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Crossroads The Evolution, Appreciation and Representation of Music Legal Parameters to Medical, Ethical and Professional Responsibilities Dansei Konenki: Narratives of Male Menopause in Contemporary Japan The Evolution, Appreciation and Representation of Music Mamatha Bhat*, B.Sc., Sharmila Udupa INTRODUCTION The arrival of novel neuroimaging techniques such as fMRI (functional magnetic resonance imaging) and PET (positron emission tomography) has enabled us to visualize which areas of the brain are stimulated under certain conditions. Researchers are using these techniques to satisfy their curiosity about brain functioning with respect to specific functions such as tasting, smelling, reading, and listening. The etiology of certain psychiatric or neurological conditions is also better understood using these methods, as they offer a view of brain stimulation in real time. It is in this context that researchers have been investigating musical representation in the brain. The therapeutic benefits of music have only recently been realized. Music therapy is an aspect of alternative mind-body medicine that is gradually gaining acceptance among medical professionals (2). It is known to have a soothing psychosomatic effect on terminally ill patients (3) and reduce anxiety associated with the diagnosis and treatment of cancer (4,5). Improvements in the pain of cancer in patients following music therapy have been noted (6), and research into this effect has implied the music may be beneficial in lowering anxiety levels associated with cancer and its treatment (7). Thus, these studies suggest music therapy to be an effective holistic practice for palliative care. In one study, quality of life was higher for those subjects receiving music therapy, and their quality of life increased over time as they received more music therapy sessions; however, life expectancy did not differ between the group receiving music therapy and those without intervention (8). Music has also been tried as an "analgesic" during procedures such as bronchoscopy (9) and colonoscopy (10), as it has a distracting effect. Wang et al. showed a decrease in preoperative anxiety and acute postoperative pain with the use of music therapy (11). Music therapy as a clinical intervention has been demonstrated to improve mood states with a variety of populations (12). But how is it that music can effect such change in one's state of mind? Functional MRIs and PET scanning have afforded researchers a view of the brain regions that light up in response to musical stimulation. The processing of sounds in general has been known as a function of the Heschl's gyrus, a component of the temporal lobe. Since music involves a variety of aspects, such as melody, rhythm, harmony and fine motor coordination, its representation is indisputably more complex. This review article attempts to explore the various studies that have been accomplished in recent years with respect to the brain's representation of these various facets of music. In addition, it looks at the purpose of such musical representation in the brain within the context of human evolution. MUSIC APPRECIATION AS AN INNATE QUALITY This incredible capacity for music perception at such a tender age might find its origins in the parent-infant relationship. Lullabies and children's melodies are sung to infants at a very early age, and from the moment of birth they are spoken to in singsong voices. The genre of music that the child listens to shares a number of features with children's songs from different cultures. During the neonatal period, infants prefer renditions of a song in the maternal style to a non-maternal version of the same song by the same performer. These early social influences on music reveal the intimate relationship of social relations and musical perception. Trehub (13) speculates that it is the social nature of music and its link to positive emotional states that has permitted its growth into an elaborate system. Hauser and McDermott believe a parallel knowledge exists within music, and it is that which contributes to its intrinsic quality (18). They have primarily used animal research so as to avoid any potential prior exposure of the subject to the music. Notably, whatever response is evoked in the animals from listening to music would reflect an auditory capacity rather than an adaptive function. Rhesus monkeys, close to humans in terms of evolution, have displayed in past studies an intrinsic inclination to tonal melodies and a similar neural response as humans to dissonant chords. It is important to bear in mind that sensitivity to musical key structure is not consistent among different species, but is within species (such as primates, infants, and adults), and that behavioral expressions may not parallel neural mechanisms at all times. EVOLUTION OF MUSIC As for its purpose, some theorists state music to have developed as a sexually selective system devised to attract mates and signal mating potential, or to more generally express emotional states (20,21). Other theorists believe music serves to guide and facilitate collaboration among groups of people (22). There exists yet another group of scientists who believe music does not have an adaptive source, and is simply an incidental consequence of unrelated perceptual and cognitive functions (23). Certain musical forms such as Indian classical music and gospel music are devotional and spiritually inclined. Among these possibilities, the one that remains prevalent in our social context is our usage of music as a means of expression. Human and nonhuman animals still manifest their emotional states via variable vocalizations, which show that music and emotional articulation have likely developed simultaneously (18). Rhythmic discrimination is an auditory mechanism that seems to have developed over the course of evolution as well (24). Studies have shown that human infants and monkeys recognize differences in speech rhythms between two languages, thus suggesting that certain tapping domain-general auditory mechanisms may have evolved prior to human production of music as we know it (24, 25, 26). Solid evidence of a biological basis for music comes in the form of a study by Blood and Zatorre (27). They uncovered fascinating evidence as to why music is so appealing to all. PET was used to determine the neural stimulation that forms the basis of our pleasant emotional response to music. Subjects reported chills when listening to their favorite pieces of music. This musical euphoria was accompanied by changes in heart rate and respiration.. Cerebral blood flow increased to brain regions implicated in reward, motivation, arousal and emotion. These areas include the amygdala, the ventral striatum, the midbrain, and the structures that are activated in response to other pleasure-inducing stimuli, such as food, sex and drug abuse. This common pattern of brain circuitry, which is involved in pleasure and reward, establishes that music is linked to "biologically-relevant, survival-related stimuli"(27). MUSICAL REPRESENTATION IN THE BRAIN This model is unique and more inclusive than its predecessors primarily because of its extensive organization and because of its outlook on input and output. It defines input as any acoustic stimulus that can be attributed to a single source. This input then goes to all auditory domains (not just that of music). The perceptual modules feed into an emotional analysis component, unique for each individual. Past experiences will shape what is considered emotionally appealing. The final output of the musical circuit will depend on which modality domain optimally responded to the stimulus. A) MUSICAL APTITUDE A study by Butcher (31) showed that auditory processing is quite different in professional musicians versus non-musicians. Primary source activity was especially localized to the anteromedial portion of Heschl's gyrus. This structure is found in the temporal lobe, and is the portion of the brain responsible for the processing of sounds. Butcher's study also detected a 130% increase in the volume of gray matter of Heschl's gyrus in professional musicians as compared to non-musicians. A study by Hutchinson et al. discovered that the absolute cerebellar volume of musicians was significantly greater (p< 0.001) than that of non-musicians, a reflection of the highly developed and specialized motor skills they have developed early in life in order to play their instruments (32). The cerebellar volume increased with reported intensity of practice, i.e. the number of hours practiced. B) PITCH Many people with musical training have the ability to quickly identify the precise position of a note in the scale without reference to any other note; this ability is known as absolute pitch. This cognitive ability seems to develop due to the interaction of genes and environmental exposure to music during childhood in particular. Such ability is seen in musicians of all traditions, due to auditory imagery and sensorimotor response codes. According to a study by Gregerson, which points toward a strong heritable component for absolute pitch, people of Eastern Asian descent have a significantly greater incidence of absolute pitch ability than those from other backgrounds (35). When the pitch of a song changes, typical listeners show an electrophysiological response in an area of the right frontal cortex as a reflection of their on-line memory system having been reset; however, those with absolute pitch ability show no such neural activity. Rather, those with absolute pitch show activity in the posterior dorsolateral cortex when they listen to tones (36). It is likely that this is how these people label pitches to sounds readily, since this region of the brain serves an associative function. C) HARMONY Adult listeners have rated the minor second (a difference of 1 semitone) as being the most dissonant sound. What is striking is that, in a study by Zentner et al., infants who were exposed to consonant sounds demonstrated visual fixation at the source of sound and significantly reduced their motor (37). When the sound was dissonant, the babies were more likely to cry and turn away from the music source, thus supporting the argument for a natural human inclination towards consonance. Harmony has been found to localize to the right lingual gyrus and the left inferior parietal lobule (38). The activation of these areas is significantly greater in musicians. D) MELODY In a study by Schmithorst et al. (38), unharmonized melodies bilaterally activated the superior temporal gyrus to an extent significantly greater than that associated with random tones. During this comparative exercise, musicians had significantly greater activation in the inferior parietal lobules and superior frontal gyrus bilaterally. Harmonized melodies stimulated a different activation pattern when compared to unharmonized melodies. The former generated a significantly greater activation in the right lingual gyrus and left inferior parietal lobule. A few other regions such as the right fusiform gyrus, left medial occipital gyrus, left frontal gyrus and anterior cingulate gyrus also lit up when the subjects heard harmonized melodies. The semantic familiarity with melodies was reflected in the increased activation of the left inferior frontal and superior temporal gyri in musicians. The exact role of the parietal areas in musical processing is unknown; however auditory working memory and visuo-auditory integration are thought to be the main musical functions served. It is thought by some researchers that the supramarginal gyrus in the parietal lobe is used for working memory during melodic processing, while visuospatial processing of harmonies is performed by the angular gyrus. The familiarity of tunes has been traced to areas of right auditory association cortex, together with right and left frontal cortices (41). It would seem that these areas are involved in imagery for familiar tunes, as evidenced by this PET scanning study. This study by Halpern and Zatorre showed retrieval from musical semantic memory as being mediated by structures in the right frontal lobe, which conflicts with results from previous studies associating left frontal areas with all semantic retrieval. The supplementary motor area (SMA) seems to be implicated specifically in image generation, and would seem to provide the link between musical perception and action. Cases of amelodia have been reported in the past. Such isolated disorders of music perception have given researchers clues as to the localization of musical components in the brain. For instance, a highly trained musician suffered an ischemic injury of the right temporal lobe, which impaired his ability to identify the melodies of popular music pieces. He was also unable to identify instruments being played. Thus, the right temporal lobe is critical in the perception of melody. Incidentally, this region is possibly responsible for "decoding environmental sounds, discerning emotional prosody, and identifying voices" (42). E) RHYTHM Sequencing behavior is key in the production of music (43). The early phase of sequence learning in music involves linking individual sequential units one at a time. As musical training progresses, the learner starts to group elements into larger combinations or "chunks". These higher-order programs become hierarchically structured into a regular pattern of sub-sequences once the subject has become familiar with a piece. Learning a sequence that is structurally complex places cognitive demands on the brain. It is not just a matter of rote memorization. Such learning involves executive processes, chiefly error monitoring and motor program structuring. The timing aspects of both perceptual and motor tasks have been found to activate regions such as the cerebellum, supplementary motor area (SMA), premotor cortex, basal ganglia and the parietal cortex. These areas of the brain are richly interconnected and form a circuit in the perception-action cycles of music production. CONCLUSION REFERENCES Legal Parameters to Medical, Ethical and Professional Responsibilities: Are Doctors Appropriately Categorised as Fiduciaries Scott Guy, B.A., L.L.B., Barbara Ann Hocking*, B.A., L.L.B.,
L.L.M., PhD, and Stewart Muirhead, L.L.B. (Hons.) Taking account of the so-called 'litigation crisis' in Australia (1), our analysis examines the doctrine of fiduciary duties, as it is presently understood, and asks whether it can be developed to provide adequate legal boundaries to the professional and ethical conduct of psychiatrists in particular. Special attention is paid to the recent Australian decision of B -v- Marinovich (2) , and the approach taken by the court in seeking to define a fiduciary relationship between doctor and patient. A review of comparative jurisdictions is further undertaken to support the argument that fiduciary duties can be expanded to create new standards in the context of medical negligence. By way of contrast, the paper then compares the ethical considerations arising in the legal profession in the context of their insurance arrangements, and examines the approach taken by the courts in defining those duties. The comparison is undertaken to demonstrate the court's ability to formulate the principle governing the fiduciary obligations of professionals. FIDUCIARY DUTIES WHAT IS A FIDUCIARY? DEFINING THE RELATIONSHIP OF FIDICIARY A further aspect of a fiduciary relationship is that one party voluntarily undertakes to act on behalf of another party. The doctor/patient relationship satisfies this requirement because "the patient is putting his health and his life in the doctor's hands" (10). The ordinary meaning of "voluntary undertaking" means an undertaking to act in the interests of another, which would imply that one party has consented to assume the role of a fiduciary. This consent would appear to be implied in the "doctor-patient" relationship because the patient has a so-called "special vulnerability". In Breen -v- Williams (11) it was considered that there was little difference between a relationship where there was a "voluntary undertaking" and one in which there was a "special vulnerability" . As well as a "voluntary undertaking" a further aspect of a fiduciary relationship is that the relationship is often one that is based on an unequal distribution of power. Because of the imbalance of power that is inherent in the doctor/patient association, this relationship can give rise to exploitation, which warrants protection in the form of an imposition of a fiduciary duty (12). It has been argued that the principle of "unequal distribution of power" cuts right to the heart of the fiduciary concept in an attempt to identify exactly what it is that makes the fiduciary special (13). THE SCOPE OF THE FIDUCIARY DUTY Like the solicitor, the doctor has to provide certainty for problems that may be uncertain, and both professions must provide a high standard of professional performance. The provision of legal advice to a client is akin to the exercise by a doctor of an independent medical judgment on the patient's behalf - be it making a diagnosis, recommending treatment or implying that no treatment is necessary. Clients entrust solicitors with confidential information, and the position with the patient is no different. It is therefore difficult to see why the scope of the fiduciary duty owed by a doctor to a patient is restricted to the beneficiary's legal interests, but does not extend to personal interests. The solicitor's fiduciary obligations are based very much on the considerations outlined above. In Re Gibson (16), the court held that the lawyer stood in a fiduciary relationship with the client and "should exercise professional judgement solely for the benefit of the client" (17). Considerations of confidence, vulnerability and the obligation that the lawyer must act in the best interests of the client are all underpinning factors giving rise to the fiduciary duty not only to legal matters but to personal matters as well. These principles represent the recognised basis upon which fiduciary responsibilities exist. The question remains as to whether doctors should be categorised as fiduciaries. On the one hand, it could be argued that the doctor is not an appropriate candidate for fiduciary liability because there is no inequality of power between the doctor and patient. The only power the doctor is likely to receive is from acts of consent for the purpose of diagnosis and treatment. However, on the other hand, it might be considered that with doctors' specialised training and knowledge, such medical practitioners are therefore at a particular advantage in the relationship. Yet, while an imbalance of power may exist, a patient does have the right of veto and can withdraw consent at any time. This argument would appear to be insufficient to negate the imposition of a fiduciary duty on a doctor. Support for this contention can be gained from McLachlin J in the Canadian decision of Norberg -v- Wynrib (18) who, when questioning whether a fiduciary relationship existed between a doctor and patient (19), observed that the medical practitioner, Dr Wynrib, was in a position of power and could exercise that power in a way that affected the interests of the patient, Ms Norberg. This position of power was accentuated by the fact that Ms Norberg was addicted to prescription drugs. Dr Wynrib:
had the power to advise her, to treat her, to give her the drug or to refuse her the drug. He could unilaterally exercise that power or discretion in a way that affected her interests and her status as a patient rendered her vulnerable and at his mercy, particularly in the light of her addiction (20). So, all the classic characteristics of a fiduciary relationship were held to be present. It would appear then that a fiduciary relationship is presumed to exist between the doctor and patient. In the Australian case of B -v- Marinovich (21), for example, Riley J highlighted the existence of a fiduciary relationship between the psychiatrist and patient and the duty of care owed by the psychiatrist as a result of this relationship. THE DUTY AND STANDARD OF CARE There have been two diverging approaches to evaluating whether a medical practitioner has fulfilled the appropriate duty or, more particularly, standard of care. The first approach was established in the leading case of Bolam -v- Friern Hospital Management Committee (25). According to the Bolam principle, so long as the conduct of the medical practitioner conformed to accepted medical practice then he or she could not have been considered to be negligent. The Court should not impose its own standard of care in preference to that of accepted medical opinion. As the House of Lords held in Bolam (26), "in short the law imposes the duty of care; but the standard of care is a matter of medical judgment." However, later cases have tended to reject this view. The appropriate standard of care, which is to be exercised by the medical practitioner, is one that is to be decided, independently, by the Court and not be reference to medical opinion. For example, the United States Supreme Court has held that it is the responsibility of the Court to decide if the medical practitioner has fulfilled his or her duty to warn patients of the risks when undergoing medical treatment (27). A similar position has been adopted in Canada where it is the Court, and not the medical profession, that decides the extent to which the risks involved in medical treatment have been adequately disclosed (28). The High Court has followed this approach in the leading decision of Rogers -v- Whitaker (29). Mason CJ held that when deciding whether a doctor has been negligent, reference needed to be made to legal principles, as well as accepted professional practice. Thus, it was the responsibility of jurors and the Court to use their own common sense when determining if a medical practitioner had been negligent, as opposed to relying on a medical "expert" (30). This latter method enables the courts to take a more interventionist and active approach in deciding issues of medical negligence. The judge has greater freedom to scrutinise the reasoning behind an expert opinion, in much the same way as judges undertake this task in other areas of professional negligence such as in solicitors' negligence cases (31). Outside the context of medical negligence, the courts have had no difficulty with the notion that commonly adopted practices may themselves be negligent (32). LIABILITY IN THE MEDICAL FIELD THE MARINOVICH CASE IN AUSTRALIA THE FINDING IN B -V- MARINOVICH The law therefore recognises that a doctor has a duty to warn a patient of the risks inherent in a proposed treatment. This duty is known as the doctrine of "informed consent". The medical profession should warn the patient of all "material" risks involved in a course of treatment. A material risk, according to the Australian High Court in Rogers -v- Whitaker, is one that a reasonable person, in the patient's position, would attach significance to. The decision in Marinovich suggests that it is the responsibility of the Court to reach an independent view, as to what constitutes a "material" risk, and not rely on accepted medical opinion. The House of Lords, however, in the Bolam decision, appeared to leave the determination of a legal duty to inform of a "material" risk to the judgment of doctors. Yet this decision is subject to criticism. The question of to what extent a patient should be warned before consenting cannot be answered by reference exclusively to medical practice, as the patient has a right to be informed of inherent risks. In short, the medical profession cannot be a judge in its own cause. This criticism was reflected in Lord Scarman's dissenting judgement in Bolam. His Lordship concluded that there was room in English law for a legal duty to warn a patient of the risks inherent in a proposed treatment: should such a duty exist, its proper legal place could be considered as an aspect of the duty of care owed by the doctor to his patient. RECENT CASE LAW ON THE STANDARD OF CARE The medical profession is best positioned to set its own standards as to appropriate professional practices in regard to what some would regard as elective procedures paid for later…Courts should not rush into areas in which subjective professional judgements predominate… (36) In Tan -v- Benkovic the plaintiff sued the defendant because of "tightness, facial asymmetry and lines on her lips" (37) following plastic surgery. The defendant surgeon promised the plaintiff that the operation would make her look "twenty years younger" (38). In determining whether there was a breach of duty, the New South Wales Court of Appeal (39) questioned whether there was a "contumelious disregard of a doctor's duty to provide adequate care" (40). It was held that the defendant surgeon's "inducements and blandishments" did not amount to a "disregard for the doctor-plaintiff relationship" (41). In the Tan case, the Court of Appeal appeared to assume a more lenient standard of care than the one adopted in Marinovich's case. It was held that Rogers -v- Whitaker did not require the surgeon to inform the plaintiff of all risks associated with the proposed operation. Further, while the plaintiff was undoubtedly "upset, vexed and depressed about the determinantal side-effects of the operation" (42) this did not amount to a breach of the doctor's standard of care. A similar approach was again adopted by the New South Wales Court of Appeal in Hunter Area South -v- Marchlewski (43). On the other hand, the later decision of Presland -v- Hunter Area Health Service (44) has again highlighted the independent role of the Court in determining the appropriate standard of care without regard to medical practice or convention. The decision would appear to confirm the approach in Marinovich. In Presland, the defendant medical service discharged the plaintiff from its care since it was believed that the patient was not suffering any mental or psychiatric disorder. The plaintiff subsequent killed his brother's fiancée. The plaintiff was found to be suffering from psychosis. The New South Wales Court of Appeal held that the Hunter Area Health Service should have diagnosed the plaintiff's mental illness and reasonably foreseen that physical injury would have resulted following his discharge from the health service. The decision again emphasised the important role the Court will play in determining whether the defendant satisfied the relevant standard of care. THE DUTY TO WARN OF RISKS INVOLVED IN TREATMENT Criticism, however, has been raised in relation to the medical profession's ability to communicate effectively and to warn patients of the risks involved in treatment. A paper delivered at the 4th annual conference of the Australian Institute of Health, Law and Ethics in July 1999 recorded that there were a number of perceived communication limitations pervasive in the medical profession and concluded that:
to communicate effectively; to act promptly to protect patients from poor practice; to be open about risks and variations in performance; and to admit to the errors that they are an everyday occurrence in judgment-based clinical decision-making (45). With the imposition of a higher but undefined standard of care requiring medical practitioners to warn of every conceivable risk in a procedure, the question needs to be raised as to whether this will lead towards defensive medicine. Professor Jones (46) considers that this argument flies in the face of common sense and experience, which suggests that private sector defendants (solicitors, accountants, surveyors, etc) would need a sharp prod from the law of tort in order to achieve acceptable levels of competence. Jones's view has been reinforced by the recent House of Lords decision in Arthur J S Hall -v- Simons (47) where the Court conducted a thorough review of arguments for and against the abolition of advocates' immunity. One such argument in favour of retaining immunity was that advocates were more likely to act defensively, to the detriment of the overriding duty owed to the court in favour of their own position. That argument could not be supported as there was no evidence to suggest that advocates would act defensively contrary to their duties owed to the court and client. CONCLUSION This paper has explored the indicia giving rise to a fiduciary duty and now suggests that these concepts can be developed in the Australian common law to produce a new standard for cases such as B -v- Marinovich. The principle of fiduciary duties, as developed in Marinovich's case, also has implications for such increasingly important issues as access to medical records, and the use of a patient's genetic information. These concerns will be the focus of attention in our second, related paper REFERENCES
Dansei Konenki: Narratives of Male Menopause in Contemporary Japan Tomoko Sakai, B.Sc. *
INTRODUCTION In the summer of 2002, I conducted archival and ethnographic research on the scientific construction and lived experience of dansei konenki in Japan. During this period, I interviewed several clinicians who specialize in treating dansei konenki, as well as patients afflicted with the disease. In addition, I conducted participant observation at one clinic, which specializes in the treatment of this disorder, and in the homes and work environments of several patients-one of whom I document in this paper. Through the analyses of these data, I argue that the indigenization of dansei konenki has been fueled by and is contingent upon a particular socio-historic moment in Japan. A movement embodied by an extended economic recession, and multitudinous shifts in family values, work ethics, and gender roles that the economic decline has induced in Japanese society over the past decade. Interestingly, this illness category has become largely divorced from its roots and taken on a distinctly different set of meanings and definitions-both in the medical community and the larger society-that reverberate within the specific context of contemporary Japan. A process frequently referred to as the localization, or indigenization of an illness category in recent anthropological literature, it is manifested in multiple layers in Japanese society: first, the western, biomedical concept of dansei konenki is grafted onto local knowledge about health and the male body, and is subsequently transformed. For example, leading Japanese physicians involved in the treatment of this condition contend that a decrease in testosterone levels leads to an imbalance in the autonomic nervous system (b), triggering chronic fatigue, shortness of breath, and bad peripheral circulation; and that obesity and smoking can negatively affect the circulating levels of the hormone. In contrast to the overwhelming emphasis placed on male sexuality and its decline in the western discourse of male menopause (c), its indigenized counterpart in contemporary Japan embodies distinctly different theories of causation and physical manifestations. The economic decline has proven to be a powerful force in reshaping important social values in the everyday lives of the Japanese-middle age men in particular-such as family values, work ethics, traditional corporate structures, and gender categories. As the illness narrative of Yoshiharu Sakaguchi, a patient diagnosed with dansei konenki will show, the drastic effects of the dragging recession on middle to old-age men-such as large-scale layoffs and major transformations in the traditional structure of companies-all signify an increasingly hostile and insecure environment for this particular population. Yoshiharu Sakaguchi is an executive of a multi-national trading company and the head of the Toyama branch. He was diagnosed with konenki while preparing for early retirement, after the company decided to close the Toyama (d) branch due to budget restraints. His narrative depicts the increasing difficulties that the creators of the current economic prosperity confront today-and accordingly, the diagnosis of konenki has added onto those distresses. For example, concurrent with the mild social stigma of being a "workaholic" who has neglected fatherly duties, which are becoming idealized as male virtues, the diagnosis also symbolizes a deprivation of masculinity for Yoshiharu Sakaguchi. Thus, dansei konenki in contemporary Japan has taken on meanings that reflect the multitude of changes and its effects that have resulted from this particular socio-economic context. THEORETICAL RELEVANCE In No Aging in India: Alzheimer's, the Bad Family, and Other Modern Things (1), for example, Lawrence Cohen tackles the puzzling observation of how Alzheimer's in India is largely denied to exist. Simply put, in contrast to the U.S., where the pathologies of old age can be predominantly discussed as an unemotional and isolated medical issue, Cohen found the discourse of senility and aging in India to be intensely moral, emotional and cultural. These discrepancies, Cohen argues, may explain the apparent difficulty that Indians have in acknowledging Alzheimer's and senile dementia as a disorder that afflicts their own people, where the elderly are well-cared for and very much part of the traditional Indian joint family. Conversely, the ethnography written by Paul Farmer looks at instances where biomedical illness categories with a western origin are taken up by non-western locales and are subsequently indigenized; similar to the case of male menopause in contemporary Japan. Paul Farmer's 1993 text, AIDS and Accusation: Haiti and the Geography of Blame documents how, as the AIDS pandemic spread in Haiti-most probably by the increased contacts between Haitian sex-workers and gay tourists in the early 1980's - local meanings, as well as theories of causation and agency were grafted onto the biomedical definition of AIDS (2). In spite of efforts to educate the public about the scientific explanation and the prevention methods of AIDS, the majority of the destitute population attributed theories of voodoo curses, Haitian black magic, and white American racism to this illness in desperate attempts to assign blame and find a cure. Like Farmer's work, the study of dansei konenki in contemporary Japan addresses the same issues of the adoption, transformation, and subsequent indigenization of an illness category with its roots in the West. However, the uniqueness of this case study lies in the fact that male menopause has become much more rapidly and readily acknowledged as a sound, biomedical illness in Japan, in contrast to the western countries where it was initially codified. In other words, this paper expands the analytic framework of Farmer by looking at the indigenization of a biomedical illness that has yet to be commonly recognized by the larger societies in the West. ETHNOGRAPHY OF ISHINKAI UROLOGY CLINIC Additionally, in contrast to defining dansei konenki as simply a consequence of declining testosterone levels, as is customary in the United States, Japanese doctors have formulated their own diagnostic requirements for this new illness category: a conspicuous example of an illness category that is re-invented in the local environment. Dr.Yokoyama notes that the myriad of symptoms patients exhibit, such as hot flashes, headaches, chronic fatigue, and lack of sexual appetite, are caused by jiritsushinkei shicchoushou (autonomic imbalance). Additionally, they must follow a cycle of ebbs and flows: if any one symptom persists, then it is not caused by menopause. As for testosterone levels, his theory holds that the large difference between circulating free testosterone levels before and after a man enters his middle age (e) is what characterizes male menopause. Hence, rather than setting an absolute standard of hormone levels to distinguish normal from abnormal ranges - one of the principal tenets of biomedicine - diagnostic standards are set differently for each individual. Thus, there are no strict diagnostic cutoffs for what is considered to be a physiologically normal or abnormal level of testosterone (f). Many times, Dr.Yokoyama will let the patient decide on the dosage of testosterone administration, according to his subjective discretion. Another physician pioneering the treatment of dansei konenki in Japan has his own set of standards for diagnosing the illness. A well-known cardiovascular specialist, Dr. Fuminobu Ishikura of Osaka University Medical School defines dansei konenki as a comprehensive term incorporating erectile dysfunction, cardiovascular abnormalities, and clinical depression (3). Interestingly, these two physicians come from two distinct backgrounds of medicine-Dr.Yokoyama from urology and prostate diseases, and Dr. Ishikura from the cardiovascular system. Thus, both doctors accommodate specific knowledge about their specialties to construct an illness category that fits their own definition of male menopause (g). Treatment methods have also undergone significant indigenization and appropriation, formulated to reverberate within local contexts. The most prominent example is Dr.Yokoyama's three main methods of treatment which he almost always combines for any patient - Testosterone replacement therapy (TRT), kanpo (h), and counseling - in contrast to the standard Western treatment which is solely confined to hormone injections. Only in cases of severe clinical depression, will he refer his patients to a psychiatrist. Dr. Yokoyama also uses supplements such as fukoidan (i), a type of dietary fiber extracted from seaweed, as part of his treatment methods. Dr. Ishikura, on the other hand, asks the first-time patient to complete a comprehensive questionnaire used in diagnosing clinical depression, and requires a session of relaxation methods, more commonly known as jiritushinkei kunren hou, or training of the autonomic nervous system, in addition to drug prescription and psychological counseling. Other means of the local indigenization of dansei konenki are manifested in Dr.Yokoyama's numerous articles and publications. In one article entitled "Male menopause, Female Menopause" he wrote for Anatani E-ru (An Eire to You) (4), a monthly subscription magazine targeted for reader audiences in their 50's. Its pages are devoted to discussing certain kinds of food that are effective in alleviating male and/or female menopausal symptoms, as well as certain personalities and professions in which there is a high or low incidence of patients with konenki. The idea of food as medicine, an emphasis on harmony, balance, and equilibrium promoting an optimal state of being are characteristic of traditionally East Asian concepts of health. In terms of daily diet, Dr.Yokoyama encourages readers to eat "sticky/slimy" food, such as fermented soybeans, a relative of the taro root, and okra, all of which supposedly have properties that "balance hormone levels, repair prostate and other male functions." Beer is discouraged because one of its main ingredients, hop, contains estrogen-like compounds (4). Personality-wise, men with "a strong sense of responsibility, a keen sense of competition who are punctual, impatient, and always hungry for success" will have a stronger tendency to develop menopausal symptoms compared to those who are "stable in their mental states, and maintain [their] own pace of life, unaffected by the environment." These translate into vulnerable professions - those that use the brain more than the body - such as corporate workers, company executives, and those who do a lot of deskwork. By contrast, gym teachers, military personnel, and construction site workers have a lower incidence of dansei konenki (4). With initial research beginning in the U.S. in the 1940's (5), the possibility that men may experience menopausal symptoms, and the use of the term as diagnostic, was first introduced to Japanese medical professionals at symposia held by prestigious academic institutions, such as the General Assembly of the Japan Medical Congress and the Japanese Urology Association. However, physicians involved in the treatment of konenki today claim that it received very little attention or understanding back then. Since then, the concept has gradually gained attention and acceptance from both the medical community as well as the general public - closely following the economic downfall which has resulted in socially significant events such as massive salary and job cuts among middle-age workers. By 2003, the institutions named above were seen to give much attention to the subject, and acknowledged the need for a collective effort to further new studies and reach an agreement about a standard definition, diagnosis, and treatment for this emerging illness category. Today, several university and public medical centers, such as St.Marianna Medical University and Tokyo Women's Medical University, have founded Departments of Andrology, holding outpatient hours specifically for dansei konenki. According to one study, a random survey of 90 men between the ages 45 and 60, using a questionnaire and interview, revealed that roughly 20-40% identified with the major symptoms associated with konenki (3). One of the pioneers in the diagnosis and treatment of dansei konenki, the Department of Urology at Kansai Medical University has also reported that it had diagnosed approximately 150 patients with the disorder-roughly 90 of whom are currently receiving testosterone replacement therapy-since it founded its outpatient clinic in January 2002 (2). Unfortunately however, large-scale, formal studies investigating the general incidence of dansei konenki, as well as the precise number of physicians or medical facilities which treat the condition in Japan today have yet to be conducted. The lack of an agreement on the specifics of the disorder, including its diagnosis and treatment by the Japanese medical community, lies at the root of the problem, and efforts to expedite the formulation of standard concepts regarding this novel illness category is much needed. Participant-observations at Ishinkai Urology Clinic suggest that dansei konenki, as an indigenized illness category in contemporary Japan, has also taken on a socially significant function: the category serves to restore the social functionality of the patient, hence contributing to the recovery of the function of his family, his company, and the dire economic climate of the society. This stands in stark contrast to the general representation of male menopause in the U.S., where the discussion is heavily centered around issues of sexuality. Indeed, many American physicians contend that male menopause is simply another way of describing sexual/erectile dysfunction in middle-age men (3). The rapid rise in the number of male patients who are visiting konenki outpatient clinics today, reflects the collective need for such an illness category in the particular socio-economic climate of contemporary Japan. The prolonged economic recession and decline starting from the early 1990's signified the demise of old corporate rules, such as shushin koyou, guaranteed lifetime employment, and nenko joretsu, a system closely following the ingrained ideas of East Asian filial piety, whereby one's position in the company directly reflects the years of service to the organization. Once the trademarks of Japanese corporations, shushin koyou and nenko joretsu both contributed to the illusion of a man's company seeming like his alternative family. The rapid demise of old corporate models have deprived men of their job security, which was once guaranteed, inducing notions of fear, instability, and anxiety as the burden of supporting his family continues to fall on his shoulders (6). The driving force behind the indigenization of dansei konenki, the need to give a voice to and contribute to the restoration of the man's social functionality, becomes understandable under this particular socio-economic context. YOSHIHARU SAKAGUCHI The long-term recession has also induced major structural changes that have marked a transition from the traditional to the new, "American" economic model. During the period of rapid economic growth in the 1970's, admission to a prestigious university, through a competitive entrance exam, secured one's position on the elite track. In turn, a good university name guaranteed a job in a good company, which lead to lifetime employment, or shushin koyou (j). Under this system, one's company essentially became an alternative family, where individuals worked with a sense of security and interdependency with one another. After the downward spiraling of the economy in the early 1990's and subsequent demise of this corporate model, men were suddenly facing an age of insecurity, where lay-offs became common, and finding a new job was extraordinarily difficult for middle-age men. This especially held true for individuals who had administrative positions and lacked specific marketable skills and knowledge needed for re-employment (6). Mr. Sakaguchi suffers from a typical set of symptoms said to accompany dansei konenki: a bad case of insomnia, night sweats and hot flashes during the day, mild depression, chronic fatigue, and prostate problems, and is currently receiving testosterone injections. Mr. Sakaguchi says he was primarily relieved when everything could be finally explained and treated, although the reaction contained inherent mixed emotions. Like many patients, the diagnosis of konenki fixes the idea of a new-found anxiety by signifying a rapid and irreversible degeneration of the masculine body to the patient. Through the process of treating his condition, Mr. Sakaguchi and his wife both acknowledge the re-establishment of a mutual understanding and new-found appreciation for each other: an instance of a favorable role that konenki has played in his life. Thus, the reverberations of this indigenized illness in the life of Mr. Sakaguchi are pluraistic and exist in constant tension with one another-unlike many one-sided theories written on the effects of indigenized biomedical diseases. The diagnosis of dansei konenki seemed to have enhanced both the quantity and quality of communication between the Sakaguchis compared to the earlier years of their marriage, when Mr. Sakaguchi was much more reticent and stoic-minded. Indeed, their experience points to another change, induced by the demise of the old economic paradigm, that the current konenki generation has to face and adopt. Posters of a young male pop star holding his new born son under the caption "We Don't Call Men Who Don't Participate in Child-Rearing Fathers," plastered throughout the subway stations around Tokyo, indicates the idealization of men as active participants of child rearing and household duties has as another prominent feature of the recent shifts in social values. Concurrent with this change, there seems to be a mild social stigma for men of his generation, for having been a "workaholic salary-man" who has neglected fatherly duties. Thus, men like Mr. Sakaguchi are confronting changes in the modern ideals of younger men: whereas male virtues traditionally embraced values such as stoicism, financial authority, and non-cooperation of household chores, modern young men are largely expected to be open and vocal in speaking their minds, viewing the opposite sex as equally competent players in the work force, and taking an active role in domestic activities. CONCLUSION To be sure, male menopause is a relatively minor illness in
terms of the degree to which it affects the physical and mental
health of the patient and his or her family, as do AIDS or Alzheimer's
disease. While illnesses that more ostensibly threaten the livelihood
of patients have long been the focus of medical anthropologists
writing about biomedical indigenization, a disorder like male
menopause is interesting in its own right. In future studies,
it would be of great interest and contribution to the field
to further explore the indigenization of biomedical illness
categories in traditionally non-western locales, and the socio-cultural
forces that mediate and drive this process.
Lady Lazarus Revisited: Reflections of a psychiatrist on the poetry and illness of Sylvia Plath Laszlo Varga, M.D., Ph.D.* Psychiatric physicians have always been attracted to study art and mental illness and Sylvia Plath's tragic history is an outstanding example for such an inquiry. The current paper received inspiration by the news that a movie has been recently completed about Sylvia Plath, and released. Therefore it was felt that some renewed reflections about her poetry and mental illness would be a timely effort. This paper is not a biography, nor any attempt for a concise analysis. Only a few selected impressions are offered here for the interested reader with some comments about "Fate" and "Determinism" in Plath's poetry. She suffered a very serious psychotic break necessitating prolonged hospitalization, but her formal diagnosis was never revealed to the public. We know that she received 26 electroconvulsive treatments which calls attention toward schizophrenia. But her general behavior as it appears in her biographies does not reveal this illness, though in her daily life she had many small bizarre elements. Schizoid personality would be one acceptable suggestion. The difficulty is buried in our recent diagnostic classification which significantly differ from that in 1963 at the time of Plath's suicide. Bipolar Disorder with a severe psychotic break would be another possibility according to our recent nomenclature, but we wish to avaoid actual compartmentalization. Glory and fame was not attained in her lifetime. This elevated literary status arrived to her through the bitterest human deed: a reproachful abandonment of herself to death. Shocking as it may be, her suicide served as a glorification of her poetic career, creating a certain literary fame that survives. Readers, young and even mature poets, grouped around her memorial legacy, paid astounded tribute to her, elevating Plath to a kind of priestess of contemporary poetry. Ann Sexton, Marianne Moore, and no less a literary leader than Richard Wilbur paid homage to her poetic achievements. George Steiner (1) went so far as to call her most demonic poem, Daddy, the Guernica of modern poetry. Certainly, not all these idolatrous responses are appropriate, but there can be no doubt that they signify the acceptance of Plath's new style and manner of lyric writing: her air of peremptory competence. In this air, created by her, reproach, disappointment and suicide are the dominating elements in her poetry. Looking at the treatments of mental illness, we often see the fact that the physician is at a disadvantage to help, because the patient is not the ally, but frequently the enemy of psychiatric intervention. The poems of Sylvia Plath serve as a penetrating literary example of the mental imagery of the psychotic artist, who has opened the Pandora's Box of her inner mental world. So, so, Herr Doktor for That melts to a shriek. Ash, ash- A cake of soap, Herr God, Herr Lucifer, (Lady Lazarus) It is not as if other creative artists haven't suffered in the stifling grip of psychiatric illness, but only Plath has been capable of conjuring the demonic representation of her mental imagery with such a high level of artistic richness. One shudders or rebels at such an outpouring of hallucinatory fervor, which shows agonizing intelligence at the border of the unconscious, often with bone-chilling preparation for suicide and death. At least the editors of the 1960's felt so, as one after the other rejected Plath's manuscripts, with comments that the intensity of her emotions over-powered form, that her verses were "out of control", and that she was "mining a destructive art" (3). These and similar comments reached her from publishers during the last few months of her life, during which she was actually forging her richest works. The memory of her father is an ever returning image in her poetry. His loss is an incurable wound throughout her life. Her father figure is a central theme in Plath's poetry. A garden of mouthings. Purple, scarlet-speckled,black (The Beekeeper's Daughter) Daddy, I have had to kill you. The early childhood shock is probably the breeding nidus for her reproachful attitude throughout her life and for her suicidal motives. Her first experimentation with suicide, hinted at in her own poetry, dates back to her early teen years. Once she tried to slash her wrists in a hot bath, in reminiscence of the merciful death sentences of the classical Roman emperors. At another time, she slashed her face with a kitchen knife, leaving a visible scar on her left cheek. A strange indifference to pain is noted in her poetry, surmising an almost perverted pleasure form the immersion, as if her sufferings were the appurtenances of a mystic purification. In spite of her destructive obsession, Plath completed all her schooling with honors, with the steadfast ambition and energy of the excellent student. She always wanted to be the first and the best and usually succeeded. Her first poems were published when she was only twelve years old. Later, she completed her college Summa Cum Laude. "Fame, Fame, Fame!" burned in her imagination in neon letters. Nothing was more important to her than looking at her name and poems in print. The flame of her internal cauldron lighted her to be up and typing by 4 a.m. in order to complete her most important poetic incantations before her suicide. Knowing her end was near, she wanted to leave a completed poetic inheritance. To do so, she worked with hallucinatory fervor. During her college years, she was perceived by her teachers as a pleasant, agreeable student, charming and feminine, with youthful energy and liveliness. They did not suspect that significant consumption of alcohol, sexual debauchery, abounding egotism and selfishness were churning under the surface. In retrospect, everyone who knew Plath personally noted that there was incomprehensible and indefinable strangeness in her. Often show was observed as overly enthusiastic, with a voluble speech peppered with mysterious comments and more than once, she created an uncomfortable atmosphere about herself. Heinz Lehmann, a Canadian professor of psychiatry, writes about this uncomfortable, uneasy aura which emanates from the behavior of the schizoid person even during symptom-free times. Sylvia Plath was a master at creating such disturbing situations. Yet, she always operated with superior intelligence and baffled some of the intellectual leaders of their time. She devoured books and knew thoroughly about everyone important in contemporary literature, even about third-rate writers. At a tea one afternoon in Cambridge, a little known beginning poet, Lucas Meyers, asked her to dance. He listened with amazement as Plath recited his newest poem, which had been published in an obscure journal that sold only in a few dozen copies. A friendship developed between them and they corresponded for a long time. Plath was a third year college student as Smith, when upon her arrival home from New York; she was notified that she has been rejected to take a writing class at Harvard, even though she had submitted her prize-winning short story as proof of her talent. She lost her emotional balance, tried to commit suicide again and was hospitalized. Her medical records are of confidential of course, but we do know that her condition deteriorated and she was transferred to a closed ward. She refused all contact with the outside world, and also refused to cooperate with doctors and nurses. She would not accept visitors and announced that she hated her mother. For her birthday, she received a large bouquet of yellow roses, which she immediately threw in the trash and announced "this is only for my funeral” (6). The expenses of her treatment in an exclusive hospital were covered by Mrs. Prout, a popular American novelist at that time, who established a fellowship at Smith for talented young women. Sylvia was one of the recipients of this scholarship. Still, she described her benefactor in her novel as a snobbish lesbian matron. These few examples serve only to describe the schizoid person's sense of reality. Plath's psychiatric hospitalization lasted almost five months,
in the same private sanatorium where Robert Lowell and Ann Sexton
were also treated for emotional indisposition. The latter was
Plath's personal friend, who also ended her life by her own
hand. While in the hospital, Eric Lindemann, Chairman of Psychiatry
at Harvard Medical School, supervised her therapy. Her biographers,
however, were not correct in saying that Plath was humiliated
or abused, because of the electroconvulsive. Nothing else helped.
She would likely have remained forever in chronic care in a
closed hospital ward, in a demented mental status, enticed by
her hallucinatory demons if she had not received treatment. Let us recall from medical people that about 40% of the psychotic patients do not respond to conventional anti-psychotic drugs, and Plath belonged to this group. Plath married the English Poet Laureat Ted Hughes after a few weeks acquaintance. After lengthy travels throughout the U.S. and Europe, she and Hughes settled in England. After seven years of marriage, in 1962, the marriage deteriorated and ended in separation. Plath's pathological and often histrionic jealousy had an important role in this; in fact, it proved to be a self-fulfilling prophesy. Hughes became involved with another woman but he probably felt an ever-increasing discomfort about his wife's theatrical exaggerations, because at the time of the separation he announced that it was impossible to live with Plath. While married, Plath idealized her husband. A marriage to Ted Hughes meant more than love and security for her: it meant a great deal of pride, status, inspiration and future. Her husband's alienation and unfaithfulness ripped open all her vulnerable, narcissistic wounds. Where apple bloom ices the night Love cannot come here. A small white soul is waving, a small white maggot. The dark is melting. We touch like cripples. Plath did not know her own role in the cooling of her husband's emotional attachment. She did not know the burden of living daily with a semi-psychotic person, always ready to incite a degree of unease in her interpersonal environment. This is exactly what Plath was most capable of doing in her private life. The plain clinical truth is that her inspirational driving forces stemmed from her inner wounds. In a polemic vengeance for her lost happiness she cried out with a quotation from Virgil: "Excoriar aliquis nostris ex ossibus ultor" (7). It is almost banal but still significant to note that after her suicide the publishers coveted exactly those writings which they had rejected earlier. Suddenly, Plath became considered to be among the most notable authors of modern American Literature, perhaps surpassing even Emily Dickinson. However, her abandonment of the contemporary academic style created a conflagration of arguments about the significance of her poetry. She fantasized that like the bird Phoenix rising from its ashes, she too would rise again free after suicide. She believed that afterwards she would achieve a life without inner turmoil, leaving her demons behind. In her verses, the objects of the outside world rapidly transcend to themes of hallucinatory projections, only to present astonishing, but dazzlingly bizarre images to the reader. Out of kitchen table or chair (Black Rook in a Rainy Weather) She led a life of self-absorption, reproaching the world, which she perceived distortedly, through the glass of her novel The Bell Jar. Sylvia Plath was an unusually complicated lyrical poet in an environment which, in those days, scorned lyrical poetry. Plath remained self-occupied, brooding over the thwarting machinations of her inner demons, who were sending undefined, but dangerous commands, ominously approaching. But is it necessary to scrutinize the mental status of a poet while analyzing her art? Is it possible to describe her poetry as clinical? The borderline is obviously indiscernible and the rest is almost impossible to answer. Naturally, it is not necessary to know the details of Sylvia Plath's life in order to appreciate her poetry. Literary work stands on its own, whether it is pure or inflamed, sublime or vulgar, or clinical. Nevertheless, analytic scrutiny always points to and searches for connections between a work and its creator's life. Nothing is more interesting to a reader than to learn the details of an author's life in connection with the finished work. This desire is not entirely wrong, for such an interpretation can enhance our appreciation of the poetic craft. The verse is not purely the product of the creator's conscious effort; it is also the product of her unconscious motives. These details are the most exciting psychological detective work. Plath was a confessional poet, as her biographers and critics called her. She knew very well that she and all such poets, are denuded before the public eye: The peanut-crunching crowd These are my hands, A miracle! For the eyeing of my scars And there is a charge (Lady Lazarus) These lines were written after one of her suicide attempts. During the last year of her life, her poetry rapidly matured. Her marmoreal poetic style appeared more chiseled and elegant. Her vituperative power bore to existence such poems as the initially "ill famed", but now highly reputed, Daddy and Lady Lazarus. However, her personality became less pleasant. She expressed her opinion without inhibition (and we don't have to explain how popular someone may be who always speaks the truth). Now and again, she came close to another collapse. The incomprehensible psychic powers reclaimed her. In early 1963 she suffered from restless insomnia, which she tried to vanquish with ever-increasing sedatives. She knew too well how to hide her troubles from her friends, and when they finally noticed her state, it was too late. They knew nothing of her first hospitalization and illness. It had been kept secret from her English acquaintances. There are unaccustomed terrains in Plath's poetry, her inspiration rarely came from ethereal domains of the Muses, but rather from the synclinal smelting furnace of the unconscious. The covenants of creative work and psychotic illness arrived to a final common path: the inherent predestination to an end, the inevitability towards both, the ill and the artist are attracted to each other in a magnetic stream. There is indeed an unexplained influence in the psychotic patient within, pulling him in one and only one possible direction. He is unable to liberate himself - like the fruitless effort in sleep paralysis - from this irresistible force. There is no other way; to surrender to the psychotic delusion is an intractable necessity. This constraint in the ill is the will in the artist. He, too, is struggling toward the inevitable, i.e. for perfection, for which he is willing to give away his life, just to make sure that one verse or line or note or brush-stroke correctly follows the others. There is a drama in this effort, pessimistic not heroic, inherited from the classical Greeks with an unmerciful "necessity" in our Western literary tradition. Therefore, Plath's suicide is not viewed as an accident or disturbance in a depressive moment, losing the Self. We respectfully disagree with A. Alvarez's interpretation (11) that she did not really want to commit suicide, that her act was only a planned cry for help. Such a style of the neurotic housewives was disdainfully undignified for her. Plath behaved at a different level of mental functioning and we believe that she planned her suicide. She had no other choice. She condemned herself in her poetry and had to follow her inner laws. She was preparing for the end; this is exactly why she worked so feverishly to complete her work. From her manuscripts, we see that she refined and finished two or three poems in a day or two, during the last few months of her life. After she reaped her harvest, completed her poems in frightful rendition, she gave herself to her demons. In Plath's history, the demons were her reality. The conclusions waited for her, as though at the end of a railroad track, with no deviation. She followed her own irreversible moral laws: The woman is perfected. Flows in the scrolls of her toga, (Edge) REFERENCES |
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