a materialistic science which

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verified human life in the same way in which it verified the physical universe. That the human body could be organized by subtle forces and represented the presence of a higher intelligence in the universe was abandoned.

In spite of rational healing explanations and scientific medicine spiritual healing has survived throughout modern Western Europe, and continues to flourish. During this century there have been new calls for a healing revival from some church groups.

This has culminated within the last decade with a recognition of the Christian churches healing ministry, albeit contentiously, and is often associated with a general interest in complementary medical initiatives calling for a consideration of the 'whole person'. There are also spiritual healing groups who have no church or religious affiliation and whose sole existence is the pursuit of spiritual healing.

In England these various spiritual healing organizations, and some religious groups, have formed themselves into a national federation so that they can practice in hospitals and take referrals from physicians. This federation issues strict guidelines for practice and conduct which have been worked out with the help of the British Medical Association and some Royal Colleges. The code of conduct covers legal obligations, how to handle t h e relationship with the patient regarding medical treatment and emphasizes full cooperation with medical authorities.

There are clear guidelines for healers visiting hospitals which include instructions about not wearing white coats, how to behave on the ward and how to obtain permission from the nursing officer. Unlike doctors healers must disclaim a n ability to cure but offer to attempt to heal in some measure, without any promise of recovery. If healing should take place in such stringent conditions of psychological pessimism, then placebo explanations must surely be found wanting.

Explanations given for how such spiritual healing works are various; paraphysical, magnetic, psychological and social. The principal explanatory principle offered by most commentators is that there are divine energies which are transformed from the spiritual level by the agency of the healer and which produce a beneficial influence upon the 'energy field of the patient'. This notion of 'energy field' is the sticking point between orthodox researchers and spiritual practitioners in that if such a field exists then it should be possible to measure by physical means. The problem probably lies in the use of the word 'energy' which has a broader interpretation in spiritual healing and is likened to organizing principles of vitalism and life force which bring about a harmonizing of the whole person. Rather than considering 'energy' as an explanatory metaphor, we may be better advised to develop the concept of 'information exchange'. While the concept of 'information' in this sense is also metaphoric, it is perhaps more illustrative of the processes involved, and addresses the issue of illness having a meaning rather than a cause.

There are two predominant forms of spiritual healing in Western Europe. The first involves a hand contact, or near contact, between the healer and the patient. This is also seen in the church ritual of the 'laying on of hands'. The second form is absent or distant healing where a healer or group of healers pray or meditate for the patient who is absent from

their presence. Patients can be far removed from the healing group. Healers emphasize that a special state of mind is required for this influence to occur.

While the state of mind necessary for healing has been elusive to research there has been quite extensive research into spiritual healing phenomena which has included investigations using controlled trials1. Enzymes and body chemicals in vitro have been studied, as have the effects of healing on cells and lower organisms (including bacteria, fungus and yeasts), human tissue cells in vitro, the motility of simple organisms and plants, on animals and on human problems. While spiritual healing is often dismissed a s purely a placebo response, the evidence from studies of lower organisms and cells would indicate that there is direct influence. Even if we introduce the idea of expectancy effects as an influence on experimental data we are still left with a body of knowledge which begs understanding. In fact the explanations of placebo and expectancy are no less metaphysical as those given for healing phenomena.

At the level of daily practice general practitioners have been willing to entertain the idea of spiritual healing and incorporate it into their practice, to use spiritual explanations for some of their patient contact, or as part of their referral network. Both doctors and clergy have worked together to care for the dying.

Prayer is described by several authors as valuable in terms of care for the elderly across several culture^^-^. Prayer and medical help seeking are not mutually exclusive, prayer being considered as a n active coping response in the face of stressful medical problems. Physicians believe that religion has a positive effect on physical health and that the older patient may ask the physician to pray with them.

From a broader medical perspective intercessory prayer has been investigated in terms of coronary care and proved to be beneficial6. For renal patients, prayer and looking a t the problem objectively were used most in coping with stress7. It is interesting to see that a t the pragmatic level of the patient, prayer and looking a t the problem objectively are not exclusive but complementary activities in their system of beliefs.

It is a t the level of health beliefs which the most acceptable forms of healing explanations take place.

For black American women with AIDS8 the sources of their illness and their remedies were classified as natural and supernatural. Prevention, prayer and spiritual were included in a treatment programme which incorporated traditional beliefs. This incorporation of modern and traditional has also been described in treating various ethnic groups throughout the world. What is important to learn from these experiences is that patients have concerns for the origins and meanings of symptoms that are important for them and for the way in which they may be healed. It is as important to recognize and respect the language of the person being treated as it is to remove a source of bacterial or viral infection.

Symbolic meaning plays a n active part in disease formation, classification, the cognitive management of illness and in therapy. It provides a bridge between cultural and physiological phenomena. Symbolic meanings are the loci of power whereby illness is explained and controlled. These symbolic meanings are often contained within particular ritual practices,

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hence the prohibition of spiritual healers from wearing white coats in hospitals. If such healers did wear white coats there would be a confusion of symbolic realities and hierarchies belonging to particular rituals of orthodox medicine. Griffith9 describes this cultural discrepancy well in a churchbased healing clinic which mixed both orthodox modem medicine and spiritual healing. Not only were there differences in healing realities, there were differences in rituals and also differences in hierarchies of practitioners. While separate rituals may exist in parallel, it is another gigantic step to ask that they work in unison. Some authors see unity as diluting the richness of the culture in that marginal practices will be medicalized and lose some of their vitalitylO. It is a change in the sense of meaning of life which appears to characterize many reports of healing rituals. Marginalized individuals; the sick, the poor, the lonely and the elderly, are brought into a group context. For some participants this offers a way of self expression and fulfilment within a social context thereby ritually affirming the social worth of the individuall1. Thus some church-based healing groups are more concerned with lifestyle approaches rather than physical pathologies. Sickness when placed in the hands of a divine authority releases the patient to a new form of living and integration within a community. This is the significance of the sacrament of the laying on of hands as a sacred reality and not to be equated as some writers do with the therapeutic touch of the doctor as a secular reality. Traditionally spiritual healers have not been allowed to benefit materially from their practice, the expectation has been that they support themselves with other work and divine healing is given free of charge.

It is clear that both medicine and spiritual healing can bring about the conditions under which healing can occur. But neither orthodox tradition, be it church or medicine, can explain how healing occurs. Nor will either until we begin to accept that our knowledge is wanting and our searching is guided by the wrong principles. Healing research or clinical outcome trials only measure the products or efficacy of healing endeavours. Our spiritual understanding of the intention of healing is lost. While we may know the social implications of healing; ie integration into the community, improving and maintaining the available pool of labour; and the psychological implications of healing; ie happier contented patients relieved of distress, we remember little of the spiritual intentions of healing. Miracles had a deeper purpose other than the restoration of physical health. It is not that the age of miracles is past, rather that the spiritual understanding is hidden and has been supplanted by

material and emotional satisfactions alone. This applies to both spiritual healers and medical scientists who doggedly pursue evidence of events solely a t the physical level, events which occur within another realm entirely.

While people claiming active membership of a religious institution in England is very low, many people report that they have had a religious experience at some time or another12.While it may not be usual to bring the sacred into the discourse of medical consultations, secular knowledge is found to be wanting a t particular critical moments in those consultations. For the patient it is vital to make sense of experience. It is a search for meaning in the face of chaos, loss, hopelessness and impending or current suffering. New efforts for lay involvement in medicine and the church, and a call for spiritual (or wholistic) understandings of illness are the expressions of individual calls for such meaning. It is not for medicine or the church alone to answer, rather that we search together. In this way we are healed.

D Aldridge Medizinische Fakultat Universitat Witten Herdecke Beckweg 4, D-5804 Herdecke (Ruhr), Germany

References 1 Benor D. Survey of spiritual healing. Complementary Med Res 1990;4:9-33 2 Bearon L, Koenig H. Religious cognitions and use of prayer in health and illness. Gerontologist 1990; 30:249-53 3 Chatters L, Taylor R. Age differences in religious participation among black adults. J Gerontol 1989; 44:S183-9 4 Koenig H, Bearon L, Dayringer R. Physician perspectives on the role of religion in the physician, older patient relationship. J Fam Pract 1989;28:441-8 Markides K. Aging, religiosity, and adjustment: a longitudinal analysis. J Gerontol 1983;38:621-5 Byrd R. Positive therapeutic effects of intercessory prayer in a coronary care unit population. South Med J 1988;81:826-9 Sutton T, Murphy S. Stressors and patterns of coping in renal transplant patients. Nurs Res 1989;38:46-9 Flaskerud J , Rush C. AIDS and traditional health beliefs and practices of black women. Nurs Res 1989;38:210-15 Griffith E , Mahy G. Psychological benefits of Spiritual Baptist "mourning". Am J Psychiatry 1984;141:769-73 Glik D. Symbolic, ritual and social dynamics of spiritual healing. Soc Set Med 1988;27:1197-206 Griffith E , Mahy G, Young J. Psychological benefits of Spiritual Baptist "mourning", 11:An empirical assessment. A m J Psychiatry 1986;143:226-9 Hay D, Morisy A. Secular society, religious meanings: a contemporary paradox. Rev Religious Research 1985;26:213-27

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4

Studying and comparing other headaches with migraine characteristics The headache of meningitis has the same characteristics as migraine, namely headache plus nausea, vomiting, photophobia and general irritability. Lumbar puncture headache is accentuated by sudden head movement, also common during, and in some cases immediately after, migraine attacks. Fifty per cent of patients after an epileptic attack were sleepy,had headaches, and some experienced nausea and vomiting; a few mentioned that even after the headache had disappeared sudden head movement briefly reproduced the headachel1. Post-insulin hypoglycaemic headaches12were of three different varieties: a headache that disappeared soon after the hypoglycaemic symptoms disappeared, corresponding to a hunger headache; a prolonged headache lasting several hours, in some cases throbbing in nature; and of those that also had migraine about half were provoked into a migraine attack.

These comparisons indicate that migraine headaches may arise in the meninges which brings us face to face that so far we have failed to answer two fundamental questions in neurological diagnosis: where is the lesion and what is the nature of the lesion responsible for the headache?

Being prepared to generalize If pain is protective13,can headaches or migraine be protective? Progressive lowering of blood sugar, or available oxygen (experiencedby mountain climbers), or increase of alcohol consumption, all produce initially a brief headache, then prolonged headaches and, if severe enough, transient neurological damage (including coma), persistent neurological damage, and untimely death. This suggests that headaches could act as a warning and be protective. There is some supporting evidence from a study of 1000 women with headaches, who compared with the national statistics had fewer stroked4; 200 migraineurs had fewer cardiac infarctions or less ECG changes than controls15.An analogy can be drawn with deafness induced by noise: excessive exposure to noise can produce initially temporary, and eventually persistent, high tone or even total deafness. Perhaps we should follow the advice of Charles Darwin16, 'the art (of discovery) consists of habitually searching for causes and meaning of everything that occurs'.

Above all we should continue critical thinking. To this end it is invaluable to hold views and be prepared to be wrong. Francis Bacon wrote (translated by T H Huxley17)'truth comes out of error much more

Of ethics and education: strategies for curriculum development There have been continuing d e m a n d ~ l ,for ~ the renewal of medical education such that the education of medical students will prepare them to meet the needs of the communities which they will serve3.The central emphasis, apart from that of maintaining a standard of knowledge and skills sufficient for

rapidly than out of confusion . . . If you go buzzing about between right and wrong, vibrating and fluctuating, you come out nowhere; but if you are absolutely thoroughly and persistently wrong, you must, some of these days, have the extreme good fortune of knocking your head against a fact, that sets you all straight again'.

J N Blau The National Hospitals for Nervous Diseases Queen Square, London WC1N 3BG

References Allbutt TC. Notes on the composition of scientificpapers.

London: Macmillan, 1923:3 Blau JN. Adult migraine: the patient observed. In: Blau JN, ed. Migraine - clinical, therapeutic, conceptual and research aspects, London: Chapman & Hall, 1987 Eadie MJ, Tyrer JN. The biochemistry of migraine.

Lancaster: MTP Press, 1985 Tunis MM, Wolff HG. Analysis of cranial artery pulse waves in patients with vascular headache of the migraine type. Am J Med Sci 1952;224:565-8 Olesen J. Some clinical features of the acute migraine attack. An analysis of 750 patients. Headache 1978;18: 268-71 Moffett AM, Swash M, Scott DE. Effect of tyramine on migraine: a double-blind study. J Neurol Neurosurg Psychiatry 1972;35:496-9 Moffett AM, Swash M, Scott DE. Effect of chocolate on migraine: a double-blind study. J Neurol Neurosurg Psychiatry 1974;37:445-8 Pickoff H. Is the muscular mode of tension headache still viable? A review of conflicting data. Headache 1984;24:186-9 Lashley KS. Patterns of cerebral integration indicated by the scotomas of migraine. Arch Neurol Psychiatry (Chicago) 1941;15:331-9 Kenney RA. The chinese restaurant syndrome: an anecdote revisited. Food Chem Toxicol 1986;24:351-4 Schon F , Blau JN. Post-epilepticheadache and migraine.

J Neurol Neurosurg Psychiatry 1987;50:1148-50 Martins I, Blau JN. Headaches in insulin-dependent diabetic patients. Headache 1989;29:660-3 Young JZ. Philosophy and the brain. Oxford: Oxford University Press, 1987:104-5 Waters WE, Campbell MJ, Ellwood PC. Migraine, headache, and survival in women. BMJ 1983;287: 1442-3 Featherstone HJ. Headaches and heart disease: the lack of a positive association. Headache 1986;26:39-41 Bowlby J . Charles Darwin: a biography. London: Hutchinson 1990:411 Huxley TH. Collected essays, v01 111. Science and education. London: Macmillan, 1895:174

licensing medical practitioners, has been on the qualitative aspects of carers.

In any new path that is proposed, it is the philosophical and social questions which gain prominence in the light of ever increasing technological development. These technological developments bring forth questions concerned with the quality of patients' lives4,ethics and morality. The imminent and pressing problems of chronic disease, old age, handicap, abortion, artificial nutrition, withdrawing medical support, organ transplantation, fertility and genetic

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, engineering raise issues relevant for the clinician in everyday practice. Furthermore, the economic costs of medical care underlying the solutions to ethical dilemmas, and the costs of medical testing and intervention, must be included in clinical thinking and thereby included in any new curriculum. In some ways this is uncomfortable knowledge5. The social sciences applied to medicine operate in a charged political arena where information often challenges established cliches and puts in question accepted solutions. Falling fertility in the Western world is occurring at a time when there is increasing longevity.

This will shift the fiscal balance necessary for the support of health care, particularly in countries where the 'new consumers' from other lands demand support from a budget to which they have not contributed in the immediate past.

Social considerations in medicine demand a long term perspective on human relationships requiring knowledge about human nature, family culture, and social welfare. As the 1988 WHO declaration states2: ' . . the aim of medical education is to produce doctors who will promote the health of all people, and that aim is not being realized in many places, despite the enormous progress that has been made during this century in the biomedical sciences. The individual patient should be able to expect a doctor as a n attentive listener, a careful observer, a sensitive communicator, and a n effective clinician; but it is not enough to treat only some of the sick'.

Strong and heady stuff, and for many of us almost impossible to contemplate in its entirety and implement in practice. Such practice requires knowledge from varying discipines concerning human behaviour.

Promoting the health of all people, a s recommended, is a social and moral consideration. Attending the individual patient, the central focus of the clinical encounter, is an ethical consideration. While both hang together easily in the above quotation, in practice they are not so easily realized.

How can we then contemplate a curriculum for medical education when the breadth of knowledge is so great, and the increasing trend of practitioners is towards specialization? One way would be to educate health professionals to work together such that they can operate as a team to develop and share individual expertise. Some initiatives in medical education have attempted to promote such activity.

For the introduction of any change in a curriculum there are essential conditions for that change. First, it is important that all who are likely to be involved in implementing change are involved in discussions regarding that change. This initiative is essentially a political and relational process. Political, because one party attempts to influence the other by argument.

Relational, because the process is dependent upon goodwill and trust between faculty and the students for whom they are responsible. Second, for new methods to be implemented then the teaching staff involved must not be defensive and protective about their own subjects. This second condition requires interdisciplinary and interdepartmental cooperation.

The implementation of change is a management task for which few of us are prepared by training.

The strength of this approach is that it mirrors the consultation approach which stresses the activity of the patient. Patients, and sometimes their families, are expected to contribute actively to treatment

decisions and identify goals for change. In areas of decision-making where ethical considerations play an important role, the negotiation of cooperation within a relationship of trust could be a vital skill for our students to learn. This skill would not entail a n encylopaedic knowledge, but the ability to seek relevant knowledge and apply it in context as the situation demands. Part of this assimilation of knowledge would be social; ie listening to what others have to say with a different world view.

Sukkar6 stated that in order to bring about change in a medical faculty it was important that the teachers were made aware of the educational processes involved and that the teachers had expertise in planning the new educational strategy. To this end members of the teaching staff were asked to participate in a programme of 2-3 day workshops.

Junior members of staff were also encouraged if they showed interest in educational activities. Specialized workshops also developed expertise in specific areas of educational activity; curriculum planning, instructional methods, the use of educational technology and other teaching media, and evaluation methods.

Small working groups were also set up to implement particular aspects of curriculum development.

This teacher training programme emphasized the role of learners in setting learning objectives. Although integration between departments was encouraged the impact was minimal. The introduction of such change involved three main strategies: (1) A fellowship strategy which involved and included the teachers.

(2) A political strategy which used power and influence to implement the necessary initial changes.

(3) An academic strategy of considering issues on their intellectual merit and the basis of information rather than the protection of territorial rights.

It is clear from the literature that there are no universal solutions to curriculum change, and each setting must generate its own particular programme, although the process of change within institutions has elements in common. What is evident from the practice of implementing change is that a tutor training programme is mandatory7. Tutor skills are paramount in new approaches to medical education.

The tutor must stimulate discussion, maintain attention to the problem being discussed and guide the learning of the group, by facilitating group dynamics12. This entails t h e tutor having a n overview of the territory of the subject while the students can explore individual features.

What we can learn from this is that although students are in individual control of their own learning, and deciding what they will learn; the faculty determines the methods by which the students will be taught. It is the faculty which remains constant over time and which must maintain the thread of education. The student weaves that thread, according to his or her own particular pattern, into a garment which fits his or her own particular needs.

The central feature of any new approach is that it is based upon set objectives. These objectives are made clear between student and tutor relating to the personal needs of the student and inevitably to the requirements set by the state exam. In the end the faculty is responsible to the community that it will produce doctors of a particular standard fit to serve

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that community. While the standard itself may be questionable we can accept it as a basic which we can enhance, rather than a ceiling to which we must aspire. This tension will always exist between individual perspectives and state requirements, but it is not necessarily counter-productive regarding new teaching approaches8.

Although in recent years a number of medical schools have adopted problem-based learning, so far there is no evidence that problem-based learning is educationally superior to the conventional curriculum.

Nor is it inferior, and students appear to like such methods. Output measures are insensitive in detecting the subtle differences that may occur using such methods; although as educators we assume that a problem-based approach may be creating an educational climate which enables students to learn in what seems to be a desirable manner.

Contract learning9 is also a form of learning by the setting of mutual objectives. The term 'contract' itself is redundant as all learning situations are a contract between student and teacher, or student and faculty.

What these methods have in common is that the contract is made explicit, rather than implicit, and given definite boundaries according to the personnel involved.

The assumed benefits of these methods are that learning occurs in a context similar to that which the student will practice as a doctor where knowledge is shared and negotiated in a team; that their eventual work as a doctor will be improved because knowledge is understood in clinical and social context; and the conditions are set for life-long learninglO.Students are not only learning how to become doctors, they are also learning how to learn. That further learning, based upon critical thinking, takes place after qualification is open to question. Much practice is based upon eliminating variability and reducing the uncertainty of facts until they fit the familiar view such that a diagnosis can be made. This is the maintenance of medical belief, not the pursuit of scientific argument.

The major implication of this approach is that if we are to implement new methods, and wish to assess the efficacy of those new methods on the standard of medical education, then assessment must occur after graduation when the new doctor is in practice. Apart from this assessment of our teaching methods on the quality of the students we produce, it is clear from the literature that new teaching methods also have a vital component of evaluation during the career of the student a t the medical school.

Current thinking in medical education emphasizes the idea that people learn best when they are helped to define their own problems, acknowledge and accept their own strengths and weakness, decide on a course of action, and evaluate the course of their decisions.

(A situation which also sounds rather like the doctorpatient encounter.) It does not mean using selfadministered tests to determine knowledge and skills; what it does mean is helping people to judge their own performance. It is important for students to define their own learning objectives, and the educator's task is to facilitate that learning. While the student identifies what he or she wants, the trainer, or support group, also identify what the student needs to expand their learning objectives. The need of the student is a point which is often missed; it is not only what the student wants (which the student can determine) but

what the student also needs (which his or her colleagues, and tutor must determine).

Any reform of the curriculum will then require a reappraisal of the principles and practices of the evaluation system. The norm-referenced test which is the primary method of evaluation was initially designed to rank students for the purpose of selection.

Difficulties arise when it is used, as it currently is, for the assessment of competence. The norm referenced test 'while it provides information regarding the relative strengths and weaknesses of students in comparison to their peers, . . . does not provide an estimate of the absolute level of performance achieved' (p 145)11.

As it is the principal responsibility of a medical school to produce competent physicians, and not to rank order them, it is more reasonable to compare student achievement to a n external standard of performance or criterion. Criterion-referenced testing is more suitable for the assessment of competence as it best meets the objectives of medical schools by emphasizing achievement of clearly established external standards and, thereby, ensuring a standard of performance. Evaluation in this sense guides both tutor and learner to the areas which must be developed.

These methods are also valuable for those students who may require remedial help, and for encouraging a broad based platform for student education.

New methods then also carry with them a component of assessment. Assessment practices are often the major barrier to developing increasing student responsibility; if students always look to others for judgements of their competence, how can they develop their ability to assess their own learning? Transactions between students and staff are critically affected by the balance of power; where it rests and how it is used determines the quality of learning. Assessment is the clearest example of this power in action. Collaborative forms of assessment are necessary to overcome the problem of authority while still meeting the need for a certificate of intellectual competence. An agreed criterion referenced test provides the neutral ground for such collaboration. Using peer reference will strengthen internal demands for consistency and respect for individual ways of learning. But, the demand of external licensing must be met and faculties cannot shirk the responsibility of meeting that demand and the authority of implementing expected criteria.

It is a t this very point where we have the dilemma of the current examination system. If we encourage students to develop their own way of learning, then surely we must encourage them to assess themselves as to their competence. However, as faculty we have responsibility to the wider community in issuing the necessary licences of competence. While the student has the responsibility to learn, we have the responsibility to guide, and ultimately judge. To include the assessment of the student, and his or her peers, is essential in respecting their ways of learning and implementing change in the curriculum. As to the criteria necessary for licensing, then it is the faculty of teachers who must conserve and maintain the curriculum such that it is coherent and recognizable to external scrutiny. If both parties are involved in the dialogue of change and conservation, within the context of a respectful and trusting relationship, then we can hope that the dilemma will be resolved satisfactorily.

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In the end there is a distinction between the student who is there to learn, and the teacher who is there to guide. If the students knew already they would not be studying. It could well be that in our new methods we are asking the student to be both doctor and educator; this would not be so far from the modern demand made of the medical practitioner, and the old meaning of the word 'doctor'. However, to attain such a social standing requires validation from the community, of which the faculty is representative, that the student when graduated can both teach and heal.

A handicap to the introduction of new teaching methods can be the students themselves. It appears that the pressure of examinations dominate the curriculum no matter how well intentioned the design, or how educationally sensible the underlying philosophy12. This can be overcome, but it is necessary to understand that these new study methods also introduce stress. First there is the stress of having little time for leisure activities. Introducing more areas of study, such as medical ethics, into the curriculum will further compound this problem.

Second, any form of assessment, no matter how valuable to the student, is an additional stressor.

Time is an important factor for students. Learning takes time and we must be concerned that students have time to absorb knowledge. Presently there is talk of producing students efficiently, meaning that doctors can be produced in one year less than is currently possible. This is a dangerous trend and totally against the move towards a qualitatively better education. What are we educating our students to become as doctors and carers if we continually stress objectivity, work and production in the shortest time? Furthermore, we are assuming that all students will learn at the same rate. We can promote excellence in all our students, but not all can achieve excellence at the same rate. The way in which we teach is as important as what we teach.

To practice medicine is to solve ethical dilemmas.

Medical consultation is a social act where one person intervenes to influence another person utilizing clinical and non-clinical expertise. As Brock writes: 'Shared decision-making does not imply a value-neutral role for physicians; it requires of them a more delicate balancing.

They must advocate for their patients' health and well being, while also being prepared ultimately to respect patients' self determination, even when they disagree with their patients' treatment choices' (p 45)13.

Such a statement could be translated substituting tutor for physician and student for patient. Medical or

educational interventions are reached by consultation which demands a social understanding lacking in medical education. Learning to make shared decisions based on consultation will be the future of health care delivery. How we implement such an actvity, and teach it to our students is a matter of debate and urgency and runs counter to the modern trend of specialization. Ethics is concerned with the decisions individuals make about their own behaviour.

Morality is the set of rules resident in the community which govern individual behaviour. The reconciliation of an individual ethic within the context of a social morality is at the heart of human decision making.

Finding solutions to this dilemma is the stuff of education.

David Aldridge Medizinische Fakultat Universitat Witten Herdecke, Beckweg 4, D5804 Herdecke, Germany

References Wiedersheim R. Medical education - too little care, too much intervention. Nordisk Medicin 1978;93:216-19 WHO. The Edinburgh Declaration. Med Educ 1988; 22:481 Prywes M. The Beer Sheva experience: integration of medical care and medical education. Zsr J Med Sci 1983;19:775-9 Tosteson D. New pathways in general medical education.

N Engl J Med 1990;322:234-8 Stein H . Uncomfortable knowledge: an ethnographic clinical training model. Family Systems Med 1988;6: 117-26 Sukkar M. Curriculum development: a strategy for change. Med Educ 1986;20:301-6 De Marchais J. Involvement of teachers as problem-based learning tutors in the New Sherbrooke Programme. Ann Community-Oriented Education 1990;3:35-54 Coles CR. The actual effects of examinations on medical student learning. Assessment and Evaluation in Higher Education 1987;12:209-19 Boud D. Developing student autonomy in learning.

London: Kogan Page, 1986 Coles CR. Elaborated learning in undergraduate medical education. Med Educ 1990;24:14-22 Turnbull J. What is normative versus criterionreferenced assessment. Med Teach 1989;11:145-50 Carney S, Mitchell K. An evaluation of student satisfaction with professional skills teaching in an integrated medical school. Med Teach 1987;9:179-82 Brock D. The idea of shared decision making between physicians and patients. Kennedy Institute of Ethics J 1991;1:28-47

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Where am I? Music therapy applied to coma patients Intensive care treatment is a highly technological branch of medicine. Even in what may appear to be hopeless cases, i t can save lives1 through the application of this modern technology. However, albeit in the context of undoubted success, intensive care treatment has fallen into disrepute. Patients are seen to suffer from a wide range of problems resulting from insufficient communication, sleep and sensory deprivation2s3 and lack of empathy between patient and medical staff.

Many activities in an intensive care situation appear to be between the unit staff and the essential machines, ie subjects and objects. To a certain extent patients become a part of this object world. We propose that improvised music therapy can be a useful adjunctive therapy in such situations both for the patient and the staff.

In these situations of intensive monitoring and machine support, particularly in the case of comatose patients, we may ask of ourselves 'Where is the self of the patient?'. Needleman4 reminds us that the power of scientific thought has been to organize our perceptions i n such a manner that we can survive in the world. Hence the value of scientific medicine and instrumentation. However, he goes on to say that science has also neglected the human body as an instrument of knowledge and a s a vehicle for sensations as direct as ordinary sensory experience, but a s subtle as consciousness.

At the suggestion of a hospital neurologist a music therapist began working with coma patients. To investigate this approach further the work was monitored i n an intensive treatment unit. Five patients, between the ages of 15 and 40 years, and with severe coma (a Glasgow Coma Scale score between 4 and 7) were treated. All the patients had been involved in some sort of accident, had sustained brain damage and most had undergone neurosurgery.

The form of music therapy used here is based on the principle that we are organized as human beings not in a mechanical way but i n a musical form; ie a harmonic complex of interacting rhythms and melodic contour^^-^. To maintain our coherence as beings in the world then we must creatively improvise our identity. Rather than search for a master clock which coordinates us chronobiologically, we argue that we are better served by the non-mechanistic concept of musical organization. Music therapy is the medium by which a coherent organization is regained, ie linking brain, body and mind. In this perspective the self is more than a corporeal being.

Each music therapy contact lasted between 8 and 12 min. The therapist improvised her wordless singing based upon the tempo of the patient's pulse, and more importantly, the patient's breathing pattern. She pitched her singing to a tuning fork. The character of the patient's breathing determined the nature of the singing. The singing was clearly phrased so that when any reaction was seen then the phrase could be repeated.

Before the first session the music therapist had met the family to gain some idea of what the patient was like a s a person. On contacting the comatose patient she would say who she was, that she would sing for the patient in the tempo of his or her pulse and the

rhythm of breathing. The unit staff were asked to be quiet during this period and not to carry out any invasive procedures for 10 min after the contact.

There were a range of reactions from a change in breathing (it became slower and deeper), fine motor movements, grabbing movements of the hand and turning of the head, eyes opening to the regaining of consciousness. When the therapist first began to sing there was a slowing down of the heart rate. Then the heart rate rose rapidly and sustained an elevated level until the end of the contact. This may indicate a n attempt at orientation and cognitive processing within the communicational c o n t e ~ t ~EEG * ~ . measurement showed a desynchronization from theta rhythm, to alpha rhythm or beta rhythm in former synchronized areas. This effect, indicating arousal and perceptual activity, faded out after the music therapy stopped.

Some of the ward staff were astonished that a patient could respond to such quiet singing. This highlights a difficulty of noisy units such as these. All communication is made above a high level of machine noise.

Furthermore commands to an 'unconscious'. patient are made by shouting formal injunctions, ie 'Show me your tongue', 'Tell me your name', 'Open your eyes'.

Few attempts are made a t normal human communication with a patient who cannot speak or with whom staff can have any psychological contact. It is as if these patients were isolated in a landscape of noise, ! and deprived of human contact.

A benefit of the music therapy was that the staff were made aware of the quality and intensity of the human contact. In the intensive care unit environment of seemingly non-responding patients, dependent upon machines to maintain vital functions and anxiety provoking in terms of possible patient death, then it is a human reaction to withdraw personal contact and interact with the machines. This is further exacerbated by a scientific epistemology which emphasizes the person only as a material being and which equates mind with brain.

A period of calm was also recognized as having potential benefit for the patient. What some staff fail to realize is that communication is dependent upon rhythm, not upon volume. We might argue that such unconscious patients, struggling to orient themselves in time and space, are further confused by an atmosphere of continuing loud and disorienting random noise. For patients seeking to orient themselves then the basic rhythmic context of their own breathing may provide the focus for that orientation. This raises the problem of intentionality in human behaviour, even when consciousness appears to be absent. It is also vital that staff in such situations do not confuse 'not acting' with 'not perceiving'.

We can speculate that the various body rhythms have become disassociated in such comatose states.

The question remains then of how those behaviours can be integrated and where is the seat of such integration.

Improvised singing appears to offer a number of possible benefits for working with coma patients in terms of human contact and promoting perceptual responses. Human contact through singing, rather than speaking, also suggests that the fundamentals of human communication are musical in form. In this way we have the a r t of medicine within the science of medicine. Perhaps the skills of human communication may become part of medical and nursing education5, particularly in the context of intensive

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care. Although what we know from machines is valuable, there are other important subtle forms of knowledge that are best gleaned through personal contact with the patient.

The question still remains for us as clinicians and scientists when faced with a patient in coma, or a persistent vegetative state, 'Where is the person and how can I reach her?, and then for ourselves as fellow human beings, 'Where am I?' This raises further the ethical issues of decisions about terminating life support when the brain and the person are no longer seen as one and the same entitylO.

D Aldridge Medical Faculty, Universitat Witten Herdecke Beckwig 4,D5804 Herdecke, FRG

D Gustorff Znstitut fur Musiktherapie, Medical Faculty, Universitat Witten Herdecke

H J Hannich Wilhelms-Universitat Klinic fur Aniisthesiologie und operatiu Intensivmedizin Albert-Schweitzer-Strasse 33, D4400 Miinster, FRG

AIDS afterthought Barts students are no different from most final year medics in the need to choose a destination for the elective period. This need occasionally encompasses a desire to journey to a warm and exotic part of the world yet a t the same time is concerned with gaining some medical experience. It is surprisingly difficult to combine these two intentions especially since hot climates are often associated with many outdoor temptations which can divert thought away from study and learning.

My elective months were spent in Sydney, Australia, a choice governed by my previous special studies in HIV and AIDS. This interest began in 1985 when I joined St Mary's hospital for one year to study 'Infection and Immunity'. From that time, the subject of AIDS and the management of the immunocompromised patient began to appear more frequently in medical journals. The neuropsychiatric complications of HIV infection were of particular interest since they demonstrated links between the immune system, opportunistic infection and psychological symptoms in patients who practised diverse lifestyles.

The extent to which the AIDS epidemic will dominate current medical practice in the UK is still unclear.

My concern was to use my particular academic knowledge to support the clinical experience obtained on elective. However, I had not had any direct personal involvement in the management of HIV infection and for that reason alone was keen to spend some time attached to a unit where there was a possibility of some teaching, not only

References 1 Hannich H. Uberlegen m m Handlungsprimat in der Intensivmedizin. Medizin Mensch Gesellschaft 1988;13:238-44 2 Wilson L. Intensive care delirium. Arch Intern fed 1972;130:225-6 3 Ulrich R. View through a window may influence recovery from surgery. Science 1984;224:420-1 4 Needleman J. A sense of the cosmos. New York:Arkana, 1988 5 Aldridge D. A phenomenological comparison of the organization of music and the self. Arts in Psychotherapy 1989;16:91-7 6 Aldridge D. Music, communication and medicine. J R Soc Med 1989;82:743-6 7 NordoffP, Robbins C. Creative music therapy. New York, John Day, 1977 8 Sandman C . Afferent influences on the cortical evoked response. In: Coles M, Jennings JR,Stern JA eds.

Psychological perspectives (festscrift for Beatrice and John Lacey). Stroudberg, PA: Hutchinson and Ross, 1984 9 Sandman C. Augmentation of the auditory event related to potentials of the brain during diastole. Znt J Physiology 1984;2:111-19 10 Mindell A. Coma: key to awakening. Boston: Shambala, 1989

regarding HIV infection, but also of general medicine in preparation for Finals. Fortunately, a gynaecologist friend of my parents had trained in Sydney and introduced me to a consultant immunologist there, Professor Ronal Penny. Thus I came to spend my elective a t St Vincent's Hospital, Sydney.

I was extremely fortunate in being funded by the Guildchrist Foundation, the Clothworkers Trust and my Medical College, all in the City of London.

It was interesting that none of the London-based AIDS organizations were able to provide any assistance despite my protocol covering the very serious negative social aspect of neuropsychiatric complications of HIV infection.

The public image of the AIDS victim has been the infected homosexual or drug addict. Sydney, with its large population of both these sources of patients, also has people from every walk of life professing beliefs and carrying out behaviour that, as in all cosmopolitan society, has no norm. AIDS is making its grim inroad, indifferent to stereotyping. During my time in Sydney, I saw many aspects of inpatient, outpatient, community and laboratory care of HIV infection. It is a sad game of numbers that the Australian population is not much more than a quarter that of the UK, but contains as many recorded cases of AIDS. The field of neuropsychiatric complications was too vast for deep investigation in the limited time of the elective period. My work covered a broad overview of the illness and gave me a deep understanding of compassion.

'AIDS patients? Did you wear a mask. I hope you wore rubber gloves!' This was the reaction of several of my fellow students on my return to London. I must say that, to an extent, these intimations of fear and caution echoed my own

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