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 C O M M U N I C AT I N G I N P R O F E S S I O N S A N D O R G A N I Z AT I O N S

series editor: Jonathan Crichton

Communicating Across
Cultures and Languages in
the Health Care Setting

Claire Penn and Jennifer Watermeyer

Communicating in Professions and Organizations

Series Editor
Jonathan Crichton
University of South Australia
Adelaide, SA, Australia
This ground-breaking series is edited by Jonathan Crichton, Senior Lecturer
in Applied Linguistics at the University of South Australia. It provides a
venue for research on issues of language and communication that matter to
professionals, their clients and stakeholders. Books in the series explore the
relevance and real world impact of communication research in professional
practice and forge reciprocal links between researchers in applied linguis-
tics/discourse analysis and practitioners from numerous professions,
including healthcare, education, business and trade, law, media, science
and technology. Central to this agenda, the series responds to contempo-
rary challenges to professional practice that are bringing issues of language
and communication to the fore. These include:

• The growing importance of communication as a form of professional

expertise that needs to be made visible and developed as a resource for
the professionals
• Political, economic, technological and social changes that are trans-
forming communicative practices in professions and organisations
• Increasing mobility and diversity (geographical, technological, cul-
tural, linguistic) of organisations, professionals and clients

Books in the series combine up to date overviews of issues of language

and communication relevant to the particular professional domain with
original research that addresses these issues at relevant sites.
The authors also explore the practical implications of this research for
the professions/organisations in question. We are actively commissioning
projects for this series and welcome proposals from authors whose experi-
ence combines linguistic and professional expertise, from those who have
long-standing knowledge of the professional and organisational settings in
which their books are located and joint editing/authorship by language
researchers and professional practitioners. The series is designed for both
academic and professional readers, for scholars and students in Applied
Linguistics, Communication Studies and related fields, and for members of
the professions and organisations whose practice is the focus of the series.

More information about this series at

http://www.palgrave.com/series/14904
Claire Penn • Jennifer Watermeyer

Communicating
Across Cultures and
Languages in the
Health Care Setting
Voices of Care
Claire Penn
Health Communication Research Unit,
School of Human and Community
Development
University of the Witwatersrand
Johannesburg, Gauteng, South Africa
Jennifer Watermeyer
Health Communication Research Unit,
School of Human and Community
Development
University of the Witwatersrand
Johannesburg, Gauteng, South Africa

Communicating in Professions and Organizations

ISBN 978-1-137-58099-3    ISBN 978-1-137-58100-6 (eBook)
https://doi.org/10.1057/978-1-137-58100-6

Library of Congress Control Number: 2017954943

© The Editor(s) (if applicable) and The Author(s) 2018

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with the Copyright, Designs and Patents Act 1988.
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We dedicate this book to those who do what matters in real time and space
 Acknowledgements

The Researchers The work and insights described in this book reflect the
efforts, vision and energy of a wonderful team of researchers and research
assistants whose ‘lived’ experience with qualitative research methods in
some very demanding contexts has added great texture and understand-
ing to this field. Our deep thanks go to Victor de Andrade, Paula Diab,
Melanie Evans, Berna Gerber, Carol Legg, Motlatso Mlambo, Joanne
Neille, Lesley Nkosi, Dale Ogilvy, Jai Seedat, Samantha Smith, Gabi
Solomon and Tina Wessels, for their pioneering work in health commu-
nication across cultures in South Africa.

The Research Assistance Team at the Health Communication

Research Unit Bianca Burkett, Johanni du Toit, Harriet Etheredge,
Victoria Hume, Caitlin Longman, Sonia Mbowa, Rhona Nattrass, Sheryl
Neel, Megan Scott, Tshegofatso Seabi and others.

The Healers Carol Baker, Astrid Berg, Edwin Cameron, Ashraf

Coovadia, Paul Farmer, Bernard Gaede, Mike Levin, Aldo Morrone,
James Nuttall, Bruno Pauly, Neil Prose, Paul Roux and others.

The Funders South African National Research Foundation (NRF),

South African Netherlands Research Program on Alternatives in
Development (SANPAD), South African Medical Research Council
vii
viii Acknowledgements

(MRC), Fogarty International, American Speech-Language-Hearing

Association, Mellon mentorship funding, Friedel Sellschop funding,
University of the Witwatersrand Faculty Research Committee grants,
Swedish Research Council, The Wellcome Trust, MRC HIV/TB Initiative
Funding (in collaboration with the Aurum Institute), Carnegie
Foundation and KidzPositive.

The Enablers Large portions of this manuscript were written while CP

was in residence at the Rockefeller Foundation in Bellagio and at the
Stellenbosch Institute for Advanced Studies (STIAS). These contexts pro-
vided peace, space and companionship, which enabled creativity and
consolidation of a body of research. PATA is acknowledged for its huge
role and continuing efforts. Drama for Life at the University of the
Witwatersrand has been a constant companion in many of our projects.

The Advisers and Mentors Srikant Sarangi, Neil Prose, Tom Koole,
Leslie Swartz, the late Chris Candlin, Brett Bowman, Garth Stevens,
Hanna Ulatowska, Audrey Holland, Elisabeth Ahlsén, Jens Allwood.

The Voices The opinions, experiences, narratives and perceptions of all

who have taken part in our research. Their precious stories have yielded
deep insights.

Thanks go to Caroline Kennard for her efficient editorial assistance.

We thank our families for their forbearance and support of a vision.
 Contents

Part I Background and Central Constructs    1

1 Prologue   3

2 The Context of Health Communication: Global, Local

and Theoretical  25

Part II Research Methods and Challenges   59

3 Methodological Issues: Approaches, Pitfalls and Solutions  61

Part III The Evidence 117

4 Islands of Good Practice 119

5 Language Diversity in the Clinic: Promoting and

Exploring Cultural Brokerage 171

ix
x Contents

6 Verbal and Non-Verbal Dimensions of the Intercultural

Health Setting 207

Part IV Implementation 263

7 Putting It All into Practice: Some Examples and Advice 265

8 Conclusions and Implications: Paradoxes and Principles 313

Appendix 347

Index 359
 List of Abbreviations or Acronyms

AIDS Acquired Immune Deficiency Syndrome

ART Antiretroviral Therapy
ARV Antiretroviral
CA Conversation Analysis
CAM Complementary and Alternative Medicine
CARM Conversation Analytic Roleplay Method
CD Communicable Disease
CHW Community Health Worker
CP Claire Penn
CVA Cerebrovascular Accident
DA Discourse Analysis
DM Diabetes Mellitus
DGs Disability Grants
DVD Digital Versatile Disk
EMS Emergency Medical Service
HAART Highly Active Antiretroviral Therapy
HCRU Health Communication Research Unit
HIV Human Immunodeficiency Virus
ICF International Classification of Functioning, Disability and Health
IRB Institutional Review Boards
JW Jennifer Watermeyer
MDR-TB Multiple Drug-Resistant Tuberculosis
MRC Medical Research Council

xi
xii List of Abbreviations or Acronyms

NCD Non-communicable Disease

NGO Non-governmental Organization
NHI National Health Insurance
PATA Paediatric Aids Treatment of Africa
PMTCT Prevention of Mother-to-Child Transmission
RA Rheumatoid Arthritis
TB Tuberculosis
UNAIDS The Joint United Nations Programme on HIV and AIDS
VCT Voluntary Counselling and Testing
WHO World Health Organization
XDR-TB Extremely Drug-Resistant Tuberculosis
 List of Figures

Fig. 1.1 Map of South Africa indicating our sites of research 6

Fig. 1.2 The voice of medicine and the voice of the lifeworld
(Photographs by Yeshiel Panchia) 12
Fig. 2.1 The pill burden associated with treatment of drug-resistant TB 33
Fig. 2.2 The chain of communication in TB care contexts 36
Fig. 2.3 Ecological model of potential influences on pharmacist-patient
communication (After Watermeyer 2008) 38
Fig. 2.4 Ecological model of micro and macro influences on
communication in emergency care settings 40
Fig. 3.1 The three Rs (After Penn 2013) 63
Fig. 3.2 Participatory action research as incorporated into our research 65
Fig. 3.3 Example of a multidimensional polyphonic notation system
(Smith 2009) 101
Fig. 3.4 Our research ‘lab’ in Mpumalanga 104
Fig. 4.1 Site 1, an HIV/AIDS clinic at a tertiary hospital in the
Western Cape (psychiatry.uct.ac.za) 122
Fig. 4.2 Site 2, a child psychiatry clinic in Khayelitsha (vocfm.com) 130
Fig. 4.3 Site 3, an HIV/AIDS clinic in Mpumalanga 138
Fig. 4.4 The deck, above and below 141
Fig. 4.5 Ethnographic notes from observations of the patient
support group 142
Fig. 4.6 Site 4, an HIV/AIDS clinic in rural Eastern Cape 146

xiii
xiv List of Figures

Fig. 4.7 The Keiskamma Guernica, based on the painting by Pablo

Picasso, depicting HIV’s slow destruction of a community 146
Fig. 6.1 Metaphor themes and examples 219
Fig. 6.2 Example of a visual illustration of the battle metaphor
such as found in an HIV/AIDS counselling manual 220
Fig. 6.3 Mount Legogote in Mpumalanga 225
Fig. 7.1 The communication bus 281
Fig. 7.2 The DRIVE model 282
Fig. 7.3 Example of a transcribed call used in the training workshop 287
Fig. 7.4 Training workshop methods 292
Fig. 7.5 Examples of team ideas of the ideal clinic space 305
Fig. 8.1 Intersecting narratives on Prevention of Mother-To-Child
Transmission male non-involvement (Mlambo 2014) 320
Fig. 8.2 The entrance to the Chris Hani Baragwanath Academic
Hospital in Soweto (Photo: AFP) 330
 List of Tables

Table 3.1 Arthur Kleinman’s eight questions 75

Table 3.2 Some useful methods and ideas for intercultural research
in the clinical setting (After Penn 2013; Penn and
Armstrong 2017) 107
Table 4.1 Features of relevance emerging from sites 121
Table 4.2 Completed research on language in the HIV/AIDS clinic 123
Table 4.3 Patient perceptions of care at Site 1 126
Table 4.4 Patient perceptions of care at Site 2 136
Table 4.5 Patient perceptions of care at Site 3 140
Table 4.6 Patients’ comments about the qualities of a good doctor
at Site 4 149
Table 4.7 Caregiver and staff perceptions of care at Site 5
(Watermeyer 2012) 153
Table 4.8 Eight qualities of care identified at the islands of good
practice154
Table 4.9 Patient perceptions about quality of care at other sites 161
Table 5.1 Examples of the content of asides (uninterpreted sections)
emerging in 17 mediated interactions (After Penn and
Watermeyer 2012b) 186
Table 6.1 Comparison of priorities for information exchange during
the consent process 245
Table 6.2 Reported barriers to enrolment in trials 246

xv
xvi List of Tables

Table 7.1 Structure and content of the two informed consent

protocols270
Table 7.2 Enrollers’ perspectives on ‘challenging’ participants 273
Table 7.3 Strategies for improving communication in informed
consent processes (After Penn and Evans 2009, 2010) 275
Table 7.4 Examples of participant feedback from communication
training278
Table 7.5 Strategies that reportedly facilitated communication
during the consent process 280
Table 7.6 Verbal and non-verbal communication strategies presented
to participants 283
Table 7.7 Communication behaviours pre- and post-training 285
Table 7.8 Feedback from workshop participants 288
Table 7.9 A comparison of recommendations across two sites 301
Table 8.1 Elements of the ‘Communication in Health’ course 324
Table 8.2 Guidelines for teaching culturally safe communication skills 334
 Part I
Background and Central Constructs
 1
Prologue

Introduction
Communication has been identified as the single biggest barrier to health
care in a global world, and the provision of culturally and linguistically
appropriate services is a top priority, particularly in the light of the
increased migration patterns and complex illness burden imposed by dis-
eases such as HIV/AIDS.
Responding to such complex challenges of communication, within the
past decade, the Health Communication Research Unit at the University
of the Witwatersrand in South Africa has produced a body of research
which has had a significant influence on ways in which intercultural
health interactions can be viewed.
Using methods from the social sciences and linguistics, this project has
explored, in detail, same- and cross-language interactions in the health-
care setting, the role of the mediator in such settings and ways in which
interactions can be modified to improve communication.

© The Author(s) 2018 3

C. Penn, J. Watermeyer, Communicating Across Cultures and
Languages in the Health Care Setting, Communicating in Professions
and Organizations, https://doi.org/10.1057/978-1-137-58100-6_1
4 1 Prologue

Our research goals have been:

1. To describe and analyse cross-language and intercultural interactions

between health professionals and patients and to understand the role
of the interpreter in this process.
2. To establish the perceptions of the different participants (patients,
health professionals and interpreters) regarding the role of the inter-
preter and the language dynamics of medical interviews.
3. To assess the influence of different sites of service delivery on the
process.
4. To develop and implement appropriate guidelines for training health
professionals who work in cross-cultural and cross-linguistic contexts.

The research to date has examined cross-linguistic communication

and interpreting practices in the areas of HIV/AIDS, TB, genetic coun-
selling, psychiatry, respiratory illness, stroke, disability, audiology, phar-
macy, antiretroviral (ARV) treatment, paediatrics, diabetes, emergency
care and general health issues. Our research has also focused on cultural
beliefs regarding illness and causality as well as the impact of healthcare
systems on rural communities. The findings of some of these studies
have shown an urgent need for revision of current practices, as well as
linguistic and cultural tailoring of information for the patient, to ensure
successful transfer of information and concordance. The research has led
to the formulation of recommendations for policy and practice as well
as the development of communication skills training programmes for
health professionals. Efficacy studies on training programmes suggest
that the communication behaviours of health personnel can be modified
effectively and demonstrably after appropriate context-specific
training.
This book represents the consolidation of this decade of experience
into a text which will hopefully significantly influence ways in which
communication practices in all intercultural health settings are managed
and understood. The culturally diverse context in which this research has
taken place has obvious and immediate application in a wider interna-
tional context, given globalization and increased patterns of migration.
 Introduction 5

Four lines of research have emerged from the research:

1. The first body of evidence stems from an investigation of intercultural

healthcare interactions in various settings and the examination of a
range of verbal and non-verbal features in such settings which facili-
tate and inhibit such interactions.
2. The second line of research has been concerned with the impact of a
third party (interpreter or cultural broker) on the dynamics of such
settings and the perceptions of the participants around this process.
3. The third body of research (including the new field of genetic counsel-
ling) has explored cultural explanations of illness and how these may
interface with the medical model.
4. The fourth line of research focused on the understanding of how this
knowledge can be transferred into training and development models
for individuals and institutions.

Having had the opportunity to work at numerous sites, across numer-

ous diseases with multiple participants and across multiple languages,
this book offers us a chance to stand back, take stock and take a bird’s-eye
view—in other words a perspective about the whole. We have worked in
seven of the nine provinces of South Africa and across six of its official
languages. Figure 1.1 shows some of our sites of research.
Much of our work has been published, and we do not want to make
the mistake here of repeating that work and its findings. Indeed, our own
perspective on that work has often changed with time and with hindsight
and with the emergence of new evidence. Rather we use this book as an
opportunity to begin to compare and contrast the evidence and to inter-
face the collective experiences with our growing insights and the global
literature, and our experience at sites with patients and doctors.
Thus, while part of the book is very much about making sense of the
real evidence (and we now have a lot of that) and highlighting useful
methods and recurrent themes, the other part is very much forward-­
looking and drawing connections where none existed, making recom-
mendations or observations which are novel and which will hopefully
influence new ways of addressing practice.
6 1 Prologue

Fig. 1.1 Map of South Africa indicating our sites of research

This text presents these findings and shows how the methods we have
developed are unique and have wide potential application. The text is
intended for health professionals, language specialists, medical educators,
researchers and practitioners, and includes a range of theoretical, meth-
odological and empirical considerations. We have developed a set of rec-
ommendations for reframing the notion of ‘cultural safety’ in health care.
This will hopefully influence both individual and systemic practices for
managing diversity.
There is a clear relationship between effective communication practices
and outcomes which can be measured in tangible benefits for patients,
the health professional and the institution. Among documented benefits
for the patients are increased accuracy of diagnosis, understanding of
treatment, improved adherence to treatment and research protocols,
 Introduction 7

greater satisfaction and greater likelihood of returning for follow-up treat-

ment. Potential benefits for the health professional include increased
speed and efficiency, more accurate diagnosis, less stress and burnout and,
in turn, greater job satisfaction and, because of the improved use of the
diagnostic power of the interaction, less dependence on costly diagnostic
tests. Institutions benefit from effective communication, as they are likely
to experience decreased turnover of staff and financial savings, and argu-
ably, most importantly, they comply with the legal and ethical obligation
of providing equitable services to all patients.
To date much of the research on such factors has not been done in the
context of the multi-lingual clinic, and where it has, some of the methods
of measurement have been unidimensional. The complexities introduced,
for example in the mediated healthcare interaction in a situation of lin-
guistic and cultural diversity, are not well understood and require meth-
ods which capture such interactional complexity. Further, little is known
about the effect of disease on the process. The work of our project has
thus been deliberately framed within a multi-dimensional perspective of
the problem. In addition to the direct evidence we have of recorded inter-
actions, we have the perceptions of the participants, as well as narrative
and ethnographic perspectives on sites of practice and from particular
illness and communication experiences. It also seems important to con-
sider the impact of the broader ‘macro’ context in health care and to
understand the socio-political and institutional context of the
interaction.
Many South African patients continue to experience numerous poten-
tial barriers to accessing the healthcare system, interacting with health
professionals or adhering to treatment regimens. These barriers are linked
to factors such as stigma and discrimination, poverty, unemployment,
gender, education, religion, literacy, access to treatment and health care,
financial resources, and trust of the healthcare system or health profes-
sional. In other words, the separate world views of the participants in
healthcare interactions have a very real impact on the process and often
cause breakdowns, which have marked consequences in terms of effi-
ciency of diagnosis and treatment.
Fascinating material has emerged from the project. As reflected in the
dissertations and publications produced, we have a body of unique material
8 1 Prologue

which spans a range of healthcare settings, a range of diseases and a number

of health professionals (see the table in the Appendix for details of each
study). We have patient narratives and health professionals’ perspectives,
and we have delved into the verbal and non-verbal minutiae of clinical inter-
actions. We have discovered multiple barriers to care and glowing islands of
good practice. We have seen how things can be demonstrably changed and
the impact that these changes have on the process of communication and on
the participants’ attitudes and behaviours. We have found that an examina-
tion of the micro-content of health interactions frequently provides insight
into broader societal issues. This suggests that many of the solutions to cur-
rent global healthcare challenges may lie in the voices of these ordinary
people and how communication takes place across this intercultural space.
We begin in this text to coalesce this material and offer some explana-
tions, solutions and methods for reframing these challenges based on
some remarkable and exciting evidence.
The following are considered some central values to this project.

F ocus on Everyday Practice and Authentic

Methods
Based on the belief that the study of everyday, local and particular is espe-
cially valuable, the emphasis in this book is a close examination of everyday
practice in a range of settings. Our research has enabled us to bear witness
to the stories and experiences of ordinary patients and health professionals.
As Jonny Steinberg (2010) has indicated in relation to effective implemen-
tation of new health policy and universal coverage of ARVs in South Africa,
“A great deal will depend on what ordinary people think and do.”
Our focus has been on just that. Methods of data collection, tran-
scription, translation and analysis have been developed with an empha-
sis on capturing accurate and nuanced language use. We have examined
interactional aspects such as openings and introductions, length, cou-
pling, symmetry and the search for collaborative moments (moments
in the interviews where participants and observers endorse mutual
understanding). Our methods also include participant observation, and
the exploration of the everyday life, experiences, events and problems
 Focus on Everyday Practice and Authentic Methods 9

of our participants through interviews and narrative methods. Some of

our methods have encouraged self-reflection —health professionals
reviewing videotapes and transcripts of their own practice— and hear-
ing their explanations for their behaviours.
In this text we also wish to highlight and illustrate the methodological
challenges of such research and to discuss in detail some lessons learned
and some mistakes made and to develop some recommendations about
these tools and their potential future use. These methods also have
enabled a certain way of presenting evidence from the project. We also
want to ensure that there is a depth and richness of illustration in this
text. As one of the health workers interviewed in this project observed,
“Sometimes the direct voice of the patient is more powerful and beautiful
than any secondary analysis or interpretation of what was said.”
Some of the evidence that we have is embedded in the narratives— sto-
ries of patients about their disease. As Rita Charon (2008) has indicated,
such narratives provide a remarkable perspective on the patient’s world
and form an important diagnostic and therapeutic function. This is par-
ticularly the case in contexts where a strong oral tradition exists. We have
stories about disability, about diseases such as HIV/AIDS and of health-
seeking paths. There are stories of resilience and adaptation to illness.
We also have the stories of doctors— doctors disillusioned with the
system, and some developing methods of communicating which are par-
ticularly unique and powerful.
We present some of these narratives in the text to provide the reader
with an opportunity to blend and merge voices of the health professional,
the patient and the mediator or third person who is so frequently present
in such interactions.
Similarly, the technique of conversation analysis, which we have used
for analysis in some of our studies, allows for the illustration of very detailed
interactional material, and the text includes a number of verbatim extracts
between health practitioners and patients which provide the reader with a
detailed understanding of both verbal and non-verbal components.
We are acutely aware of the ethical complexities of research of this
nature. By definition, this book deals with vulnerable populations of peo-
ple who are often sick, poor or uneducated. These are the very people who
have been marginalized by society, and their voice is often ­misrepresented
10 1 Prologue

and silenced. Our qualitative methods seek to directly represent their

voices, and we believe it is our ethical obligation to do so. Both of us have
been active members of our university’s ethics committees for a number
of years. All our research has received ethical clearance from the relevant
Institutional Review Boards and informed consent was obtained from all
participants. We have taken care to anonymize the people involved and to
use pseudonyms where necessary. In some instances however, and partic-
ularly where we highlight excellence of settings, we have chosen not to
completely anonymize all of the clinic details. Similarly, finding and using
the appropriate terminology within clinic spaces has proven an important
but challenging aspect of our research endeavours. As will be described in
more detail in Chapter 3, the words we use to refer to those who work in
clinics and with patients have direct links with our own approach to
research, our views of participants and our perceptions of ourselves as
researchers in the clinic space. In our research we have seen that when
issues around team membership, acknowledgement of role and the use of
inclusive terminology have been actively considered and addressed, there
have been positive consequences.
While this book reflects the products and efforts of a long-term partner-
ship, at times we discuss our own experiences and perspectives on particu-
lar projects, and we have taken care to label these perspectives as particular
to one author. We have also on occasion included ‘small stories’ (Bamberg
and Georgakopoulou 2008) to illustrate our research experiences.

Emergent Themes
In this text we highlight some of the themes which have emerged from
the research and which have a cohesive potential, in terms of both theory
and practical import.
Some examples link to:

• A consideration of the interface between a Western biomedical health-

care framework, which operates alongside established systems of tradi-
tional medicine.
• The powerful influence of gender on the health communication pro-
cess. What factors help women to express themselves and enable their
 Emergent Themes 11

voice to be heard? What barriers to care exist for women, and how can
the clinical relationship assist in resolution of these issues?
• The interaction between disease, poverty and communication. We are
interested in exploring what Paul Farmer et al. (2006, 2013) refer to as
“structural violence” imposed in a context of poverty and how tempo-
ral and spatial factors interface with health communication.
• Why do community structures of support sometimes have limits?
• How do the voices of different generations interface in the health con-
text? Our body of research on grandmothers, for example, has high-
lighted a number of differing models of illness causation.
• The delicate tension between the emergence of established organiza-
tional routines in healthcare interactions, in a context of fluidity and
uncertainty and scarce resources.

Just as many of the problems in health delivery link to communication

issues, so too do many of the solutions. Some of these are surprisingly
practical and simple and are described and illustrated in the text. For
example, asking the right questions, changing the seating in the interview
or the tea room arrangements in a clinic, negotiation of language rules,
the conscious deployment of non-verbal strategies (e.g., the use of ges-
ture, facial expression and using props) are some mechanisms that have
been explored. Similarly, ways in which vocabulary and terminology can
be clarified and understood have been a feature of our research.
The essence of our research endeavour is, in short, to blend the voice
of the lifeworld with the voice of medicine (Mishler 1984) and to use
communication as that bridge.
This is beautifully illustrated by the following pair of photographs
(Fig. 1.2), taken (with permission of all participants) in a diabetes clinic
in a large hospital in which one of our projects was sited.
In the one picture we see the messages of the clinic (in this case about
foot care) and the standard mediator for that message (the nurse ­educator)
whose primary role is to educate patients coming to the clinic about the
­complexities of diabetes management. In the other picture we see part of
our drama intervention involving actors, patients, nurses and facilitators,
the use of a cell phone and a snapshot of a group interaction whose goals
were entirely similar. The images complement each other and indicate the
potential role of communication strategies in helping to bridge the gap.
12 1 Prologue

Fig. 1.2 The voice of medicine and the voice of the lifeworld (Photographs by
Yeshiel Panchia)
 Emergent Themes 13

We have some really pleasing evidence for how such factors enhance
communication, reduce barriers to mutual understanding and promote
concordance even in the most challenging intercultural contexts. It is in
the initial and subsequent interface between the health system and the
patient that lives can be changed or that paths are set. We have begun to
see the emergence of what we call ‘magic moments’ in clinical settings—
points at which the participants collaborate and show evidence of mutual
understanding and intention. Such moments mostly occur around non-­
medical topics and are characterized as having greater interaction, being
more informal and personalized, demonstrating more coupling and mir-
roring behaviours, facial animation, increased eye gaze, forward body
posture and increased gesture. Such findings have major implications for
medical education.
Interwoven into this discussion is a consideration of biomedical ethics
and the role that communication factors play in this field. We consider,
for example, how communication variables are central to determining
and enhancing autonomy, self-efficacy and decision-making capacity and
can be actively enhanced in cross-linguistic research trial settings.
Other questions and solutions are more complex. How, for example,
can communication dimensions interface with the barriers to care which
continue to exist in the context of HIV/AIDS? What are the language
dimensions of the process of disclosure? Why do fewer than 30% of
women take up counselling services and why is there no apparent decline
in new infections in pregnant women? The fact that staying alive depends
on maintaining high adherence rates to ARV regimens in order to pro-
mote treatment success requires a detailed understanding of the language
of the pharmacy which is considered in depth in this text. Similarly, com-
munication is implicated in the complex treatment regimens and in rec-
ommended nutritional practice for patients.
How can some of our findings influence confidence and effectiveness
of young doctors working in contexts of cultural and linguistic diversity?
What mechanisms will best aid and assist systems and settings to cope
with what has been termed ‘organizational shock’ brought about by the
rapid and profound demographic changes and the complexity and sever-
ity of the diseases encountered?
14 1 Prologue

Emerging Solutions
This text aims to address some of the above issues and offer some concep-
tual and some practical proposals for individuals, institutions and policy.
Amongst some of the issues we explore (and which inform the last section
of the book) are the following:

 he Move Towards a Revised Model of Cultural

T
Brokerage

Our findings have strengthened the notion that in an intercultural set-

ting, a traditional conduit model of interpreting (where interpreters are
expected to remain neutral and merely transfer information verbatim
between patient and health professional), is ineffective and a cultural
brokerage model of interpreting is most effective for the transmission of
meaning in intercultural contexts. In this model the cultural broker acts
as a mediator between the health professional and patient, offers a cul-
tural framework in which the message can be interpreted and assists
both parties to negotiate cultural and linguistic barriers in order to
achieve a specific communicative goal. The text presents the discrete
profiles of cultural brokerage interpreting which have emerged in differ-
ent settings.

Islands of Good Practice: Characteristics of a Caring

Clinic

In our setting, because systems of health care are often underdeveloped or

even malfunctional, because the monitoring of such systems may be
erratic and because of profound resource limitations imposed by the
needs of a developing country, such difficulties are mapped daily onto the
clinic and its people. Ironically, this has created a space or vacuum which
has enabled an opportunity to exercise creativity, resourcefulness and
adaptation, and this has enabled the emergence of unique organizational
routines. A fascinating picture emerges in some cases about not only how
the role players have made do in a context of scarce resources, but also
 Emerging Solutions 15

how they have flourished, retained integrity and dealt with the challenges
in meaningful ways.
The intention here is not to harp on the bad-luck stories, the global
pattern of health inequities, the overwhelming disease profile, and the
health budget and mismanagement that beset clinical practice. These are
well described and acknowledged and hopefully will be systematically
addressed in the future on a global level. Rather, what we hope to do is
show humanization within such systems and show that despite, or
­perhaps because of, these systems, interpersonal and systemic evidence
emerges which point the way for us all. There is space for care and it
emerges when suffering is recognized and responded to.
Thus, a focus of this text is about the discovery and analysis of such
islands of good practice—settings or individuals where intercultural
communication is demonstrably effective, where patients are satisfied
and where indices of success (such as adherence to treatment and return
to the clinic) are remarkable. An examination of these interactions has
considerable promise: understanding the features characterizing such
interactions has the potential to yield a number of important directions
for future clinicians. We highlight eight features of good care common to
them all.
Five such examples of islands of good practice are described in detail in
the text:

• The first is the interactions between patients and one particular doctor
in the context of a paediatric HIV/AIDS clinic in the Western Cape.
We observed a number of his sessions and were able to interview him
about his perceptions of his practice and the individual sessions
observed. He worked both with and without interpreters and his par-
ticular style seemed to facilitate a number of positive interactions. His
management of disclosure (in the case of an adolescent girl) is a ­keynote
exemplar. A detailed description of this session is used in the text to
focus on this complex issue.
• The second context in which exceptional practice has been observed is
in a small rural village in the Eastern Cape. We spent some time at the
Keiskamma health programme (linked to the internationally recog-
nized art programme of this area), interviewing members of the
Another random document with
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fragments of the tentacles and fringe of the Medusa, whilst the
Medusa will in its turn occasionally capture and devour one of the
fish.

A great many of the Scyphozoa, particularly the larger kinds, have

the reputation of being able to sting the human skin, and in
consequence the name Acalephae[346] was formerly used to
designate the order. Of the British species Aurelia aurita is almost
harmless, and so is the rarer Rhizostoma pulmo; but the
nematocysts on the tentacles of Cyanaea, Chrysaora, and Pelagia
can inflict stings on the more delicate parts of the skin which are very
painful for several hours, although the pain has been undoubtedly
greatly exaggerated in many popular works.

The soft structure of the Medusae does not favour their preservation
in the rocks, but the impressions left by several genera, all belonging
apparently to the Rhizostomata, have been found in Cambrian,
Liassic, and Cretaceous deposits.

There is reason to believe that many Scyphozoa exhibit a

considerable range of variation in the symmetry of the most
important organs of the body. Very little information is, however, at
hand concerning the variation of any species except Aurelia aurita,
which has been the subject of several investigations. Browne[347]
has found that in a local race of this species about 20 per cent
exhibit variations from the normal in the number of the statorhabs,
and about 2 per cent in the number of gastric pouches.

The Scyphozoa are not usually regarded as of any commercial or

other value, but in China and Japan two species of Rhizostomata
(Rhopilema esculenta and R. verrucosa) are used as food. The jelly-
fish is preserved with a mixture of alum and salt or between the
steamed leaves of a kind of oak. To prepare the preserved food for
the table it is soaked in water, cut into small pieces, and flavoured. It
is also stated that these Medusae are used by fishermen as bait for
file-fish and sea-bream.[348]

In general structure the Scyphozoa occupy an intermediate position

between the Hydrozoa and the Anthozoa. The very striking
resemblance of the body-form to the Medusa of the Hydrozoa, and
the discovery of a fixed hydriform stage in the life-history of some
species, led the older zoologists to the conclusion that they should
be included in the class Hydrozoa. Recently the finer details of
development have been invoked to support the view that they are
Anthozoa specially adapted for a free-swimming existence, but the
evidence for this does not appear to us to be conclusive.

They differ from the Hydrozoa and resemble the Anthozoa in the
character that the sexual cells are matured in the endoderm, and
escape to the exterior by way of the coelenteric cavity, and not
directly to the exterior by the rupture of the ectoderm as in all
Hydrozoa. They differ, on the other hand, from the Anthozoa in the
absence of a stomodaeum and of mesenteries.

The view that the Scyphozoa are Anthozoa is based on the belief
that the manubrium of the former is lined by ectoderm, and is
homologous with the stomodaeum of the latter; and that the folds of
mesogloea between the gastric pouches are homologous with the
septa.[349]

The Scyphozoa, notwithstanding their general resemblance to the

Medusae of Hydrozoa, can be readily distinguished from them by
several important characters. The absence of a velum in all of them
(except the Cubomedusae) is an important and conspicuous
character which gave to the class the name of Acraspeda. The
velum of the Cubomedusae can, however, be distinguished from that
of the Craspedote Medusae (i.e. the Medusae of the Hydrozoa) by
the fact that it contains endodermal canals.
Sense-organs are present in all Scyphozoa except some of the
Stauromedusae, and they are in the form of statorhabs
(tentaculocysts), bearing statoliths at the extremity, and in many
species, at the base or between the base and the extremity, one or
more eyes. These organs differ from the statorhabs of the Hydrozoa
in having, usually, a cavity in the axial endoderm; but as they are
undoubtedly specially modified marginal tentacles, they are strictly
homologous in the two classes. In nearly all the Scyphozoa these
organs are protected by a hood or fold formed from the free margin
of the umbrella, and this character, although not of great
morphological importance, serves to distinguish the common species
from the Craspedote Medusae. It was owing to this character that
Forbes gave the name Steganophthalmata, or "covered-eyed
Medusae," to the class.

Another character of some importance is the presence in the

coelenteric cavity of all Scyphozoa of clusters or rows of delicate
filaments called the "phacellae." These filaments are covered with a
glandular epithelium, and are usually provided with numerous
nematocysts. They have a considerable resemblance to the acontia
of certain Anthozoa, and are probably mainly digestive in function.
These three characters, in addition to the very important character of
the position and method of discharge of the sexual cells already
referred to, justify the separation of the Scyphozoa from the
Medusae of the Hydrozoa as a distinct class of Coelenterata.

The umbrella of the Scyphozoa varies a good deal in shape. It is

usually flattened and disc-like (Discophora), but it may be almost
globular (Atorella), conical (some species of Periphylla), or cubical
(Cubomedusae). It is divided into an aboral and a marginal region by
a circular groove in the Coronata. The margin may be almost entire,
marked only by notches where the statorhabs occur, or deeply lobed
as in the Coronata and many Discophora. Marginal tentacles are
present in all but the Rhizostomata, and may be few in number, four
in Charybdea, eight in Ulmaris (Fig. 143), or very numerous in
Aurelia and many others. The tentacles may be short (Aurelia), or
very long as in Chrysaora isosceles, in which they extend for a
length of twenty yards from the disc.

The manubrium of the Scyphozoa is usually quadrangular in section,

and in those forms in which the shape is modified in the adult
Medusa the quadrangular shape can be recognised in the earlier
stages of development. The four angles of the manubrium are of
importance in descriptive anatomy, as the planes drawn through the
angles to the centre of the manubrium are called "perradial," while
those bisecting the perradial planes and passing therefore through
the middle line of the flat sides of the manubrium are called
"interradial."

The free extremity of the manubrium in many Scyphozoa is provided

with four triangular perradial lips, which may be simple or may
become bifurcated or branched, and have frequently very elaborate
crenate edges beset with batteries of nematocysts. In Pelagia and
Chrysaora and other genera these lips hang down from the
manubrium as long, ribbon-like, folded bands, and according to the
size of the specimen may be a foot or more in length, or twice the
diameter of the disc.

In the Rhizostomata a peculiar modification of structure takes place

in the fusion of the free edges of the lips to form a suture perforated
by a row of small apertures, so that the lips have the appearance of
long cylindrical rods or tubes attached to the manubrium, and then
frequently called the "oral arms." The oral arms may be further
provided with tentacles of varying size and importance. In many
Rhizostomata branched or knobbed processes project from the outer
side of the upper part of the oral arms. These are called the
"epaulettes."
 Fig. 143.—Ulmaris prototypus. g, Gonad; I, interradial canal; M, the fringed lip of
the manubrium; P, perradial canal; S, marginal sense-organ; t, tentacle. × 1.
(After Haeckel.)

The lumen of the manubrium leads into a large cavity in the disc,
which is usually called the gastric cavity, and this is extended into
four or more interradial or perradial gastric pouches. The number of
these pouches is usually four, but in this, as in other features of their
radial symmetry, the jelly-fish frequently exhibit duplication or
irregular variation of the radii.[350]

The gastric pouches may extend to the margin of the disc, where
they are united to form a large ring sinus, or they may be in
communication at the periphery by only a very narrow passage
(Cubomedusae). In the Discophora the gastric pouches, however, do
not extend more than half-way to the margin, and they may be
connected with the marginal ring-canal by a series of branched
interradial canals. Between the gastric pouches in these forms
branched perradial canals pass from the gastric cavity to the
marginal ring canal, and the system of canals is completed by
unbranched "adradial" canals passing between the perradials and
interradials from the sides of the gastric pouches to the ring-canal
(Fig. 143).

In the Discophora there are four shallow interradial pits or pouches

lined by ectoderm on the under side of the umbrella-wall. As these
pits correspond with the position of the gonads in the gastric
pouches they are frequently called the "sub-genital pits." In the
Stauromedusae and Cubomedusae they are continued through the
interradial gastric septa to the aboral side of the disc, and they are
generally known in these cases by the name "interradial funnels."
The functions and homologies of these ectodermic pits and funnels
are still uncertain.

The Scyphozoa are usually dioecious, but Chrysaora and Linerges

are sometimes hermaphrodite. The female Medusae can usually be
distinguished from the male by the darker or brighter colour of the
gonads, which are band-shaped, horseshoe-shaped, or circular
organs, situated on the endoderm of the interradial gastric pouches.
They are, when nearly ripe, conspicuous and brightly coloured
organs, and in nearly all species can be clearly seen through the
transparent or semi-transparent tissues of the disc. The reproductive
cells are discharged into the gastric cavity and escape by the mouth.
The eggs are probably fertilised in the water, and may be retained in
special pouches on the lips of the manubrium until the segmentation
is completed.[351] Asexual reproduction does not occur in the free-
swimming or adult stage of any Scyphozoa. In some cases (probably
exceptional) the development is direct. In Pelagia, for example, it is
known that the fertilised egg gives rise to a free-swimming Medusa
similar in all essential features to the parent.

In many species, however, the planula larva sinks to the bottom of

the sea, develops tentacles, and becomes attached by its aboral
extremity to a rock or weed, forming a sedentary asexual stage of
development with a superficial resemblance to a Hydra. This stage is
the "Scyphistoma," and notwithstanding its simple external features it
is already in all essential anatomical characters a Scyphozoon.

The Scyphistoma may remain as such for some time, during which it
reproduces by budding, and in some localities it may be found in
great numbers on seaweeds and stones.[352]
In the course of time, however, the Scyphistoma exhibits a ring-like
constriction of the body just below the crown of tentacles, and as this
deepens the general features of a Scyphomedusa are developed in
the free part above the constriction. In time this free part escapes as
a small free-swimming jelly-fish, called an "Ephyra," while the
attached part remains to repeat the process. In many species the
first constriction is followed by a second immediately below it, then a
third, a fourth, and so on, until the Scyphistoma is transformed into a
long series of narrow discs, each one acquiring, as it grows, the
Ephyra characters. Such a stage has been compared in form to a
pile of saucers, and is known as the "Strobila."

The Ephyra differs from the adult in many respects. The disc is thin
and flat, the manubrium short, the margin of the umbrella deeply
grooved, while the statorhabs are mounted on bifid lobes which
project outwards from the margin. The stabilisation of the
Scyphistoma is a process of reproduction by transverse fission, and
in some cases this is supplemented by gemmation, the Scyphistoma
giving rise to a number of buds which become detached from the
parent and subsequently undergo the process of strobilisation.

Fig. 144.—The perisarc tubes of a specimen of Spongicola fistularis (N)

ramifying in the skeleton of the Sponge Esperella bauriana (Sp.), as seen in
a macerated specimen, × 1. (After Schulze.)

The Scyphistoma of Nausithoe presents us with the most remarkable

example of this mode of reproduction (Fig. 144), as it forms an
elaborate branching colony in the substance of certain species of
sponges. The ectoderm secretes a chitinous perisarc, similar to that
of the hydrosome stage of many of the Hydrozoa, and consequently
Stephanoscyphus (Spongicola), as this Scyphistoma was called,
was formerly placed among the Gymnoblastea. It is remarkable that,
although the Scyphozoan characters of Spongicola were proved by
Schulze[353] in 1877, a similar Scyphistoma stage has not been
discovered in any other genus.

Order I. Cubomedusae.
Scyphozoa provided with four perradial statorhabs, each of which
bears a statolith and one or several eyes. There are four interradial
tentacles or groups of tentacles. The stomach is a large cavity
bearing four tufts of phacellae (Fig. 145, Ph), situated interradially.
There are four flattened perradial gastric pouches in the wall of the
umbrella which communicate with the stomach by the gastric ostia
(Go). These pouches are separated from one another by four
interradial septa; and the long leaf-like gonads are attached by one
edge to each side of the septa. In many respects the Cubomedusae
appear to be of simple structure, but the remarkable differentiation of
the eyes and the occurrence of a velum (p. 313) suggest that the
order is a highly specialised offshoot from a primitive stock.

Fig. 145.—Vertical section in the interradial plane of Tripedalia cystophora. Go,

Gastric ostia; Man, manubrium; Ph, group of phacellae; T, tentacles in four
groups of three; tent, perradial sense-organs; V, velum. (After Conant.)

Fam. 1. Charybdeidae.—Cubomedusae with four interradial

tentacles.
Charybdea appears to have a very wide geographical distribution.
Some of the species are usually found in deep water and come to
the surface only occasionally, but others (C. xaymacana) are only
found at the surface of shallow water near the shore. The genus can
be easily recognised by the four-sided prismatic shape of the bell
and the oral flattened expansion of the base of the tentacles. The
bell varies from 2-6 cm. in length (or height) in C. marsupialis, but a
giant form, C. grandis,[354] has recently been discovered off
Paumotu Island which is as much as 23 cm. in height. The colour is
usually yellow or brown, but C. grandis is white and C. xaymacana
perfectly transparent.

"Charybdea is a strong and active swimmer, and presents a very

beautiful appearance in its movements through the water; the quick,
vigorous pulsations contrasting sharply with the sluggish
contractions seen in most Scyphomedusae." It appears to be a
voracious feeder. "Some of the specimens taken contained in the
stomach small fish, so disproportionately large in comparison with
the stomach that they lay coiled up, head overlapping tail."[355]

Very little is known of the development, but it is possible that Tamoya

punctata, which lacks gonads, phacellae, and canals in the velum,
may be a young form of a species of Charybdea.

Fam. 2. Chirodropidae.—Cubomedusae with four interradial groups

of tentacles.

This family is represented by the genera Chirodropus from the

Atlantic and Chiropsalmus from the Indian Ocean and the coast of
North Carolina.

Fam. 3. Tripedaliidae.—Cubomedusae with four interradial groups

of three tentacles.
The single genus and species Tripedalia cystophora has only been
found in shallow water off the coast of Jamaica. Specimens of this
species were kept for some time by Conant in an aquarium, and
produced a number of free-swimming planulae which settled on the
glass, and quickly developed into small hydras with a mouth and four
tentacles. The further development of this sedentary stage is
unfortunately not known.

Order II. Stauromedusae.

This order contains several genera provided with an aboral stalk
which usually terminates in a sucker, by means of which the animal
is temporarily fixed to some foreign object. There can be little doubt
that this sedentary habit is recently acquired, and the wide range of
the characteristic features of the order may be accounted for as a
series of adaptations to the change from a free-swimming to a
sedentary habit.

It is difficult to give in a few words the characters of the order, but the
Stauromedusae differ from other Scyphozoa in the absence or
profound modification in structure and function of the statorhabs.
They are absent in Lucernaria and the Depastridae, and very
variable in number in Haliclystus.

The statorhab of Haliclystus terminates in a spherical knob, which is

succeeded by a large annular pad or collar bearing a number of
glandular cells which secrete a sticky fluid. At the base of the organ
there is a rudimentary ocellus. The number is very variable, and
sometimes they are abnormal in character, being "crowned with
tentacles." There can be little doubt that the principal function of
these organs is not sensory but adhesive, and hence they have
received the names "colletocystophores" and "marginal anchors,"
but they are undoubtedly homologous with the statorhabs of other
Scyphozoa.
The tentacles are short and numerous, and are frequently mounted
in groups on the summit of digitate outgrowths from the margin of the
umbrella. They are capitate, except in Tessera, the terminal swelling
containing a battery of nematocysts.

Very little is known concerning the life-history and development of

the Stauromedusae.

Fam. 1. Lucernariidae.—Marginal lobes digitate, bearing the

capitate tentacles in groups. Haliclystus auricula is a common form
on the shores of the Channel Islands, at Plymouth, and other
localities on the British coast. It may be recognised by the prominent
statorhabs situated in the bays between the digitate lobes of the
margin of the umbrella. Each of the marginal lobes bears from 15 to
20 capitate tentacles. It is from 2 to 3 cm. in length. The genus
occurs in shallow water off the coasts of Europe and North America,
extending south into the Antarctic region.

Lucernaria differs from Haliclystus in the absence of statorhabs. It

has the same habit as Haliclystus, and is often found associated with
it. L. campanulata is British.

Halicyathus is similar in external features to Haliclystus, but differs

from it in certain important characters of the coelenteric cavities. It is
found off the coasts of Norway, Greenland, and the Atlantic side of
North America.

In Capria, from the Mediterranean, the tentacles are replaced by a

denticulated membrane bearing nematocysts.

The rare genus Tessera, from the Antarctic Ocean, differs from all
the other Stauromedusae in having no stalk and in having only a few
relatively long non-capitate tentacles. If Tessera is really an adult
form it should be placed in a separate family, but, notwithstanding
the presence of gonads, it may prove to be but a free-swimming
stage in the history of a normally stalked genus.

Fam. 2. Depastridae.—The margin of the umbrella is provided with

eight shallow lobes bearing one or more rows of tentacles.
Statorhabs absent.

Depastrum cyathiforme occurs in shallow water at Plymouth, Port

Erin, and in other localities on the coasts of Britain and Norway. The
tentacles are arranged in several rows on the margin of the umbrella.
In Depastrella from the Canaries there is only one row of marginal
tentacles.

Fam. 3. Stenoscyphidae.[356]—Stauromedusae with simple

undivided umbrella margin. The eight principal tentacles are
converted into adhesive anchors. Secondary tentacles arranged in
eight adradial groups. Stenoscyphus inabai, 25 cm., Japan.

Order III. Coronata.[357]

The external surface of the umbrella is divided into two regions, an
aboral region and a marginal region, by a well-marked circular
groove (the coronal groove). The aboral region is usually smooth
and undivided, but it is an elongated dome, thimble- or cone-shaped,
in marked contrast to the flattened umbrella of the Discophora. The
margin is divided into a number of triangular or rounded lobes, and
these are continued as far as the coronal groove as distinct areas
delimited by shallow grooves on the surface of the umbrella. The
tentacles arise from the grooves between the marginal areas, and
are provided with expanded bases called the pedalia. The
manubrium may be short or moderately long, but it is never provided
with long lips.

Fam. 1. Periphyllidae.[358]—Coronata with four or six statorhabs.

In Pericolpa (Kerguelen) there are only four tentacles and four
statorhabs. In Periphylla, a remarkable deep-sea genus from 700 to
2000 fathoms in all seas, but occasionally found at the surface, there
are twelve tentacles and four statorhabs. The specimens from deep
water have a characteristic dark red-brown or violet-brown colour.
They are usually small Medusae, but the umbrella of P. regina is
over 21 cm. in diameter. Atorella has six tentacles and six
statorhabs.

Fam. 2. Ephyropsidae.—Coronata with eight or more than eight

statorhabs.

Nausithoe punctata is a small, transparent jelly-fish, not exceeding

10 mm. in diameter, of world-wide distribution. Its Scyphistoma stage
is described on p. 317. N. rubra, a species of a reddish colour found
at a considerable depth in the South Atlantic and Indian Oceans, is
probably an abysmal form. Palephyra differs from Nausithoe in
having elongated instead of rounded gonads. Linantha and Linuche
differ from the others in having subdivided marginal lobes.

Fam. 3. Atollidae.—Atolla is a deep-sea jelly-fish of very wide

geographical distribution. It is characterised by the multiplication of
the marginal appendages, but the number is very irregular. There
may be double or quadruple the usual number of marginal lobes, or
an indefinite number. There may be sixteen to thirty-two statorhabs,
and the number of tentacles is quite irregular. Some of the species
attain a considerable size, the diameter of the umbrella of A.
gigantea being 150 mm., of A. valdiviae sometimes 130 mm., and of
A. bairdi 110 mm.

Order IV. Discophora.

This order contains not only by far the greater number of the species
of Scyphozoa, but those of the largest size, and all those that are
familiar to the seaside visitor and the mariner under the general term
jelly-fish.

They may be distinguished from the other Scyphozoa by several

well-marked characters. The umbrella is flattened and disc-shaped
or slightly domed, but not divided by a coronary groove. The
perradial angles of the mouth are prolonged into long lips, which may
remain free (Semaeostomata) or fuse to form an elaborate proboscis
(Rhizostomata).

Sub-Order I. Semaeostomata.
In this sub-order the mouth is a large aperture leading into the cavity
of the manubrium, and is guarded by four long grooved and often
tuberculated lips. The margin of the umbrella is provided with long
tentacles.

Fam. 1. Pelagiidae.—Semaeostomata with wide gastric pouches,

which are not united by a marginal ring sinus. Pelagia, which forms
the type of this family, has eight long marginal tentacles. It develops
directly from the egg, the fixed Scyphistoma stage being eliminated.
[359] It is probably in consequence of this peculiarity of its
development and independence of a shore for fixation that Pelagia
has become a common and widespread inhabitant of the high seas.
In the Atlantic and Indian Oceans P. phosphora occurs in swarms or
in long narrow lines many miles in length. It is remarkable for its
power of emitting phosphorescent light. In the Atlantic it extends
from 50° N. to 40° S., but is rare or absent from the colder regions. P.
perla is found occasionally on the west coast of Ireland. Chrysaora
differs from Pelagia in the larger number of tentacles. There are, in
all, 24 tentacles and 8 statorhabs, separated by 32 lobes of the
margin of the umbrella. C. isosceles is occasionally found off the
British coast. It passes through a typical Scyphistoma stage in
development. Dactylometra, a very common jelly-fish of the
American Atlantic shores, differs from Chrysaora in having sixteen
additional but small tentacles arranged in pairs at the sides of the
statorhabs.

Fam. 2. Cyanaeidae.—Semaeostomata with eight radial and eight

adradial pouches, which give off ramifying canals to the margin of
the umbrella; but these canals are not united by a ring-canal. The
tentacles are arranged in bundles on the margin of the deeply lobed
umbrella.

The yellow Cyanaea capillata and the blue C. lamarcki are

commonly found on the British coasts.

Fam. 3. Ulmaridae.—The gastric pouches are relatively small, and

communicate with a marginal ring-canal by branching perradial and
interradial canals and unbranched adradial canals.

In Ulmaris prototypus (Fig. 143, p. 315) there are only eight long
adradial tentacles, and the lips of the manubrium are relatively short.
It is found in the South Atlantic.

Aurelia is a well-known and cosmopolitan genus, which may be

recognised by the eight shallow lobes of the umbrella-margin beset
with a fringe of numerous small tentacles.

Sub-Order II. Rhizostomata.

In this sub-order the lips are very much exaggerated in size, and are
fused together by their margin in such a manner that the mouth of
the animal is reduced to a number of small apertures situated along
the lines of suture. Tentacles are absent on the margin of the
umbrella. This sub-order contains some of the largest known jelly-
fishes, and exhibits a considerable range of structure. The families
are arranged by Maas[360] in three groups.
Group I. Arcadomyaria.—Musculature of the disc arranged in
feather-like arcades. Oral arms pinnate.

Fam. Cassiopeidae.—There are no epaulettes on the arms. Labial

tentacles present. Cassiopea is common in the Indo-Pacific seas,
and extends into the Red Sea. It includes a great many species
varying in size from 4 to about 12 cm. in diameter.

Group II. Radiomyaria.—Musculature arranged in radial tracts. Oral

arms bifid.

Fam. Cepheidae.—The genera included in this family differ from the

Cassiopeidae in the characters of the group. Cephea is found in the
Indo-Pacific Oceans and Red Sea. Cotylorhiza is common in the
Mediterranean Sea and extends into the Atlantic Ocean.

Group III. Cyclomyaria.—The group contains the majority of the

Rhizostomata. Musculature arranged in circular bands round the
disc. Oral arms primarily trifid, but becoming in some cases very
complicated. The principal families are:—

Fam. Rhizostomatidae.—With well-marked epaulettes, and sixteen

radial canals passing to the margin of the umbrella.

Rhizostoma pulmo (= Pilema octopus), a widely distributed species,

is often found floating at the surface off the western coasts of
Scotland and Ireland, and sometimes drifts up the English Channel
into the German Ocean in the autumn. The umbrella is about two
feet in diameter, and the combined length of the umbrella and arms
is four feet. The colour varies considerably, but that of a specimen
obtained off Valencia in 1895 was described as follows: "The colour
of the umbrella was pale green, with a deep reddish margin. Arms
bright blue."[361]

The family includes Stomolophus, of the Pacific and Atlantic coasts

of America, in which the oral arms are united at the base, and
Rhopilema, the edible Medusa of Japan and China.

Fam. Lychnorhizidae.—Here there are only eight radial canals

reaching as far as the margin of the umbrella, and eight terminating
in the ring-canal. There are no epaulettes, and the oral tentacles are
often very long. The family includes Lychnorhiza from the coast of
Brazil, Crambione from the Malay Archipelago, and Crambessa from
the Atlantic shores of France and Spain and from Brazil and
Australia. The last-named genus has been found in brackish water at
the mouth of the Loire.

In the families Leptobrachiidae and Catostylidae there are eight

radial canals reaching the margin of the umbrella, and between them
a network of canals with many openings into the ring-canal. In a few
of the Leptobrachiidae the intermediate canal-network has only eight
openings into the ring-canal, as in the Lychnorhizidae.

CHAPTER XIII

COELENTERATA (CONTINUED): ANTHOZOA = ACTINOZOA—GENERAL

CHARACTERS—ALCYONARIA

CLASS III. ANTHOZOA = ACTINOZOA

Among the familiar objects included in this class are the Sea-
anemones, the Stony Corals (Madrepores), the Flexible Corals, the
Precious Coral, and the Sea-pens. With the exception of a few
species of Sea-anemone, Anthozoa are not commonly found on
British sea-shores; but in those parts of the tropical world where
coral reefs occur, the shore at low tide is carpeted with various forms
of this class, and the sands and beaches are almost entirely
composed of their broken-down skeletons.

The majority of the Anthozoa are colonial in habit, a large number of

individuals, or zooids as they are called, being organically connected
together by a network of nutritive canals, and forming a communal
gelatinous or stony matrix for their protection and support. Whilst the
individuals are usually small or minute, the colonial masses they
form are frequently large. Single colonies of the stony corals form
blocks of stone which are sometimes five feet in diameter, and reach
a height of two or three feet from the ground. From the tree or shrub-
like form assumed by many of the colonies they were formerly
included in a class Zoophyta or animal-plants.

But whether the individual polyps are large or small, whether they
form colonies in the adult condition or remain independent, they
exhibit certain characters in common which distinguish them not only
from the other Coelenterata, but from all other animals. When an
individual zooid is examined in the living and fully expanded
condition, it is seen to possess a cylindrical body, attached at one
end (the aboral end) to the common colonial matrix or to some
foreign object. At the opposite or free extremity it is provided with a
mouth surrounded by a crown of tentacles. In these respects,
however, they resemble in a general way some of the Hydrozoa. It is
only when the internal anatomy is examined that we find the
characters which are absolutely diagnostic of the group.

In the Hydrozoa the mouth leads directly into the coelenteric cavity;
in the Anthozoa, however, the mouth leads into a short tube or
throat, called the "stomodaeum," which opens into the coelenteric
cavity. Moreover, this tube is connected with the body-wall, and is
supported by a series of fleshy vertical bands called the mesenteries
(Fig. 146). The mesenteries not only support the stomodaeum, but
extend some distance below it. Where the mesenteries are free from
the stomodaeum their edges are thickened to form the important
digestive organs known as the mesenteric filaments (mf). It is in the
possession of a stomodaeum, mesenteries, and mesenteric
filaments that the Anthozoa differ from all the other Coelenterata.
There is one character that the Anthozoa share with the Scyphozoa,
and that is, that the gonads or sexual cells (G) are derived from the
endoderm. They are discharged first into the coelenteric cavity, and
then by way of the mouth to the exterior. In the Anthozoa the gonads
are situated on the mesenteries.

Fig. 146.—Diagram of a vertical section through an Anthozoan zooid. B, Body-

wall; G, gonads; M, mesentery; mf, mesenteric filament; St, stomodaeum;
T, tentacle.

Nearly all the Anthozoa are sedentary in habit. They begin life as
ciliated free-swimming larvae, and then, in a few hours or days, they
become attached to some rock or shell at the bottom and
immediately (if colonial) start the process of budding, which gives
rise to the colonies of the adult stage. Many of the Sea-anemones,
however, move considerable distances by gliding over the rocks or
seaweeds, others habitually burrow in the sand (Edwardsia,
Cerianthus), and one family (the Minyadidae) are supported by a gas
bladder, and float at the surface of the sea. The Sea-pens, too,
although usually partly buried in the sand or mud, are capable of
shifting their position by alternate distension and contraction of the
stalk.[362] The Anthozoa are exclusively marine. With the exception
of a few Sea-anemones that are found in brackish or almost fresh
water in river estuaries, they only occur in salt sea water. The
presence of a considerable admixture of fresh water, such as we find
at the mouths of rivers, seems to interfere very materially with the
development and growth of all the reef-forming Corals, as will be
noticed again in the chapter on coral reefs. A few genera descend
into the greatest depths of the ocean, but the home of the Anthozoa
is pre-eminently the shallow seas, and they are usually found in
great abundance in depths of 0-40 fathoms from the shores of the
Arctic and Antarctic lands to the equatorial belt.

The only Anthozoa of any commercial importance are the Precious

Corals belonging to the Alcyonarian family Coralliidae. The hard pink
axis of these corals has been used extensively from remote times in
the manufacture of jewellery and ornaments. Until quite recently the
only considerable and systematic fishery for the Precious Corals was
carried on in the Mediterranean Sea, and this practically supplied the
markets of the world. In more recent times, however, an important
industry in corals has been developed in Japan. In 1901 the value of
the coral obtained on the coasts of Japan was over £50,000, the
greater part of which was exported to Italy, a smaller part to China,
and a fraction only retained for home consumption. The history of the
coral fishery in Japan is of considerable interest. Coral was
occasionally taken off the coast of Tsukinada in early times. But in
the time of the Daimyos the collection and sale of coral was
prohibited, for fear, it is said, that the Daimyo of Tosa might be
compelled to present such precious treasure to the Shogun. After the
Meiji reform, however (1868), the industry revived, new grounds
were discovered, improved methods employed, and a large export
trade developed.

There is evidence, however, in the art of Japan, of another coral

fishery in ancient times, of which the history is lost. Coral was
imported into Japan at least two hundred years ago, and used
largely in the manufacture of those exquisite pieces of handicraft for
which that country is so justly famous. On many of the carved