Strategies of influence in medical authorship

Sm. Sci. Med. Vol. 37, No. 4, pp. 521-530, 1993 Printed in Great Britain. All rights reserved

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0277-9536193 $6.00 + 0.00 1993 Pergamon Press Ltd

AUTHORSHIP

JUDY Z. SEGAL Department of English, University of British Columbia, Vancouver, British Columbia, Canada V6T 1Zl

Abstract-The notion of a rhetoric of science argues that scientific writing is not unproblematically neutral and objective, but rather laden with both theory and value and necessarily persuasive. The nature of persuasion within the profession of medicine is studied here through an analysis of rhetorical strategies at work in medical journal articles. (All articles are on the subject of functional headache and appear after 1982 in such journals as the Journal of the American Medical Association, The Lancer, The New England Journal ofMedicine and Headache.) The analysis is organized using the Aristotelian categories of invention (the discovery or creation of arguments), arrangement (their organization in the most persuasive order) and style (including such matters as the use of the passive voice and the avoidance of figurative language). The result of the analysis is a comprehensive inventory of strategies medical authors use in order to influence their peers. The inventory provides a vocabulary and a procedure for analysis of medical rhetoric in general; that is, it goes some way to enabling a medical metadiscourse. The analysis further suggests that rhetorical studies, as a discipline, has much to contribute to medicine’s project of examining its own assumptions and scrutinizing its own dominant paradigm. Identifying rhetorical strategies at work in medical iournals is one way to articulate medical values and to understand them as instruments of action within the profession. Key words-rhetoric,

medicine, criticism, values

STRATEGIESOF INFLUENCE IN MEDICAL AUTHORSHIP

The notion that scientific writing is not simply neutral and objective but fundamentally persuasive is wellestablished among scholars in sociology [1,2], philosophy [3,4] and rhetoric [5-71. The notion, however, is less well-established among scientists. In their study of the discourse of biochemists, Gilbert and Mulkay found, for example, that while many scientists acknowledged the ‘contingent’ nature of their colleagues’ research, they, in general, saw their own work as simply ‘empirical’ and in the service of ‘truth’ [8]. Gilbert and Mulkay, like many other students of the culture of science, have demonstrated that scientific accounting is, however, necessarily a system of influence. The present paper reports on a study undertaken to localize and specify the notion of a ‘rhetoric of science’ in the professional journals of medicine. Specifically, two hundred articles, all published in established medical journals since 1982, were examined for an overview of a relatively contained subject-functional headache. Thirty-five of these articles were then selected for analysis. Selection was random, except for some attempt to maintain coverage across journals and types of articles. The full sample was distributed across articles on diagnosis, etiology and treatment, and included pieces on theory and classification, reports on research, clinical reports, case studies and review articles. The articles were analyzed using a rhetorical critical methodology [9, lo] in order to identify common strategies of influence.

While other work of the author has commented on the significance of particular rhetorical features found in medical journal articles, describing the interaction between elements of the western medical model and elements of its discourse [1 11, this paper primarily offers an inventory of discourse features. Its purpose is to bring rhetorical strategies themselves to the surface of discourse in medicine, and so to enable a medical metadiscourse. As theory multiplies concerning the social, cultural and hermeneutic features of western medicine [12-141, one way to ground the discussion of medicine’s ecology is to analyze the habits of influence in the professional conversation. This paper offers a theoretical context, a vocabulary and a method for just such a project. Over two thousand years ago, Aristotle defined rhetoric as the “faculty of discovering in the particular case what are the available means of persuasion” [15]. The work of discovery falls to both authors and readers. Authors-whether consciously or not-deploy a variety of means to persuade readers; readers, in the performance of rhetorical analysis, name those manoeuvers, and in doing so, neutralize them, to some extent. Aristotle also suggested a procedure for establishing the available means of persuasion, discussing in his Rhetoric four categories of rhetorical means: invention (referring to arguments found or created); arrangement (their organization in the most persuasive order); style; and delivery. Aristotle, of course, was talking about oral texts; the counterpart of delivery in written prose might be presentation. While the other theorists in two thousand years of rhetorical history have modified, expanded and even challenged Aristotle’s rhetorical framework, his 521

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divisions are still useful for both composition and analysis. For Aristotle and for many who came after, rhetoric and science were in separate realms: rhetoric was about matters of opinion; science, about matters of fact. As recently as 1970, one sociologist wrote, a “scientist says only what ‘is’. [a] rhetorician says whatever he wants” [16]. Recent revisions of theory. however, have repudiated such a division and recognize scientific writing-and indeed scientific inquiry itself-not only as rhetorical but as necessarily, inescapably so. Rhetorical theorist Kenneth Burke writes, for example: Even if any given terminology is a rq?ecrion of reality, by its very nature as a terminology it must be a .selection of reality; and to this extent it must function also as a deflrction of reality [17].

In a similar vein, literary theorist Terry Eagleton writes that even such a seemingly unproblematic statement as “This cathedral was built in 1612,” a statement of fact, is not completely neutral: it betrays an interest in dates of origin [18]. To say that such a statement is rhetorical does not suggest the cathedral was not built in 1612; it suggests only that reporting itself is never innocent, but always laden with some kind of value, with some attempt to direct the attention to one thing rather than another. The following analysis is undertaken with this understanding of pervasive rhetoricity. It proceeds also with a consciousness of its own rhetoricity. At every turn, the present paper uses the very rhetorical features it finds in medical journal articles. Even to say. “the present paper uses” is to employ a rhetorical strategy-one which adds an air of science to the analysis by placing agency in the paper itself rather than in the paper’s author, who is, in good scientific spirit, effaced. This paper reproduces the rhetoric of science for good reasons, not the least of which is that it is meant for a scientific audience. Rhetorical conventions, that is, constitute a kind of hegemony: the conventions of scholarly and scientific writing are so entrenched in the academy and associated institutions that these conventions are not only tools to write with but also tools to think with. If the reader is interested enough by the present analysis to apply its terms to the present article, an important goal of the writer (me) will certainly have been met. My own purpose. of course, is persuasive. In general, articles in medical journals must be reasons. First. persuasive for two practical competition within the profession dictates that, in order to secure a publication source for their findings, medical authors must convince an editorial board that their work is creditable. and that they themselves are reliable reporters of their work. Secondly, once a piece of work is published, the reputation of the authors depends on its reception within the professional community. When authors fail to convince a substantial readership of the worth of their research

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(or observation or analysis), their work is not cited in the publications of their peers and dissolves into obscurity. Within the study of headache, the degree to which certain scientific explanations fall in and out of favor over time testifies to the persuasive nature of the professional literature. In the 1970s for example, it became common to name temporomandibular joint disease as the cause of chronic headache in a significant number of patients. The diagnosis became so popular that one study found, after a number of years, that fully a fifth of ‘consecutive headache clinic patients’ (that is, patients not preselected according to previous therapies) had been treated for the disease [19]. In his 1985 article, “Unnecessary dental treatment of headache patients for temporomandibular joint disorders,” Reik reports that only 20% of the headache patients who were treated for TMJ actually satisfied diagnostic criteria for the disease. Reik concludes that “increased patient awareness of the TMJ syndrome, inappropriate referral by physicians. and incorrect diagnosis by dentists all probably led to the unnecessary dental treatment” [19, p. 2461. In other words, a large number of people, professional and non-professional, had been persuaded that TMJ disease was a reasonable diagnosis for sufferers of chronic headache. By 1985, they were being persuaded that it was not. The openness of the medical profession to both accepting and rejecting new concepts in diagnosis and treatment testifies to the commitment of the profession to monitor itself and to abandon what does not work. There is no doubt, however, that the work of headache researchers is, in general, seen, within the profession, not as contingent, or subject in any serious way to the consequences of argumentation, but as ‘scientific.’ The editor of the journal, Heuduche, considers it to be a ‘scientific journal’ [20]; articles which discuss headache in other journals are generally classified as ‘scientific articles’; meetings of the American Association for the Study of Headache are considered ‘scientific meetings’ [21]. Still, a close reading of headache articles reveals that they are no less rhetorical for being scientific, and, arguably. no less scientific for being rhetorical. The following analysis will consider the rhetorical invention, arrangement and style of medical journal articles. Since matters of presentation (typesetting, column width. white space, font size, layout, documentation system, location of notes, type, number and quality of graphics) are most often matters of publishers’ rather than authors’ choice, they will not be considered here. An appendix to the paper glosses many of the terms used in the analysis. INVENTION

Several strategies of rhetorical invention recur in the headache literature. They include the following: (1) use of an opening argument about the article’s

Strategies

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use of arguments of comparison, importance; example, definition, classification and authority; and distribution of emphasis (all, in Aristotelian terms, logical appeals); (2) use of appeals which establish an alliance between reader and audience (pathetic appeals); (3) use of arguments concerning the character of the author (ethical appeals). A remarkable number of article introductions argue the significance of the problem of headache in terms of number of people affected and number of dollars lost. The purpose of such introductions seems to be reader seduction. While variation in statistics is itself interesting, more interesting, from the rhetorical point of view, is the fact that so many authors seek to win the attention of audiences with what Aristotle called the topos of degree, a comment on “the relative greatness . . of things” [15, p. 1471. The following is a sampling of claims appearing in the opening paragraphs of headache articles: Migraine is among the most common disorders seen in office practice. Some epidemiologists believe it may occur in up to 25 percent of the general population [22]. Epidemiological studies indicate that about two-thirds of adults in the United States experience headaches and that 40% of these suffer from muscle contraction or tension headache [23]. In the U.S.A., 24 million Americans are reported to suffer from severe headaches, contributing to lost time at work and decreased productivity, costing 15.1 billion dollars annually

[241. Each year 550 million workdays are lost in the United States because of pain, which is probably the principal complaint presented by patients and the major determinant in their decision to consult a physician [25]. Headache is a common problem, affecting approximately 70-75% of men and more than 80% of women in a year’s time [26]. Headache is one of the most common of medical complaints and is presumed to affect more than 80% of the population 1271. Migraine headache is one of the most common neurological disorders, with an estimated prevalence of 5% to 25% in western society [28]. Migraine is a common disorder, occurring 5% of the general population [29].

in an estimated

The purpose of such openings is (in part, at least) to secure reader attention. Once reader attention is secured, arguments of comparison are often used to establish the importance not of the topic any longer but of the particular study at hand. The conventional strategy is to announce a place for the present research by demonstrating a lack or absence in other research. One group of authors, for example, writes, “In spite of well documented exacerbation [of headache] in relation to menstruation, there has only been one study on the effect of behavioral treatment on menstrual migraine” [24, p. 861. Another research group writes that, since reports implicate stress in 80% of tension (muscle-contraction) headaches, it is “surprising that the role of stress in promoting or exacerbating recurrent tension headaches has

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received so little empirical attention” [30]. A further team of researchers points out that while numerous studies have focused on the psychology of headache sufferers and of headache itself, “little of that research effort has gone to study patient attitudes toward the disorder” [31]. While the strategy of using comparison to argue for the relevance of a particular piece of work is by no means unique to medical literature, neither is medical literature unique for the absence of such a rhetorical strategy. The abundance of arguments from example in the articles studied illustrates that certain assumptions so underlie medical discourse that claims based on those assumptions are widely considered to be not arguments at all, but statements of fact. It is a premise of the scientific method that every instance of a phenomenon neither can nor should be observed, but that reliable conclusions can be drawn from repetitions of a phenomenon in a number of particular cases. This premise empowers statistical reasoning. What is interesting, given the prominence of statistics in scientific accounting, is the way in which numbers are massaged to appear in the best possibleor most persuasive-light. For example, one group of researchers claims that “93% of 88 children with severe migraine recovered on oligoantigenic diets” [32]. The study began with 99 subjects, eleven of whom withdrew for reasons unstated in the article. Of the 88 remaining subjects, six did not improve at all, and eight who improved continued to do so even when presumably offending foods were reintroduced. (The authors say, rather indirectly, “all but 8 relapsed on reintroduction of one or more foods” [32, p. 8661.) That is, researchers demonstrated that 74 of 88 subjects (approximately 83%) improved because of dietary control. The strategic presentation of findings is one of the most ‘available’ of the scientist’s ‘means of persuasion’. Another study, which assesses the effects of behavioral treatment on 16 women suffering from paramenstrual headache, drew its subjects from a pool of 93 potential subjects, 77 of whom were deemed unqualified to participate [24, p. 871. Ironically, this article uses language so scientific it has the effect of obfuscating the common-sense fact that findings based on a 16-person sample are not of great scientific value. It reports, subjects “self-monitored 4 times daily for a 2-cycle baseline, then were matched on pre-treatment pain levels into 8 pairs and randomly assigned to treatment. . . . Post-treatment group data analysis was by three-way analysis of variance with 2 repeated measures” [24, p. 861. In fact, the study used two treatments on 16 women suffering from four different headache conditions and then asked them to report how they felt. Here statistical language is itself a factor in persuasion. In the articles surveyed, scientific logic also relies heavily on classical arguments of definition and classification. Beginning with the assumption that conditions must be named before they can be treated,

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medical researchers and practitioners have a special concern with questions of defining and classifying disorders. This accounts for the large number of articles devoted specifically to these questions: “Are classical and common migraine different entities?” [33], “Is the muscular model of headache still viable?” of head pain: an idiographic ]341, “Diagnosis approach to assessment and classification” [35], “Towards a definition of migraine headache” [36], “Migraine and muscle contraction headaches: a continuum” [26, pp. 194-1981. Definition and classification are important not only to authors who address those concerns directly, but to others who use them as supporting arguments. One study claims that pharmacological treatment of headache is haphazard, and not correlated closely enough to ‘subtypes’ of headache [35, p. 2211. Another study, reporting the results of a survey on dietary precipitants of migraine, expresses concern that ‘some investigators’ have used the term ‘dietary migraine’ as though it were an accepted entity [37]. That is, as in classical rhetorical theory, arguments from classification and division are considered primary. Aristotle called arguments from authority ‘inartistic’ because they were not the product of the rhetor’s art but rather existed beforehand. However, the deployment of arguments from authority certainly is artful. In medical and other scientific writing, inartistic proofs take the form of citations of and references to other scientists and other work. That scientists will name other scientists in developing their own arguments is not only expected but required in publication. However, the choice of whom to cite resides with authors. The literature surveyed provides many examples of cases in which supporting testimony is cited, while testimony which might weaken the effect of an article is not. For example, the author who enumerates the physician’s drug choices in managing the migraine patient [22, p. 1381 does not refer to the authors who claim that narcotic treatment of headache is “one of the commonest antecedents to significant iatrogenic drug addiction” [38], or to the study which shows that withdrawal of all analgesics significantly reduced headache days in most patients who had been taking more than 30 analgesic tablets per month [39]. Similarly, the authors who use a self-monitoring anxiety measure in their study of headache patients [24, p. 871 do not refer to the literature which claims that headache patients are poor witnesses of their own states of anxiety [40]. The principle of selective citation has an important pragmatic function: authors could not possibly cite every source related to their research. Still, what is selected is often a matter of what best supports the case at hand. A related inventional strategy concerns the principle of emphasis itself. For example, while one author spends pages of his article on pharmacological

treatments of headache [41], another, interested in non-pharmacological treatment, handles drug interventions in a single sentence [25, p. 911. Similarly, while some headache specialists see classification as a central concern of their discipline (see above), one clinician dismisses the question of positively separating migraine (vascular) from tension (muscular) headaches with this: “[Dlistinguishing between the two types can be overstressed, since a patient with muscle contraction headaches will seldom suffer from a well-planned trial of migraine management . .” [22, p. 1381. An exemplary case of comparative emphasis is in two solicited responses to a reader inquiry in the Journal of the American Medical Association. The query involved a patient experiencing ‘coital cephalagia’-vascular headache associated with sexual intercourse. The journal published two responsesone from a neurologist, another from a psychiatrist. While both consultants insist on the need to rule out serious organic illness, the neurologist ends by suggesting the prescription of ergotamines for use prior to intercourse [42]. The psychiatrist, whose answer is approximately four times longer than that of the neurologist, recommends, among other things, “at least three 30-minute visits with the couple . to focus on the patient’s unusual symptom and how it has affected their lives” [43]. The question of emphasis illustrates the extent to which theoretical allegiances and problem-perception inform professional commentary. While logical appeals are prevalent in medical literature, pathetic appeals are less so. Certainly, directly emotional appeals are unconventional in medicine. Nevertheless, one powerful means of persuasion lies in the formation of an alliance between author and audience. In medical writing, this alliance frequently works by dissociation from the subject of the prose-the patient. One message implicit in the headache literature is that ‘they’ (patients) get headaches and ‘we’ (the author and the readers together) do not. One author refers to “the hard-core headache patient” as “our specialty albatross” [20, p. 3421, expressing his puzzlement at the ‘peculiar’ tendency of headache patients to be more concerned with having an explanation for their headaches than with getting relief from them. “Most of us,” he writes, “_ would be far more interested in getting rid of our pain than in knowing why we had it [my emphasis]” [20, p. 3431. In the articles surveyed, there is a single case in which the physician is not dissociated from the patient. In this account, the physician-author describes in some detail his own history of migraine 1441. Here quite a different pathos is at work-the reader identifies with the plight of the author-but, despite the credentials of the author and the publication source (The New England Journal of Medicine), the article is not read as science. It is given the latitude accorded to case studies. In this case, scientific value

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Strategies of influence in medical authorship is further compromised as the report blurs the distinction between observer and observed. The ethical argument, or the argument from the character of the speaker, is central to all persuasive discourse including medical writing. Walter J. Ong has written that the speaker’s voice is a “summons for belief’: “the belief that something is true is secondary to belief in the person or persona sharing the information” [45]. Authors of medical articles have to establish themselves as knowledgeable and trustworthy, and they accomplish this in a number of ways. Initially, credibility accrues to medical writers borrowed from the journals in which their articles appear. Essentially, what appears in a respected scientific journal is read as both respectable and scientific. In addition, some authors have the benefit of reputation. Most, in any case, have credentials that establish their right to be read-minimally a Ph.D. or M.D., and frequently, positions as heads of departments, directors of clinics, consultants to govemment. (Of course, issues concerning authorship are complicated by the effect of multiple authorship and ‘first author’ politics. Indeed, in the context of the traditional meaning of authorship, it is astonishing that The Journal of the American Medical Association, for example, now asks contributors to certify they have “participated sufficiently in the conception and design of [the] work and the analysis of data. . as well as the writing of the manuscript, to take public responsibility for it” [46].) The sense of an author created by affiliations, degrees and photographs is often belied in the articles themselves from which authors are peculiarly absent. However, authorial absence is itself, ironically, a source. of authorial credibility, for by identifying with the ethos of science, authors establish their own reliable character, declaring through their prose their modesty (the sign of universality) and their neutrality (the sign of disinterestedness). The assumption underlying this inverse ethical argument is that the contributors to scientific journals are reporting on empirical events revealed through accepted methodologies with replicable results. Passive voice (to be discussed under the heading of Style) is the most obvious stylistic strategy for removing authors from their texts. It should be noted that in several of the articles surveyed, authors do deviate momentarily from conventional impersonality. When they do, the effect seems to be to increase reader confidence in their authority. One group of authors, arguing the importance of dietary manipulation in the treatment of some migraine patients, adopts a first person speaker in the Discussion section. The authors anticipate reader objections to their argument by acknowledging that placebo effect is high in the treatment of migraine. They write, “We (except J.F.S. [one of the researchers]) embarked on this study believing that any favorable response. . . could be explained as a placebo response” [32, p. 8671. The authors go on to

explain that this was not the case. The rhetorical strategy is called pro/e@ and it recurs in the sample of articles. Another author, addressing the critical reader, writes, “One can argue that the neurotic triad is the result of chronic pain [rather than the reverse] . . .” [47]. Thus are the readers’ concerns anticipated, shared and allayed. Whatever their specific rhetorical choices, however, published authors invariably remain within the discourse conventions of their discipline. In effect, their command of those conventions is itself, as a sign of their membership in the professional community for which they write, an important aspect of the ethos of their articles. ARRANGEMENT

Not only arguments themselves but features of their arrangement in a discourse influence readers. The following strategies recur in the literature surveyed: (1) use of a promotional synopsis; (2) use of opening and concluding sections of an article for frank persuasive appeals-and the embedding of the weakest material in the dense middle section of the article; (3) use of a device of dissociation or disjunction in presentation of information; and (4) use in research reports of the AGREED. . . INDEED rhetorical structure noted by Blanton [48]. The use of synopses is conventional in scholarly literature, and medical literature is no exception. These short summary pieces, in any discipline, are persuasive: they inform readers’ decisions as to whether to read an article and how to read it. Aristotle explains, “Men pay attention to things of importance, to their own interests, to anything wonderful, to anything pleasant; and hence you must give the impression that your speech has to do with the like” [15, p. 2241. Many synopses promise reports of both significance and priority. The attention authors devote to writing synopses is rewarded, not only because some readers decide on their account that the ensuing article is worth reading, but also because many readers look only at synopses of articles, along with introductions and conclusions, as a way of securing an overview of research in a field. Those who read only the beginnings and ends of research articles are usually met with their most frankly persuasive appeals. It is in the opening section of an article that authors make the case for their research, and it is in the closing that they specify the significance of their results. If there are weaknesses in research design or methodology, or if findings are obscured by the circumstances of the experiment, these matters will be evident only in the middle of the article. That is, the disposition of the scientific article is typically “Nestorian,” wherein, as neo-Aristotelian theorist Chaim Perelman explains, “we begin and end with the strongest arguments, leaving the others in the middle” [49].

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A group of authors, for example, whose work examines the role of physical and sexual abuse in women with headache, reports in mid-article that “none of the abused women identified abuse as a significant factor in pain onset” [50]. Similarly, a group of authors who claim in their synopsis that “timolol is a safe and effective treatment” for migraine mention mid-article that “the total amount of concomitant medication required during drug treatment with timolol or placebo was not analyzed,” and that overall response rates were only 14% higher with timolol than with placebo (43 vs 29%) [28, p. 25791. Another rhetorical dimension of arrangement concerns the separation within a single text of items which, placed together, would seem somewhat incompatible. In the article on oligoantigenic diets for children with migraine [32, pp. 865-8681, for example, the researchers report that they depended for evidence of treatment success on each patient’s diary of symptom-,. They also report-but a page laterthat some of their subjects were as young as 3 years old. The potential methodological problem is not discussed. Similarly, the authors conclude that “during the diet period smoke and perfume still provoked migraine, but only three patients still had symptoms after exposure to other [provocations]“. These authors had, in an earlier section, stated that patients “were encouraged to continue full activities”. Presenting related points in separate sections, the authors avoid the question of how they isolated the almost infinite number of variables that would affect 88 children living in their normal environments. To some extent, the authors subvert a methodological critique by separating the pieces of the methodological puzzle Certain discontinuities notwithstanding, research articles as a whole are essentially structured as coherent arguments, adhering to a ‘grammar’ discussed by M. J.-V. Blanton as the AGREED. INDEED model. Blanton points out that the scientific paper is “designed to guide the reader’s attention and thought through the developmental shifts of AGREED. BUT, BUT SUPPOSE, THEN, INDEED [48. p. 1361. A typical research report can be paraphrased according to Blanton’s shifts. For example, an article describing trials of the drug chlorpromazine for emergency-room treatment of migraine [38, pp. 302-3041 can be structurally reduced as follows: AGREED: the use of narcotics to treat emergency room patients presenting with migraine is unsatisfactory. BUT: no effective alternatives have been established to date. BUT SUPPOSE: we found that a safe, non-addictive drug was effective in most patients with acute migraine. THEN: more trials would be appropriate to establish this new form of treatment. INDEED: the promise of such a drug could not be ignored. Blanton’s grammar can be shown to underlie the structure of most research reports, and the predictive

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value of Blanton’s observations is further evidence of the rhetorical structure of medical journal articles. Unlike research articles, review or ‘update’ articles tend to display a rather homogeneous organization: they are not organized with persuasive introduction and discussion sections flanking a more descriptive middle; rather they are divided according to topics. Review articles, however, are not less persuasive because of their relatively flat organization. Their apparent rhetorical shapelessness contributes to the impression that they are unproblematically reportorial. STYLE

Style, like invention and arrangement, constitutes a category of persuasive strategies. According to Aristotle, “it is not enough to know what to say-one must also know how to say it” [15, p. 1821. For the scientific writer, style is especially important: not only is author familiarity with conventional scientific style a prerequisite to credibility, but also, according to John Ziman, appropriate use of such a style has the effect of identifying a piece of writing with knowledge already accepted in the field--effectively begging the question of significance by creating the impression that what is argued is already known [51]. Additional rhetorical uses of style are found in medical journals. They include the following: (1) use of the passive voice; (2) management of syntax; (3) use of qualifiers; (4) use of the interrogative; and (5) avoidance of poetic language. Commentators on the style of scientific prose frequently refer to injunctions to the scientist, going back as far as the Royal Society in the seventeenthcentury, to be clear, to offer scientific truth in language unadorned by stylistic embellishment. Most frequently quoted is Thomas Sprat’s statement in the History of the Royal Society that members should strive after “the primitive purity, and shortness [of language], when men deliver’d so many rhings, almost in an equal number of words” [52]. In fact, directives to the scientific writer have not substantially changed in 300 years. Medical authors are advised by the style manual of the Journal ofrhe American Medical Association, that “the primary purpose of medical writing is communication of scientific knowledge to other physicians” and that, therefore, “information must be presented with accuracy and clarity in a manner that can be read easily and rapidly” [53]. Certain forms, such as the passive voice, have become conventionalized in the literature as markers of authorial distance and their use is a prerequisite to scientific publication, The JAMA style manual continues: “It is often said in books about writing that the active voice is preferred. This is not always true, and it may be true less often in medical writing than in some types of narrative prose” [53, p. 91. The more recent American Medical Association Manual of

Strategies of influence in medical authorship Style,

8th edition,

is preferred,

says, “In general, the active voice except in instances in which the interest

concerns what is acted on” [54]. In medical reporting, interest in “what is acted on” predominates-and so does passive voice. The survey of medical articles verifies the dominance of the passive verb in scientific accounting. A typical paragraph in the Methods section of a research article reports that patients “were studied” and “were carefully analyzed”; analysis in this case “was done” in three ways; and a second group of patients “was analyzed in a similar fashion” [47, p. 661. The Methods section of another article contains eight verbs, six of which are in the passive voice: patients were “referred” to the clinic, then “assigned” a diagnosis, and “assigned” again to the appropriate clinical category; their history “was recorded,” certain items were “marked,” and findings “were recorded” [40, p. 3621. The passive is less apparent in the openings and closings of articleswhere it is common for fewer than half of the verbs to be in the passive voice. This is consistent with observations about the rhetorical arrangement of the research article. Syntax in scientific writing also has a rhetorical function, directing reader attention or giving a particular cast to assertions. Information is deemphasized in embedded structures; minor sentence elements reduce the effect of the information they contain-or imply the information is not new, but given. In one study, results of a treatment (which researchers hypothesized would not be effective) were diminished because subjects did not continue treatment in the follow-up period. The authors do not focus syntactically on experimental confounding of results, but on patient behavior, and mention the effect on results as an apparent afterthought: “During the follow-up, half of the behavioral group failed to practise their techniques regularly, which decreased some of the gains” [24, p. 901. Another group of authors alters the force of its advice about pharmacological management of headache by embedding much of that advice in minor sentence elements. They say that in the treatment of certain patients, “a decision to advise the use of either 650 mg aspirin or 1000 mg acetaminophen for headaches of the tension type, and a prescription drug for the tension-vascular headaches, is rational” [55]. Another case of syntax bearing meaning concerns various authors’ working descriptions of migraine. While the most widely accepted description of the disorder says that migraine is “often familial,” and “in some cases. . associated with. . . mood disturbances” [56], some authors vary syntax to compose descriptions which seem to confirm what the traditional description only suggests. One pair of authors writes that migraine is a “familial disorder” [33, p. 2121; another describes migraine as a “stressrelated syndrome” [57]. Less seriously, a similar process of suggestion becoming fact in syntax takes

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place when a researcher writes of the phenomenon of the “hot dog headache” [58] while specialists continue to debate the role of dietary triggers of migraine [59]. Qualifiers are essential to scientific writing in part because they allow for accuracy in reporting. While it may be accurate to say that an experimental drug “would appear to be superior to the alternative modes of therapy available” [38, p. 3041, it might be less accurate to say that the drug is superior. Similarly, researchers can claim with confidence that “it appears that patterns of responses to emotional stress are significant correlates of outcomes of... therapy” [57, p. 1101. The vagueness of the claim enhances its truth-value, and minimizes grounds for disagreement. Qualifiers also give authors a protected way of dealing with matters that are hypothetical, theoretical or controversial. One pair of authors distills research on diet and migraine by saying, “foods or alcohol can provoke occasional attacks [of migraine] in some patients” [37, p. 1841.Another author reports that the demands of child rearing can foster migraine attacks, and unresolved grief may play a role in some patients” [60]. (All emphasis is mine.) While qualifiers are essential to accounting in medicine, they also pose a rhetorical problem. When readers are told, for example, that “some epidemiologists report migraine in up to 25% of the population” [22, p. 1371, they do not normally (given a credible author) ask which epidemiologists say so and under what circumstances; the statement is taken as an assertion that approximately this percentage of the population does suffer from migraine. That is, some quality of certainty is virtually a byproduct of textuality. With this in mind, it is interesting to take a second look at the assertions which open some of the articles under review (see p. 523 above). My emphasis is supplied this time. believe [migraine] may occur in up to 25 percent of the general population [22]. Some epidemiologists

Epidemiological studies indicate that abouf two-thirds of adults in the United States experience headaches. [23]. In the U.S.A., 24 million Americans are reported to suffer from severe headaches. [24]. Each year 550 million workdays are lost in the United States because of pain, which is probably the principal complaint presented by patients . [25]. Headache is a common problem, affecting approximately 7&75% of men. [26]. Headache is one of the most common of medical complaints and is presumed to affect more than 80% of the population v71. Migraine headache is one of the most common neurological disorders, with an estimated prevalence of 5% to 25% in western society [28]. Migraine is a common disorder, occurring in an estimated 5% of the general population 1291. Tentative certainty is complemented by another feature of medical writing: its mood of inquiry. Some

authors, for example, actually pose whole articles as

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scientific questions-“Diet and headache. Is there a link?’ [59, pp. 279-2861, “Are classical and common migraine different entities?’ [33, pp. 212-2131, “Is the muscular model of headache still viable?” [34, pp. 186-1981, “Is migraine food allergy?” [32, pp. 865-8681. The articles seem to be offered in spirit of inquiry. It is noteworthy that, almost a year after it published “Is migraine food allergy,” The Lancer published an article by different authors entitled, “Migraine is a food allergic disease” [61]. The reception of the two articles, judged by ensuing letters to the editor, seems, in part to be a reception of their different moods. Letters in response to the first point out strengths and weaknesses of the study and raise further questions for investigation; letters in response to the second are somewhat argumentative, with one writer, for example, accusing the authors of drawing “unwarranted conclusions” [62]. Other authors achieve an effect of inquiry by presenting articles as contributions to dialogue, as these titles suggest: “Dietary factors in migraine precipitation: the physicians’ view” [37, pp. 1841871, “Towards a definition of migraine headache” [63], “The mixed headache syndrome: a new perspective” [64]. Scientific style, that is, reproduces the scientific value that research should invite responses in the form of criticism, follow-up, or replication-the taking of the next conversational turn. On the other hand, scientific writers seem to avoid stylistic devices which are obviously figurative. Figures of speech and thought, catalogued in classical rhetoric, are, in general, actually shunned by the scientific writer. The scarcity of such language in scientific texts accounts in part for their known amenability to translation [65]. Although scientists strive for the non-rhetorical effect in their writing (a striving which is itself rhetorical), some of the medical authors surveyed do, as is unavoidable, use certain well-known devices of style. One pair of authors uses the rhetorical question (erotema) to articulate their concerns about headache classification: ‘Should all these [patient] groups be said to be suffering from classic migraine,” they ask, “and if so what do we call the headaches that [two of the groups] have without an aura?” [33, p. 2121. The trope litotes, or rhetorical understatement, is at work in this sentence: “It would be helpful to both physicians and patients if there were a treatment which was relatively safe, was not addictive and gave prompt relief” [66]. In addition, parallel constructions are common in scientific writing, often taking the form of lists [67]. A number of authors, to make their points, turn to metaphor. The term, ‘aura’, used to describe the premonitory symptoms of migraine, suggests the ineffable quality of the warning. In the theoretical discussion of neuronal as opposed to vascular genesis of migraine, the term ‘nerve storms’ is used to describe the behavior of neurons [21, p. 111. One group of researchers describes the phenomenon of the

‘turtle’ headache, the curse of the late sleeper, who “retracts his head beneath the blankets” to avert the sun and is thereby deprived of oxygen [68]. Metaphor and simile are frequently used also as pain descriptors, a virtual necessity since the pain lexicon is itself largely metaphorical. One doctor describes patient complaints of “tightness” [50, p. 3101; another refers to the sense of “squeezing” or “the sensation of wearing a tight band” [69]; a third describes patients’ “icepick-like” pains [70]. Interestingly, the aversion which does exist to overt rhetoricity in the scientific writing of medical authors is much less apparent in the unscientific writing of the same authors. Medical journal editorials, for example, constitute a different genre for medical authors, a genre with fewer-at least, differentstylistic constraints. In a guest editorial, one researcher uses analogy to suggest an explanation for headache: The word for the discomfort experienced when the heart is overwhelmed by demands placed upon it as a pump is angina-angina pectoris. Webster tells us that these are the Latin words for a painful suffocating contraction in the chest-a throttling. Headache may represent a similar situation-but one resulting from suffocation or throttling or overloading of the brain, and maybe, even of the soul? [711.

In fact, editorial writings supply good evidence that the ‘neutral’ nature of scientific texts is a matter neither of the basic inclinations of scientific authors nor the nature of their subject matter; the neutral style is a cultivated style which has become conventionalized in a particular forum for scientific writing: the scientific article [72]. Its use, like the use of research rationales and other arguments, is part of the rhetoric of science.

CONCLUSION

The question, once the rhetorical nature of medical texts has been established, is “of what are readers of medical journals being persuaded?” The answer is twofold at least. Readers “in the particular case” are being persuaded of the validity of claims made by particular authors. Readers are also, however, being persuaded of the validity of the medical model of which particular claims are only instances. That is, while individual authors make specific claims, a collective (the ethos of medicine) asserts and renews an existing paradigm. Rhetorical analysis is useful in both the particular and the general case. To identify rhetorical strategies at work in medical journals is one way to understand medical values as instruments of action within the profession. Such values include, for example, medicine’s privileging of statistical proofs, its attachment to market principles (apparent in the topos of degree), and its dissociation from patients-all values that count also as motives. Over the past several years, scholars from medicine, sociology, anthropology and other disciplines have

Strategies of influence in medical authorship been examining the assumptions of western medicine and subjecting to scrutiny its dominant scientific model. Rhetorical studies, with its interest in how minds are made up and minds are changed, how paradigms are maintained and paradigms are challenged, has much to contribute to this interdisciplinary project. REFERENCES

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APPENDIX Glossary

of Terms

Artistic/inarrislic proofs-Aristotle calls artistic those proofs which depend on the ingenuity of the speaker, that is, the inductive or deductive arguments which the speaker has to ‘invent’. Inartistic arguments are, in contrast, externally available; these are based, for example, on evidence or testimony. Dissociation-this term is adapted from Chaim Perelman [49] to refer to disjunctions in organization, the effect of which is separation. Perelman uses the term liaisons to refer to those bonds between subjects or terms which speakers

forge, and he uses dissociation to refer to the breaking bonds which existed beforehand.

of

Erotema-this is the commonly noted rhetorical question. the question posed not in order to be answered, but in order indirectly to make a point. Ethical appeals-these are persuasive appeals which derive from the character of the speaker. External ethos may be formed by credentials and the like, whereas internal erhos is the character of the speaker as it is created by the speech itself-for example, by evidence of great intellect or fairness. Figurafiue language-this is an encompassing term to refer to deviations from the structure and sense of ordinary language. They include, commonly, schemes which are variations in ordinary word pattern, and tropes which are variations in ordinary signification. Metaphor is a type of trope. Identification-Kenneth Burke [73] writes that ‘identification’ is actually a synonym for persuasion, since we “induce action in people” only when we convince them to identify with our position. Identification is thus the starting place for rhetoric, as well as both its means of operation and its goal. Lifotes-this rhetorical figure of understatement is exemplified when an author makes a particularly modest claim. (On the subject of headache), rhetorician E. P. J. Corbett [74] cites this example of lifoles from Catcher in the Rye: “It isn’t very serious. I have this tiny little tumor on the brain.” Mefaphor-in this claim is made about of something more the figure of speech example, “the pain

trope, a comparison is implied, and a something relatively unfamiliar in terms familiar. Where comparison is explicit, is the simile, in which one might say. for was like an ice-pick”.

ParallelLrm-as a matter of both grammar and style, certain related elements of a sentence may be rendered in similar or identical structures. Since a well-written list offers its terms in such structures, a list may be considered an example of parallelism. Passive voice-the passive voice exists in contrast to the active voice in the matter of verb form. Using the active voice, a writer might say, “I selected seven subjects”; using the passive, he or she might say, “seven subjects were selected (by me)“. When the passive is employed, the verb is made complex, the object of the action is placed in the primary position and the agent, or doer of the action, may be suppressed. In the previous sentence, the passive appears four times. Purhetic appeals-these are best seen emotional appeals, but as attempts to make whole of the person in the audience or the his or her rational, critical self. The appeal is, in part, an appeal of pathos.

not simply as contact with the reader, not only of iden@cabon

Prolepsis-the strategy here is simply one of anticipating and responding to questions that may arise in the audience, thus defusing those questions. Topos-this Greek term translates as ‘place’, and refers in rhetoric figuratively to ‘locations’ where a speaker or writer might discover arguments. One such location would be, for example, in the realm of “past fact and future fact,” so that a rhetor might argue, almost irrespective of subject matter, that what happened in the past can or even will happen in the future. Another such location would be “greater and lesser” (the ropes of degree) wherein the rhetor might argue that something which affects a large number of people is more deserving of attention than something which affects a few.