As a boy, I used to carry along with me a small loose-leaf notebook. It had been a prize in a holiday beach contest, and it constantly reminded me of my success as a sand sculptor. I have always been a timid boy, and this prized talisman helped to bolster my weak identity. Equally significant to me was the fact that my grandfather, according to my mother, had taken notes in a similar little book. By my standards Cornelis Harm Wind, my grandfather, was a legendary figure. My mother was only 15 when he died at the age of 43; my two sisters and I never had the pleasure of knowing him. Yet I felt a great reverence for my unknown grandpa. He was a great experimenter. After the discovery of X-rays he had been the first to determine the wavelength of the new form of radiation. He served as Director of the National Institute of Meteorology at De Bilt (just imagine: my grandfather the chief weather forecaster!) before he became a professor of mathematical physics at the University of Utrecht. He participated in conferences in Copenhagen and Brussels and knew such celebrities as Lorentz, Curie, Rutherford and Einstein. He ardently took part in debates on issues that were later to be resolved by Lorentz's and Einstein's magnificent discoveries (about C.H.Wind , in Dutch).
My grandfather's notes have not been preserved. Neither have mine, but I remember some of the notes I took when I was about 18 years old: thoughts about the nature of life, sketches of both practical and useless inventions, and many aphorisms. "Themes in a musical fugue reflect the forms in nature: modifications in space and time". "Beauty is implicit logic". "Consciousness is sparked by incongruence". Thoughts like these have remained precious to me as leading lights that never lost their meaning. When episodes of anguish and turmoil had shattered my confidence, I was always able to fall back on an early formed fundamental and reassuring understanding of the world around me. Now I realise with some awe that these early aphorisms have evolved from their limited beginnings into a comprehensive reflection on my world, on its inhabitants and their actions. Apparently, a few well springs of thinking, activated early in life, can expand and eventually feed a fully developed mind.
The Dutch novelist, Harry Mulisch, has described the far-reaching effect of thoughts budding at an early age. He remembers a 'mystical' realisation in his youth: the sudden awareness that the two tones of an octave interval are the same and yet not the same (a universal phenomenon according to E.G.McClain, 1978). This enlightened insight led to his philosophical novel The composition of the world (1980). Artistic inspiration and insight illuminate essential aspects of our time and our world. Since Boethius in the 6th century AD we have learnt much about the periodicity of planetary movement, the seasonal cycles, the spiral of evolution. With expanding knowledge, the language and metaphors in which we think have changed. No longer do we listen to the harmony of spheres, we now look at them. Our image of the universe has become more a visual than an auditory one. The way in which music reflects the properties of the universe was still apparent to the cultured people of Babylon (1800 BC) and to Boethius, but has lost its meaning in our technological age.
Let me share with you some details about my educational background, and about the role that music has played in it. I began to play the cello at the age of seven, under the guidance of my father, who was an accomplished amateur musician. Since then I've been engaged in ensembles for chamber music.
You can listen to a sample of Beethoven Variations, played by Lucie Roodvoets, piano and the author (cello).
Ensemble playing is a cooperative effort: with your fellow-musicians you enter a time-structure designed by the composer. Together you shape complicated structures in a time-sequence: rhythmic and melodic successions differ slightly from each other, are remembered, varied and restructured. It is a training of practical intelligence and motor skills; it is also sharing with others the powerful reverberations induced in one's emotional life by the music.
The fine receptive and imaginative skills involved in music have a practical application in science when a "participating and listening" attitude is needed (12.6). Musical sound patterns succeed each other in a way that can be compared to a natural evolution, from elementary forms to a complex creation, which, in turn, can be compared to developing ideas, institutions and cultures. In earlier civilisations the role of music in education has been more predominant than it is now (E.G.McLain 1978). Religious music was considered to be an abstract image of the world, it served to establish harmony between man and his universe. Many composers have attempted to depict the cosmos and nature in monumental compositions: among them S.ten Holt, K-H. Stockhausen, P.Schat. The present book lays out a comparable trail: it is an exercise in time-structures (governing material structures) that are the essence of living nature and also that of humankind and the society we live in.
After my elementary school years I have never participated in formal religious practice. I appreciated religion as one does an idealistic myth, leading to prejudice and holding some risk of stagnation as to moral and intellectual unfolding. A key experience gave further shape to my view of spiritual life. In a conference organised shortly after the second world war by the reformed Christian student body about the topic of nuclear energy, the opinion was formulated that it could not be God's intention that man should touch the secrets of His atom. This was in contradiction my grandpa's achievements: in his inaugural lecture (1906) he had mentioned the bountiful energy, contained within the atom, that might in time become available to mankind; the time had now come for this energy to be exploited. The conservative opinion of the Christian students was contrary to my own view and that of several other participants. We decided to promote a more progressive and liberal platform and founded a Humanistic student movement. It is only recently, since I started writing this book, that I have realised that a religious view of life is bound to have strained relations with pivotal issues in science, education, health care and social dynamics. Self-organisation, evolution, self-unfolding, interactive growth, autonomy of the patient in the doctor-patient relationship, they all loose their meaning if mixed with even a trace of "divine guidance". There is a solution: one can be religious if divine guidance is the same as the laws of nature.
At school I turned out to be quite good at foreign languages but my main interests were biology and chemistry. When the moment came to register as a student, I entered the Department of Medicine because it seemed to combine my diverse interests. In the first three years of study the basic sciences and the biological foundations of medicine were revealed. The years of clinical education that followed were disappointing; I found that too little of the acquired knowledge was used to arrive at a diagnosis, and in the bed-side teaching by the master-clinicians I missed the scientific pattern.
For one year I held a junior assistantship in medical physiology. This rewarding experience compensated for the deprivation of fundamental scientific study after the first three years of my career as a student. The professor in charge, Janus Jongbloed, had been an eminent military aircraft pilot before he entered a medical career, and had later become a pioneer in aviation medicine. He asked me if I wanted to consider specialisation in this area and offered me a position in his laboratory. If I accepted, it would mean choosing a career in science and giving up a future in clinical work. After seriously considering his offer, I resolved to finish the two years that separated me from the doctor's license, before deciding about specialisation.
After graduating as an M.D., I was drafted for training in military medicine and, encouraged by Janus Jongbloed, I served in the Air Force from 1953 to '55. The challenge that faced human beings when adapting to high altitudes and to space travel (quite a novelty in post-war Holland!) attracted me and I enjoyed taking a close look at space physiology and aviation medicine. My daily work consisted of periodic medical checkups of military and civilian aircraft pilots. The rest of the time I spent in the well-stocked (thanks to gifts from the U.S.) library of the National Centre for Aviation Medicine at Soesterberg. The concepts of Cybernetics, introduced in 1943 by Norbert Wiener, and General Systems Theory seemed promising as a universal language for scientific transactions. The habit of ‘systems thinking’ has never left me. My first publication (in Nederlands Tijdschrift voor Militaire Geneeskunde, 1956) discussed the interaction between fighter pilots and their aircraft. Unimpaired communication of man with his environment seemed to me a vital aspect of personal health, and a necessity for survival in combat.
In the early fifties physicians were encouraged to become professionally active in the field of disorders of voice, speech, and hearing. For the second half of my tour of active military duty I was stationed at a small air-base where few demands were made on me as to medical services. I could spend most of my time studying phonetics and voice/speech/language pathology. By the time I left the military service in 1955, I had decided on a career as a medical specialist focussing on voice, speech, and hearing problems. The choice became easier when I learned that collegues in Finland (Aatto Sonninen) and Sweden (Björn Fritzell) held positions as precisely such specialists.This field of professional specialisation appealed to me as offering opportunity to study pathology and therapy, and, at the same time, offering scope for my interest in languages and music. It presented an inviting challenge to bring together complementary disciplines, such as linguistics, behavioural sciences and medical sciences.
I felt a strong urge to penetrate into the undiscovered regions of human voice and speech production. It was not at all a vague feeling of 'I would like to know more about this'; I was determined to discover as much as I could, and would not allow myself to be satisfied with meagre results. During four years in the department of medicine at Groningen university I did experimental work in voice physiology under the direction of the excellent medical physicist Jan Willem van den Berg. Eelco Huizinga, my professor of Ear, Nose and Throat diseases, warned me when we parted: Don't let your horizon be narrowed by fanaticism. In retrospect I think that the opposite happened. A strong drive has been necessary to expand the study of speech, voice and language beyond the limits of the Ear, Nose and Throat specialty. It requires some courage and a lot of energy to enter neighbouring territories , and to traverse large mental distances. When I started, linguistics, psychology and medicine were separate worlds, light-years apart. Mental acrobatics were required to reach members on the other side of the abyss. The combined efforts of other ‘trespassers’ like myself have changed this.
Since no formally directed training in my chosen area existed in Holland, I applied for and received a fellowship sponsored by the World Health Organisation. This award enabled me to visit centres offering specialisation in voice and speech pathology and laboratories for scientific research in human communication in France, Austria, Germany, and the Scandinavian countries. In the meantime I had met my wife, Tiete Terpstra, an accomplished speech therapist from Amsterdam. Just before leaving on this journey of exploratory study, we were married. Together, we set out as wandering students. On our return, an appointment awaited me at the University of Utrecht as an associate of Piet Gerlings, professor of diseases of the ear, nose and throat (ENT). My assigned task was to develop a clinical program in voice, speech, and language pathology within the ENT department of the Medical School.
We launched our work in the basement of a new building, with two speech therapists and a part-time psychiatrist. We found that for many of the problems presented by our patients we could offer no solutions. This deficiency was in part caused by the fact that at that time logopedics (speech therapy) was still functioning in a medical framework dating from the 1930s: reforms were over-due. Embarking on this project we experienced exhilarating moments. Theoretical innovation resulted in the discovery of new methods, enabling us to deliver productive work. In cooperation with plastic surgeons and dental specialists we reconsidered the diagnosis and treatment of short palate and cleft palate, and confirmed the notion that the widespread occurrence of habitual mouth-breathing and as well as other abnormal oral habits were the causes of orthodontic as well as speech-articulation problems. We also developed intensive treatment programs for voice disorders and stuttering, the latter in close association with Theo Schoenaker, a logopedist who later succesfully developed and promoted Individual Psychology along the lines set out by Adler and Dreikurs.
As our professional role metamorphosed from organic specialists to behaviour oriented physicians, we were supported by colleagues in internal medicine who had found that conversion symptoms and psychosomatic dysfunctions accounted for hitherto inadequately explained forms of disease. Researchers of other specialties venturing into this area were still few in number. Clinicians who were skilled in counselling patients as to the modification of their attitudes and behaviours were altogether rare. For this reason, our research effort moved to factors of personal growth, as well as considering emotional hazards in the family and the life of the individual patient. Our results have shown that medicine will gain in value and standing if it will join forces with the sciences of behaviour. The unified approach has diminished the number of inappropriate treatments and has led to more appropriate diagnostics. Not only is behavioural medicine a desirable supplement to medical training, it will also give patients a chance to develop higher levels of maturity, autonomy, and resiliency. This will enable them to better cope with future health hazards.
Training programs to achieve a positive attitude towards one's personal health problems are now available for several categories of patients, and these programs should receive full support in the curriculum of medical schools. Actively promoting health instead of merely treating disease is the proper response of the medical community to the challenges posed by so-called alternative therapies offered by narrowly trained healers. In order to assure a programme of behavioural medicine taking the place it deserves, it must be founded on firm biological principles. Throughout this book suggestions will be found on which such a curriculum might be constructed.
"An ounce of prevention is worth a pound of cure". Proper health management should spend as much money and energy on strengthening resiliency of body and mind as on curing disease. A state of physical and mental health depends to a large degree on resiliency of the immune and of the nervous systems. The idea of a parallel between the immune and the nervous systems, and the connections between the two, came to my mind in the 1970s. At that time I studied Communication Sciences at the University of Florida at Gainesville. That program was headed by Paul Moore, and later by Harry Hollien; they promoted exchanges with people of various disciplines. I had the opportunity to discuss, with behavioural scientists and biologists, such topics as the connection between early development and learning, and the basic motivation of human behaviour. In most areas of health care it is of prime importance to know the dividing line between voluntary and involuntary behaviour, and to master the procedures to move the boundary line in the wished for direction.
For a long time, I could only make slow progress in these fundamental issues, because in Utrecht I was constantly occupied with supervising clinical and educational activities. To give an example of our patient load in those times: between 1965 and 1985 we managed to clear with a small number of staff over ten thousand stutterers, who all found their way to appropriate kinds of treatment. Our group of clinicians, psychologists and physicians shared ideas about learning processes in personal development. Because we followed large numbers of patients over long periods of time we discerned new diachronic patterns. The concurrence of eczema, asthma and stuttering in families and individuals was a topic of study. Until then the division between the sciences had obstructed the view on possible logical connections between such diverse phenomena. We took on the task of designing a biological framework in which various hazards to the developing human body and mind could be accommodated: metabolic functions, sensomotor learning, social behaviour, cognitive style and speech-language development. Since heredity (species adaptation) and environment (individual adaptation) contribute in equal parts, the theory hinges on communication in nature and in man. Coping with the environment, characterised in this book as Adaptation and Defence (AcD), is directly related to physical and mental health.
Visual-spatial perception, is usually considered to be a reliable way to look at and to understand the world. During a study with laryngectomised patients, I noticed that there were exceptions. Visual observation, for example in the interpretation of X-rays, was at best incomplete and often misleading. The most valuable discoveries were made by accurate listening, thus avoiding visual deceptions. The French philosopher and columnist, Alain (nom de plume of E.A.Chartier), apparently agreed, as is witnessed by this line: "Voir n'est qu'une bâtarde façon de connaitre" (seeing is a spurious way of knowing). I took this as a motto for my thesis (1958) on "Oesophageal Speech", a substitute way of voice production used by laryngectomised people. Although Alain's quote is on the cover-page, nobody has ever asked for an explanation. Let me give it now.
With our eyes we perceive spatial relations between objects: small differences in size, in measured time. The visually oriented person is staring at proximal causes; the auditorily oriented person grasps the ultimate cause. With our ears we perceive temporal relations: we recognise and remember intricate rhythmic figures, melodic lines, complex harmonies, and we learn to integrate these into a meaningful auditory Gestalt. The skill to discern "Gestalts in time" assists us to recognise patterns of development, even if the time-scale is stretched or shortened by a factor 10 or a multiple of 10. J.Pringle has remarked that complexity of matter cannot explain life, it can only be understood as complexity in time.
Through listening much is revealed that is not noticeable to the eye. When one looks at an object only features within one's field of vision are perceived. When listening however one perceives all surrounding sources of sound, also those that hide behind other objects. To the visual world of surfaces, auditory perception adds understanding of the inner structure of objects and the core of things. A crack in a porcelain or crystal vase may be hardly visible, but will always be heard. A "crack" in the voice of a patient is understood, not so much by fiberoptic laryngoscopy, nor by X-rays, but by listening  to the way he uses his voice and  to the story of his life. The "visual" person is liable to limit his scope of attention to one particular preconceived area. A visual orientation may be a handicap for a diagnostician. The "listening" person on the contrary notices hidden cues and will be well disposed to make sense of them.
In an essay for the journal Hospital Practice, Morowitz has defined the difference between "Splitters" and "Lumpers". The former concentrate on a detail which they study for a lifetime; the latter take an encompassing bird's eye view and discover connections and grand patterns. The lumper and the splitter can ideally combine into one person. Since I have done a significant amount of splitting in my younger years, I now feel the need to overview vast areas. We must develop comprehensive theories that connect various disciplines. With increasing differentiation, specialists grow ever more wide apart and tend to lose touch. I am driven by a counteracting force destined to effect integration and I hope that my readers will share this attitude. We have discussed such questions as :
For those who feel uneasy with 'grand' theories I have a word of reassurance. There is nothing more practical than a good theory: it is the essence of our knowledge in a ready-to-use form. No one can function efficiently without theoretical groundwork. I have come to this conclusion since it is apparent how easily people, even well established scientists, have been led astray by traditional but false expectations, dominant prejudices and quasi-obvious judgments. Especially in medicine we must draw upon different sources of knowledge to guide us in the diagnostic process and on the tortuous roads of therapy. Also outside the clinic, in a more general context, we rely on theories to direct our exploration of the world. Besides, there is nothing absolute about theories; they are continuously improved by empirical testing.
During the long period I've been hatching the contents for this book I've received enormous encouragement from my wife Titia. My colleagues Hans van Wijngaarden, Joop Wilms en Sjoeke van der Meulen have tolerated an occasional absence and have been patiently wondering what kind of bird would be hatched from the egg, since this could hardly be guessed after the disclosure of some wet feathers. Elisabeth Versteegh has contributed perceptive criticism and correction of style and language. From Don Williams and Gerlof van der Veen I have received valuable comments on an earlier version of the manuscript. Stan Tempelaars taught me how to appease a wayward computer. I thank them all for their support which has been indispensable.
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