A Doctor's Journal
Revenge on Life
By MILES HOWARD
FOR the past two decades, and more especially since the war, the prevalence of self- destructive impulses. seems to have been rising. The number of deaths by suicide in England and Wales in 1956 was over 5,000, the highest ever recorded; the number of known attempts was about the same, and no doubt there are many that never reach the records. A colleague from one of the larger London hospitals wrote re- cently (Moya Woodside: BM!, August 16) on an analysis of some fifty patients admitted during 1957. Suicide is a topic which attracts study, and many papers on it have been published; but as the author of this latest one points out, most of them are studies of patients in the lower- income groups. What lies behind the moment of despair, the overdose of sleeping pills, among more prosperous people—this has been less often examined. Rather over one-third of. the series under review, however, were taken into the hospital's private wing, so there was some oppor- tunity to compare the 'background' of illness in these with the remainder.
Of the series as a whole, the majority were women—about 70 per cent.; two-thirds made use of an excessive dose of one of the barbiturate sedatives; and most were suffering from an illness in the psychiatric sphere. These three features would, I imagine, be found in any survey of attempts at suicide, whether in Stockholm or London, Edinburgh or St. Louis. Alcohol often tips the balance in the direction of doing some- thing rather than just thinking about it; since going on the bottle is more usually an evening pastime, more patients reach hospital at night. In contrast to patients who went into the general wards, those admitted to the private clinic had their main sources of stress inside them rather than outside, so to speak : there was more mental disturbance, and less domestic and social up- heaval. Being financially more secure, they were less exposed to the threats of poverty, un- employment and lack of a settled home. As a group, they were unstable, had a low stress- tolerance and a limited capacity for handling personal relations. Among those in the less prosperous two-thirds of the series, social isola- tion was a common finding: loneliness, life in digs, feeling lost and out of it.
The author comments on the present state of the law. Few patients who come to hospital appear to know it, but an attempt at suicide is of course a criminal offence. Of one series of 100 women sent to Holloway Prison for such attempts, seventy-five had gone straight to court from a general hospital. In my experience, the police take a humane view of the law, and seldom prefer a charge against one of these un- happy people if they are satisfied that the case is under medical supervision. Punitive measures have no place in dealing with patients like these, whose chief needs are for psychiatric care and emotional 'involvement' in a community of some kind.
The average stay of the ward patients was eleven days, much less than the usual length of stay of a patient in a medical ward. Many of them, in fact, had not taken enough drug, or done enough damage, to endanger life or health very seriously. Here the action had been less of a determined journey to death than a gesture of escape, an appeal for help or attention, a tem- porary dive into oblivion. But for all that it is still a symptom of illness, and can never be lightly dismissed. Taking an overdose of Mother's pills may be a stroke of revenge against Mother herself, but the trouble with such strokes is that now and again they kill the revenger. .
What do patients expect from their doctors? Here is an important question : most people have an image in their minds, more or less clearly defined, of the kind of man they wish their doctor to be, and some doctors at least have given thought to the expectations, expressed or unexpressed, which their patients have of them. A team from the Cornell Medical Centre, New York, set out to explore the views of fifty patients attending one of their clinics and inquire into their attitude and aims. (Modern Hospital, July, 1957.) Two-thirds of the series came to the clinic because they feared the existence of some serious disease; the three most often mentioned were tuberculosis, cancer and heart diseases. The rest were very vague on what their problem was: they wanted a 'check-up,' or thought they knew the diagnosis already and wanted treatment. On being asked what qualities they felt a doctor should have, half of them put kindness, under- standing and interest at the top of the list; a quar- ter wanted `results' and 'progress'; and only four (oddly enough) said the doctor should not be in a hurry.
However, when they were further asked what they did not like, 1 was intrigued to find that `No results or bad results' got most marks; 'unfriendly, heartless' came second. So the doctor can be heartless, provided he gets results! Another point, not unexpected, that emerged from this inquiry was that one patient in three ended up with no clear idea of what was wrong; of this, the authors very properly say that it calls for further study. Indeed it does. Was information about the illness not given? Or not understood? Or, perhaps, not asked for? Many ill people are in point of fact afraid to ask for the truth about their illness, lest the truth should turn out to be terrifying. One function of an effective doctor-patient re- lationship is to foster useful communication. Yet there are surprising gaps in our knowledge of what is conveyed, how much gets through and how much is blocked. I suspect that a good deal of the interchange, and maybe the crucial part of it, is non-verbal : not words at all, but sign, tone and gesture, mood, 'atmosphere,' k.hatever you like to call it.
In the States, the medical profession takes an active part in the classifying and assessment of new drugs, and a special committee of the American Medical Association reports regularly on its findings, and issues lists of drugs of proven value. There is even a committee on cosmetics, with two distinguished dermatologists; its com- ments on remedies for body odour and the con- trol of sweating was published lately (JAMA, June 28). It appears that most of the advertised anti-sweating remedies contain aluminium salts, which have very few unpleasant side effects. However, the same can't be said for the most recent innovation—salts of zirconium; both in Britain and in America unpleasant consequences of these have been reported.
Deodorant preparations are, in general, harm- less. Body odour is mostly the result of bacterial action on sweat, and a simple way of dealing with it is frequent washing. Remedies contain- ing aluminium salts owe their efficacy to reduc- tion in the output of sweat. Creams with an antibiotic (like penicillin) will also do the trick, but their cost—to the State or the individual—is of course much higher. Chlorophyll, much praised in former days, has not been shown to have any value as a deodorant.
Strix and Leslie Adrian are on holiday.
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