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Associations are rarely as free as theory assumes; at the same time, they may tell us more than what appears on the surface. Memories, on the other hand, are rarely as reliable as they might appear. We are overtrained to listen to the unfolding story and to the narrative truth of the moment; much harder to capture is what might be called its rhetorical truth. Learning to listen for sequence, repetition, and co-occurrence tends to minimize the importance of the narrative thread and clarify instead the more suppressed meanings. In rare cases, we can even sense something of what the analysand is saying before it comes into awareness.

Reports of clinical happenings are coming under increasing suspicion because of their piecemeal nature and their problematic reliance on memory. Recent research on eyewitness testimony has raised the further concern that memory of an event can be easily and unwittingly influenced by something heard or seen after the fact. Once the psychoanalyst's memory has come under the influence of whatever theory is dominant, we can expect both an overselection of clinical happenings consistent with that theory, and an unwitting alteration of those that do not agree. Seemingly true case reports may be more virtual than veridical.

The anecdotal case study tradition in psychoanalysis has a long, hallowed history and continues to seem the best way to describe our clinical encounters. But reliance on memory in the absence of witnesses or other kinds of corroboration (such as audio recording) can (a) protect standard theory from necessary corrections; (b) lead to the underreporting of technical mistakes, outright clinical failures, and, paradoxically, innovative approaches; (c) tempt us to substitute, by way of narrative smoothing, what ought to happen for what actually transpired; and (d) lead to the loss of an invaluable, one-of-a-kind set of observations that can never be replaced.

A case of relapsing polychondritis presenting as tracheomalacia is reported in which an unusual low pitched sound was heard at the mouth and over the chest wall during expiration. The sound was associated with expiratory airflow limitation and oscillation on the flow trace of approximately 50 Hz. Spectral analysis of the sound showed it to have the characteristics of sounds produced by flutter in flow limited flexible tubes. These observations suggest that the sound was produced by airflow induced flutter in the trachea and main airways and is further evidence in support of the dynamic flutter theory of wheeze production.

Setting: Metropolitan areas of England, including London boroughs, in 1991., Objective: To investigate the relative importance of deprivation, immigration and the elderly in explaining variations in tuberculosis rate., Design: A retrospective study using multiple Poisson regression models to assess the interrelationship between various population parameters., Result: Significant differences ere observed between London and other metropolitan districts in the measures of tuberculosis, immigration and the elderly. In addition, all population parameters were significantly intercorrelated in London: areas with a high proportion of immigrants had high levels of deprivation and low proportions of elderly. In other metropolitan districts, only immigration and the Jarman index were significantly associated, and removing the immigration component from the index removed this statistical significance. Multiple Poisson regression models revealed that the immigrant index had the strongest explanatory power in explaining tuberculosis rates, but there were significant interactions between this and measures of urban deprivation indices. That is, there was a greater effect of increasing deprivation at lower levels of immigration than at higher levels. This phenomenon was more pronounced in London boroughs than other metropolitan districts. The elderly index had no significant influence on tuberculosis rates., Conclusion: Although the association between tuberculosis and deprivation previously reported for the city of Liverpool is confirmed across all urban areas of England, the immigrant proportion of the population has a greater statistical power in explaining variations in rates of urban tuberculosis. However, tuberculosis notifications can be most accurately predicted by combining both measures than by either one alone.

Wheeze is a classic sign of airflow obstruction but relatively little is known of its mechanism of production or its relationship to the development of airflow obstruction. We studied eight asthmatic subjects age (mean +/- 5D) 42 +/- 5 yr, FEV1 2.46 +/- 0.36 L during an extended, symptom-limited methacholine challenge test. Breath sounds were detected by a microphone over the right upper anterior chest. Spectral analysis was by a fast Fourier transform algorithm. Mean FEV1 fell by 51 +/- 14% to 1.28 +/- 0.61 L during the challenge and airways resistance increased by 119 +/- 50%. There were no consistent changes in breathing pattern or tidal volume during the challenge. Wheeze occurred late in the challenge at the highest concentration of methacholine administered and only after expiratory tidal flow limitation had been reached. Five subjects developed wheeze on tidal breathing, the remaining three only wheezed on deep breathing. Wheezing sounds were reproducible between breaths, coefficient of variation of starting sound frequency was 4.2% and ending frequency 12%. Mean frequency of expiratory wheezes was 669 +/- 100 Hz and inspiratory wheezes 710 +/- 76 Hz. Expiratory wheeze fell in pitch during a breath (mean fall in sound frequency 187 +/- 43 Hz) but inspiratory wheezes were more variable. Expiratory wheezes occurred late in the respiratory cycle at a mean of 58% of the maximal tidal expiratory flow, whereas inspiratory wheezes occurred around maximal tidal inspiratory flows, suggesting that the mechanisms of production of inspiratory and expiratory wheezes may be different. In this model, the presence of wheeze during tidal breathing was a sign of severe airflow limitation.

Patients with obstructive sleep apnea (OSA) experience severe sleep disruption and consequent daytime sleepiness. Current arousal scoring criteria show that some obstructive apneic events do not end in a recognizable cortical electroencephalographic (EEG) arousal. It is not known whether events that end in an obvious EEG arousal differ from those that do not, in terms of EEG frequency changes during the apneic event, the respiratory effort developed prior to apnea termination, the degree of the postapneic increase in blood pressure, or changes in CO2 tensions. We studied 15 patients with OSA in early Stage 2 sleep and analyzed obstructive apneic events with and without typical EEG arousals, defining an arousal as a frequency shift to waking alpha rhythm of 1 s or longer. EEG signals were digitized and analyzed by fast Fourier transform during and immediately after each apnea. The median EEG frequency and mean pleural pressure of the first and second halves of the apneic episode were compared with that of the first breath. Peak pleural pressure was measured just before the end of the apneic episode. Systolic and diastolic blood pressures and CO2 tensions were measured at the onset and termination of apnea. For each patient, 10 events that ended in EEG arousal were compared with 10 events that did not. Mean apnea duration did not differ for the two groups of events. Median EEG frequency and pleural pressure increased significantly from 8.14 to 9.25 Hz and 15.4 to 22.1 cm H2O, respectively, as the apnea progressed, but there was no difference between the groups nor any difference in the peak pleural pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Background: Although mortality from tuberculosis has continued to fall in recent years, there has been little change in the case fatality rate for tuberculosis over the same period. This has previously been shown to be due to the increasing proportion of cases of tuberculosis occurring in the elderly. Tuberculosis mortality and case fatality were therefore analysed to determine if this disappointing trend in case fatality rate has occurred from disease in all or only certain sites., Methods: A retrospective analysis of the tuberculosis mortality and case fatality rates in England and Wales for the period 1972-92 was carried out. The average annual percentage change in tuberculosis was calculated for each disease site and by age group and the results were compared., Results: The analysis showed that, although the mortality rate fell steadily by 5.6% per annum, the case fatality rate decreased by only 0.9% (95% CI -1.7 to -0.1) per annum. The case fatality rate for respiratory and central nervous system disease declined, but no decline in tuberculosis at "other" sites was observed (1.01% (+2.2 to -0.2) for all age groups combined). In the group aged 75 and over, however, the proportion of deaths due to disease at other sites increased by 3.2% (2.2 to 4.3) per annum whilst in the other age groups the mortality rate declined., Conclusions: This analysis suggests that clinicians may be becoming less able to recognise non-respiratory presentations of tuberculosis, particularly in the elderly, and underlines the need to consider tuberculosis as a diagnosis to avoid delay in treatment.

Setting: A retrospective study of tuberculosis notifications in England and Wales published by the Office of Population Censuses and Surveys., Objective: To analyse the rise in tuberculosis notifications in England and Wales by different sub groups over the time period 1982-91., Design: The average annual percentage change in tuberculosis notification rates (per 100,000) for the groups were analysed by age, sex, standard region and disease site., Results: The average annual increase in tuberculosis notifications from 1987-91 in females was +2.55 (95% confidence interval [CI] 0.5-4.7); males showed no significant change (-0.6%, 95% CI: -2.9 to +2.7). The increase was greater in younger subjects: 3.2% in females aged 25-44 (95% CI 0.9-5.5) and 4.3% in males aged 15-24 (95% CI 1.7-6.9). Only three standard regions showed an increase: the South East, the West Midlands, Yorkshire and Humberside. This increase was significant only in females from the South East, and was predominantly in non-respiratory tuberculosis., Conclusion: The rise in tuberculosis notification rates from 1987-91 has been predominantly in females, in those under 65, has occurred in 3 regions, and predominantly in non-respiratory tuberculosis. The analysis highlights some of the inadequacies of the present notification system for tuberculosis.

A case of obstructive sleep apnoea associated with the Arnold-Chiari malformation is described, in which the loss of pharyngeal sensation seems to have played an important part in the aetiology of the obstruction of the upper airway.

Background: Computerised x-ray planimetry has been advocated as an alternative to body plethysmography and helium dilution for measuring static lung volumes. The accuracy and reproducibility of this method has been assessed in comparison with these standard methods., Methods: Plethysmographic and planimetric measurements of total lung capacity (TLC) and functional residual capacity (FRC) were made in 10 normal subjects and in 12 patients with chronic obstructive pulmonary disease (COPD), with additional helium dilution measurements in the latter 12 patients., Results: Mean lung volumes (TLC and FRC) for groups of subjects measured by planimetry and by plethysmography were similar in both groups and larger than the helium dilution measurement in patients with COPD. Intraindividual agreement between planimetry and plethysmography was poor, however, with a wide confidence interval (-2.2 to +2.31). The planimeter did not measure reliably changes in volume from TLC to FRC in individuals., Conclusions: Mean lung volumes measured by planimetry in a group of patients probably reflect a regression to the mean of the computer algorithm rather than accurate TLC estimation. The technique is not yet robust enough to replace the established techniques of helium dilution or plethysmography.

Interpretations seem to matter most (at least in the case of Mrs. C) when the analyst feels included in the patient's thoughts. During hours of this kind (Related hours, scoring high on the cooccurrence of first- and second-person pronouns such as me/you), the analyst's interpretations are more comprehensive and probing; he intervenes earlier and more often within the session; and his specific interpretations have a greater effect on the patient's associations, as measured by an increased frequency of specific discourse markers. Low-scoring hours, with relatively few pronominal references to the analyst, were characterized by more superficial interpretations; later and fewer interventions; a greater tendency for the analyst to misunderstand the patient's productions; and a decreased effect of specific interventions. Special care was taken to protect the findings from the dangers of suggestion (the Achensee question).

Psychoanalytic facts are almost always capable of being put into words and they include things the patient tells us, things we tell the patient, and things we tell our colleagues. They include various combinations of observation and theory, evidence and hearsay, dream and reality. In contrast to the more usual facts of the everyday world, a psychoanalytic fact is almost never based on pure observation and it is partly for this reason that a dispute over facts frequently conceals a dispute over theory. It also follows that bare facts are almost never presented by themselves; when they are presented (as in a publication), they are almost never quite the same as when experienced in the session. Some meanings are lost in publication; others are inadvertently added by the reader, as he tries to fill in the gaps of a vague report. 'Clinical' facts (which have just been described) should be distinguished from 'contextual' facts, which colour the way we hear the patient's reports, and from 'latent' facts, which cannot be detected by the analyst in the session but must be measured by other techniques. Because the proportion of theory to observation is probably greater in clinical facts than in latent facts, the latter may provide more reliable measures of a clinical happening. Greater reliance on latent facts may also reduce our dependence on metaphor and smooth the transition from clinical moment to published account.

Memories of early child abuse can be read in at least two distinct ways--as true accounts of an unspeakable event or as metaphors for a wide range of boundary violations which belong to both past and present. An actual memory of an early experience tends to fade unless repeatedly rehearsed; because abuse memories are inherently shameful, it seems reasonable to be skeptical of this kind of repetition and to be suspicious of their sudden emergence. An actual memory of an early experience would be told from the child's point of view and would probably contain many false starts, internal contradictions, and all the other earmarks of a confused memory that refer to an early happening; by contrast, a seamless account with a tight narrative structure and an almost total absence of doubt or irrelevant detail is almost certainly false. An actual memory would tend to have its own flavor and style; by contrast, a memory of child abuse that sounds too much like other memories is more likely a metaphor for something else. Therapists, lawyers, and other professionals need to be trained to listen metaphorically to these accounts, to be on guard against hearing them as concrete references to a particular time and place, and to beware of reinforcing them prematurely.

Platelet-activating factor (PAF) may be a major mediator of asthma and bronchial hyperreactivity through its many proinflammatory actions. Specific antagonism of PAF might offer an alternative anti-inflammatory treatment to inhaled corticosteroids. To test this, we have studied the effect of an orally active PAF antagonist, WEB 2086, on the inhaled steroid requirements of symptomatic atopic asthmatics in a double-blind randomized placebo-controlled parallel group study. The inhaled corticosteroid dose required for symptomatic control of asthma was established and further steroid reduction was attempted after treatment with WEB 2086 40 mg three times daily for 12 wk. Of 106 patients recruited, 68 entered the treatment phase and 65 completed 6 wk of treatment. The mean daily corticosteroid dose (SE) at study entry was 1,257 (75) micrograms which was reduced by 323 (66) micrograms during the run-in period without loss of symptomatic control. A further 416 (57) micrograms reduction in inhaled corticosteroid dosage was possible during the treatment phase but this was almost identical in the WEB 2086 and placebo-treated groups, amounting to 353 (92) and 481 (65) micrograms/day respectively (not significant [NS]). Rate of relapse following corticosteroid reduction was a continuous variable and relapse occurred at different times depending on the variable used to define it. Time to relapse measured by an increase in symptoms correlated with disease duration (r = 0.41, p < 0.01) and with the dose of inhaled corticosteroid at study entry (r = 0.36, p < 0.01) but no other measured variable predicted the time to relapse.(ABSTRACT TRUNCATED AT 250 WORDS)

A root metaphor for the psychoanalytic therapeutic process is the mother-infant caretaking relationship. This developmental metaphor has assumed a dominant role for some analysts in how the psychoanalytic process and therapeutic relationship are conceptualized. In this paper, a distinction is made between two uses of the developmental metaphor--naïve and informed. The naïve view as commonly applied constrains our view of the unique relationship between analyst and analysand. The informed view takes into account current research in early social development that has emerged in the last decade of empirical studies with infants, young children, and their parents. While the parent-child relationship may be an inexact model for the analytic connection, some of the implications of the former, as they become more clearly understood in the course of careful research, may provide useful information about how change does or does not occur as a result of the analytic process, and how an analytic process needs to be in place in the analysand before that change can occur.

How do we listen during an analytic hour? Systematic analysis of the speech patterns of one patient (Mrs. C.) strongly suggests that the clustering of shared pronouns (e.g., you/me) represents an important aspect of the analytic surface, preconsciously sensed by the analyst and used by him to determine when to intervene. Sensitivity to these patterns increases over the course of treatment, and in a final block of 10 hours shows a striking degree of contingent responsivity: specific utterances by the patient are consistently echoed by the analyst's interventions.

Background: Although exercise induced desaturation can occur in patients with chronic obstructive pulmonary disease (COPD), little is known about its frequency during everyday exercise, or how it relates to dyspnoea or prior drug treatment., Methods: The effects of 200 micrograms inhaled oxitropium bromide, an anticholinergic bronchodilator drug, on spirometric values, dyspnoea score, and oxygen saturation during corridor walking and cycle ergometry were studied in a double blind, randomised, placebo controlled study., Results: Oxitropium produced a small increase in forced expired volume in one second (FEV1) from 0.76 (0.28) 1 to 0.93 (0.69) 1 and in six minute walking distance from 311 (93) m to 332 (86) m, but did not change progressive cycle exercise duration. Resting and end exercise breathlessness levels were reduced in both forms of exercise after oxitropium. Resting oxygen saturation fell significantly after active bronchodilator from 92.9% (3.7%) to 92.0% (4.1%) but the nadir saturation during exercise was unchanged. The patients desaturated more during corridor walking than cycle ergometry [walking 7.8% (4.4%), cycle ergometry 2.1% (2.1%)]. Baseline walking distance was related to FVC, resting breathlessness and resting oxygen saturation (multiple r2 = 0.46) but only resting saturation correlated with end exercise breathlessness (r2 = -0.25). Improvements in symptoms or exercise performance after oxitropium could not be predicted by changes in spirometric indices or oxygen saturation., Conclusions: In patients with COPD arterial oxygen desaturation during self-paced walking is common, of greater severity than that during cycle ergometry, but is unaffected by inhaled oxitropium bromide. The factors that predict initial performance are not appropriate markers of functional improvement after an active bronchodilator drug.

Objective: To examine whether the historical link between tuberculosis and poverty still exists., Design: Retrospective study examining the notifications of all forms of tuberculosis by council ward over a six year period and correlating this with four indices of poverty; council housing, free school meals, the Townsend overall deprivation index, and the Jarman index., Setting: The 33 electoral wards of the city of Liverpool., Subjects: 344 residents of Liverpool with tuberculosis., Results: The rate of tuberculosis was correlated with all measures of poverty, the strongest correlation being with the Jarman index (r = 0.73, p < 0.0001). This link was independent of the high rates of tuberculosis seen in ethnic minorities., Conclusion: Tuberculosis remains strongly associated with poverty.

A growing body of research on the way children change their forms of thinking and views of the world from around the ages of 2 to 5 strongly suggests that something called a 'theory of mind' is acquired during this time which significantly affects the course of language acquisition, moral development, interactive problem-solving and other cognitive attributes. As we learn more about the adult varieties of this theory of mind we begin to realise their implications for psychoanalysis. This paper considers such issues as: what kind of theory of mind is assumed by our reliance on the Basic Rule? What kind of theory is required to understand the usual range of standard interventions? How can deficiencies in the analysand's theory of mind interfere with standard interpretations? As research on theory of mind makes us increasingly sensitive to the importance of different forms of thinking about thinking, we can apply many of these insights to common problems of psychoanalytic technique.

Seventy hours from the psychoanalytic case of Mrs. C, covering the full course of treatment, were scored for associative freedom, number of interventions, and a variety of clinical phenomena such as clarifications, interpretations, different forms of resistance, transference manifestations, and the like. Associative freedom significantly increased over the course of treatment and was significantly related to the number of analyst interventions per hour. The relationship was particularly strong in the latter stages of treatment. Three specific types of interventions were found to increase associative freedom in the latter stages of treatment. The effect of each type was found to influence both the session containing the interpretation and the next 3 sessions. This carryover effect was specific to the latter stages of the analysis.

Cold air may worsen asthmatic bronchoconstriction but can lessen breathlessness in normal individuals. Patients with COPD sometimes report improvement in their dyspnea in cold weather. We examined the effect of breathing cold air on exercise tolerance and the perception of breathlessness in 19 patients with stable COPD (age [+/- SD], 63 +/- 6 years; FEV1, 0.99 +/- 0.28 L) in a randomized open study. Patients exercised on a cycle ergometer breathing either room or cold air (-13 degrees C), breathlessness being assessed by Borg scaling. Peak exercise performance improved when breathing cold air (mean +/- SE), 46 +/- 6 W compared with 37 +/- 7 W (p < 0.05) while end-exercise breathlessness fell from 4.6 +/- 0.4 compared with 4.1 +/- 0.5 (p < 0.05) when breathing cold air. End-exercise ETCO2 was higher breathing cold air (6.1 +/- 0.3 kPa compared with 5.5 +/- 0.3 kPa) (p < 0.005). There was no difference in breathlessness at equivalent levels of ventilation. Cold air reduces breathlessness in COPD, probably by inducing relative hypoventilation.

Background: Analysis of breath sounds by digital techniques offers an attractive non-invasive method of monitoring changes in airway calibre. Asthmatic breath sounds have been analysed and related to changes in forced expiratory volume in one second (FEV1)., Methods: Bronchoconstriction was induced with methacholine in six asthmatic subjects on two occasions and changes in FEV1 and breath sound spectra were measured., Results: Audible wheeze appeared after a mean (SE) fall in FEV1 of 35% (6.3%) but the level was not reproducible within patients. The mean and median frequency of the spectra of breath sounds correlated with the percentage of predicted FEV1 (r = -0.5 and -0.6 respectively; p < 0.001). Inclusion of the quartile frequencies in a stepwise multiple regression reduced the residual variance by a further 9%., Conclusion: Detecting changes in airway calibre by this method of sound analysis so far produces qualitative data only and will not yield quantitative data in individual patients.

Background: Heat and moisture loss from the respiratory tract during exercise are important triggers of exercise induced asthma., Methods: A new heat and moisture exchange mask has been developed which both recovers exhaled heat and water and has a sufficiently low resistance for use during exercise. The effect of the mask on inspired air temperature was studied in four normal subjects. Eight asthmatic subjects performed identical exercise protocols on three separate days, breathing room air through a conventional mouthpiece, a dummy mask, and the new heat and moisture exchange mask. Seven different asthmatic subjects exercised while breathing cold air at -13 degrees C through a dummy or active mask., Results: All subjects found the new mask comfortable to wear. The mean inspired temperature when the mask was used rose to 32.5 (1.4) degrees C when normal subjects breathed room air at 24 degrees C and to 19.1 (2.7) degrees C when they inhaled subfreezing air at -13 degrees C. The heat and moisture exchange mask significantly reduced the median fall in forced expiratory volume in one second (FEV1) after exercise to 13% (range 0-49%) when asthmatic subjects breathed room air compared with 33% (10-65%) with the dummy mask and 28% (21-70%) with the mouthpiece. The fall in FEV1 when the asthmatic subjects breathed cold air was 10% (0-26%) with the heat and moisture exchange mask compared with 22% (13-51%) with the dummy mask., Conclusion: Use of a heat and moisture exchange mask can raise the inspired temperature and humidity and ameliorate the severity of exercise induced asthma. The mask may be of practical value in non-contact sport or for people working in subzero temperatures.

The rhetorical voice of psychoanalysis has a long history and has only recently come to be seen as a special feature of the theory. Its beginnings can be found in Freud's earliest pleadings for the usefulness of metaphor and analogy, although he felt that they were largely provisional and would eventually be replaced by more durable concepts. We have begun to see problems in replacing the central metaphors; the rhetorical base of psychoanalysis may be more enduring than we thought. While our metaphors may never provide epistemic access to the stuff of the mind, they can and do point to specific clinical encounters. Ways must be found to expand our rhetorical treasure chest and develop language even better suited to our concepts and observations.

The principal goal of the clinical interpretation (and of the larger clinical narrative) is to bring about insight and change in the patient, and not to present a reasoned argument that relies on public data and shared rules of evidence and logic. When the clinical account is transposed to the public domain and presented as a form of explanation, it is no longer designed for the benefit of one individual but must now be accessible to all. We are still under the shadow of Freud's five famous cases which are literary landmarks of exposition and persuasion. As a result, we are less sensitive to what happens when interpretations are substituted for explanations. The time has come to develop a new genre and a new mode of clinical reporting that would allow the reader to participate in the argument, allow him to evaluate the proposed links between evidence and conclusion (instead of relying on the authority of the analyst-author), and open up the clinical report to the possibilities of refutation, disconfirmation, and falsification.

Schafer's action language can be criticized on purely theoretical grounds; here, the emphasis is on some of its clinical implications. First, action language tends to put the patient into an adversary position with respect to the analyst; this interferes with the therapeutic alliance, discourages regression, and encourages self-consciousness and problem-solving reasoning. Second, action language tempts the analyst to use premature labels in place of ambiguous metaphors; premature clarification may undercut the process of analytic discovery. Third, a focus on action and responsibility, because it highlights conscious mechanisms and the secondary process, may run the danger of working against the analytic process. It may yield rationalization rather than insight and convey the message that the analyst does not take seriously the concept of the unconscious. Fourth, by emphasizing clarity in favor of metaphor, action language may put an unnecessary emphasis on rationality and may discourage the kind of groping self-exploration that is the essence of productive analysis.

Criticizes three replications of experiments on subliminal perception for not being true replications. The lack of subliminal effects in the replications could very well be explained by a change from sensitive to insensitive instruments of measurement.

Heart rate and respiration were monitored while the subject listened for the appearance of a target sentence in a subsequent block of text. In two-thirds of the trails, the target sentence was altered by major or minor changes in wording, and the subject was asked to indicate whether or not a change had occurred. Heart rate preceding the first appearance of correctly recognized target sentences showed a steeper acceleration than heart rate preceding incorrectly recognized sentences. Mean heart rate during the correctly recognized embedded sentences showed a steeper deceleration than was present when the wording change was not recognized. Respiration amplitude decreased signifidantly discriminate between hits and misses, and did not correlate with change of heart rate. It was concluded that falling heart rate may be triggered by a shift in style of listening set in motion when the subject attends more closely to the specific words in the sentence as opposed to its underlying meaning.

The choice of specific words during face-to-face conversations may be just as overdetermined as the choice of words during free association. To explore this hypothesis, we looked in detail at three words used by patients who were at risk for cervical cancer and who were interviewed during a hospital visit for cone biopsy. We hypothesized that an ongoing disease process would influence choice of language, even though the interviews were conducted before the patients were informed of the results of the biopsy. We also hypothesized that choice of words by the interviewer would be affected by the patient's language. More distant derivatives, if they can be identified, may also behave in an equally lawful manner, and further research is needed to find ways of uncovering and measuring these silent markers.

Psychoanalytic competence can be defined as the knowledge and background necessary and sufficient to understand a therapeutic encounter. We can distinguish between normative competence, which belongs to all members of the psychoanalytic community, and privileged competence, which belongs only to the treating analyst at a particular time in a specific clinical situation. The two kinds of competence are frequently confused; as a result, the author of a clinical paper unwittingly assumes that he and the reader share all important information. In fact, the typical piece of clinical writing is largely inaccessible to anyone with only normative competence and because the reader does not have all necessary information, he is tempted to fill in the gaps and clarify the ambiguities with his own private set of meanings. Each paper in the literature runs the risk of generating as many "texts' as there are readers. To prevent this kind of misreading, we argue for the systematic clarification (naturalization) of each clinical encounter to make it accessible to anyone with normative competence. Systematic naturalization provides the link between normative and privileged competence and allows the reader more complete access to the clinical issues at stake.