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CONSULTANT AND SPECIALIST
387
Was it necessary for Mr. Clarke, whose article appeared in your issue of Aug. 17, to take 3 radiographs of a patient to demonstrate what has clearly been indicated by the article by Ardran which he quotes? Was it not
unnecessary irradiation*! If the propaganda about the dangers of irradiation continues with its exaggerations we shall soon find it. difficult to get any workers in X-ray departments ; but if that leads to an improvement in clinical methods it could be claimed to have done a good service. The criticism which Dr. Thomas Addison made of the stethoscope can be much more truthfully applied to the X ray, as I have indicated.! JAMES F. BRAILSFORD.
to suicide only when alcohol intoxication fails to blot out the undesirable aspects of life.7 The relative frequency of suicidal attempts among alcoholics is easily understandable in the light of those hypotheses which regard social isolation 8 and the loss of the inner feeling of identity will) a recognised social grouping (" subjective excommunication ") 9 as highly important factors in the genesis of suicidal attempts. Such experiences must be very common and severe in the case of alcoholics, whose behaviour leads to " a progressive withdrawal from the social environment and to a system of isolation." 10
turning
"
to a recent American review of alcoholism and those who are psychopaths or depressives are more likely to try this way out."2 A third of Dr. Epps’s series of 24 alcoholics were " psychopathic." Among the W.P.H. alcoholics a history of suicidal attempts was relatively more common in psychopaths (33% of 86 men and women) than in nonpsychopaths (21% of 182 men and women), younger agegroups (21-40 years) predominating among the suicidal psychopathic alcoholics, older ones among the non-psycho-
‘
CONSULTANT AND SPECIALIST
SIR,-" Senior Registrar"
asks (Aug. 17) if the of Health has rejected any applications for the creation of a new consultant appointment. I can report two happenings at one teaching hospital. A special reference clinic was proposed. I was told I could have a room and a nurse but it would be no good asking to be paid for the extra session a month. (The need for such a clinic is shown by one having developed a waiting-list of 5 months, despite having 2 consultants and doing 2 or 3 sessions a month.) Two years ago the medical committee recommended a new consultant appointment for 4 sessions a week. After about a year the Ministry approved such an appointment but said they would make no extra allotment of moneys to pay him (which seems to me rathei
Ministry
According
suicide,
paths.
Of
dishonest behaviour). TEACHING-HOSPITAL CONSULTANT. WOMEN IN PRISON ON "ATTEMPTED SUICIDE " CHARGES SIR,—Dr. Epps (July 27) touches on the problems
presented by suicidal alcoholics. " " She found 24 chronic alcoholics among 100 women on This is a slightly higher pro"attempted suicide charges. portion than usually reported among suicidal women, where the percentage of alcoholics has been said to range between 3 and 12 (average 8) ;among suicidal men, alcoholics formed a proportion of between 25 and 40% (average 30).2 Figures also seem to vary a great deal if, instead of asking for the frequency of alcoholics among attempted suicides," one investigates the question of how many alcoholics have made suicidal attempts. Thus, in a large German study, of the alcoholics admitted to a university clinic, about 4% of the men and 4’5% of the women had attempted suicide.3 Figures in recent years in this country seem to show that suicidal attempts are not uncommon among alcoholics of all social classes. Thus, a quarter of the middle-class alcoholics (predominantly occupational groups i and II) seen at Warlingham Park Hospital had a history of suicidal attempts (24% of 200 men, 265% of 68 women). Among a series of 56 male and female alcoholics recently admitted to a London observation ward-the majority belonging to occupational groups III-V—12 (24%) had attempted suicide in the past.4 finally, among homeless men admitted to a London observation ward-mostly occupational groups iv and v-out of 40 in whom alcohol consumption had been excessive, 13 (33%) gave a history of suicidal attempts, as against only 11% among 90 men who had not been heavy drinkers. Of the 40 heavy drinkers, 15 were classified as alcoholics ;4 of them "
"
had attempted and 4 threatened suicide.5 Alcoholism is regarded by some as chronic suicide,"6 "
by
others
as an
" avoidance of suicide," the alcoholic
1. 2. 3. 4.
Radiography, June, 1957, p. 157. Conn. Rev. Alc. 1955, 7, 14. Graute, P. Allg. Z. Psychiat. 1939, 111, 47. Fleminger, J. J., Glatt, M. M. To be published. Mschr. Psychiat. Neurol. 1956, 5. Glatt, M. M., Whiteley, J. S. 132, 1. 6. Menninger, K. A. chapter 3.
Man Against Himself.
"
New York, 1938 ;
the suicidal women described by Dr. Epps, most had gone to a general hospital after their suicidal attempt but had stayed there for only a very short time. One reason for this, according to Dr. Epps, is that " some of them-usually the alcoholics and psychopaths-can be a nuisance to those around them, and may be unwelcome in both general and psychiatric wards." According to Dr. Epps the non-psychotic alcoholics In general seen by her " might or might not be treatable." it would probably be fair to say that at least some of the 10 psychoneurotic alcoholics in her series-seeing that the great majority were of at least average intelligence-should have some chance of improving under treatment, and that if treated in the setting of an alcoholic group within the hospital, these (neurotic) patients would not prove a nuisance. "
"
The problem of the treatment of alcoholic offenders is also touched upon in your annotation (July 27) on a report on some recent suggestions by the Advisory The council Council on the Treatment of Offenders. agreed that in the case of the " chronic alcoholics " their offence suggests that prison is prima facie unsuitable and useless " ; but it could see no alternative at present to imprisonment, though occasionally probation and residential treatment might be tried. The council reports that very few of the alcohol addicts seen in prisons are of suitable character and intelligence for psychotherapy. But occasionally a more intelligent type of alcoholic, responding to psychotherapy, must turn up in prisons, as is evident from the fact that more than a fifth of the W.P.H. alcoholics had been in prison (and another third before the courts) at some time before hospital admission. Anyhow, facilities for the residential treatment of alcoholics outside prisons are very scarce, and, where present, their permissiveness makes them not very suitable for the treatment of aggressive psychopathic alcoholics. As the council did not suggest any alternative to imprisonment, the question arises whether more could not be done for these people while in prison. The council reports that prisoners are allowed to make contact with Alcoholics Anonymous, but (in contrast to the United States) there are as yet apparently no A.A. prison groups in this country. A great number of the prison alcoholics must be psychopaths who may easily disrupt such a group 11 12 though it might be expected that the group " would be able to carry " a few psychopaths. It might, therefore, be more advisable to have the alcoholic prisoners " screened " by a psychiatrist and to create separate (and perhaps psychotherapeutic) groups for non"
Haggard, H. W., Jellinek, E. M. Alcohol Explored. New York, 1950 ; p. 162. 8. Sainsbury, P. Suicide in London. Maudsley Monographs No. 1. London, 1955. Brit. med. J. 1956, ii, 818. 9. Strauss, E. B. 10. Alcoholism subcommittee (2nd report). Wld Hlth Org. tech. Rep. Ser. 1952, 48, 34. 11. Slavson, S. R. (editor). The Fields of Group Psychotherapy. New York, 1956 ; chapter 1. 12. Pfeffer, A. Z., Friedland, P., Wortis, S. B. Quart. J. Stud. Alc. 1949, 10, 198. 7.
Was it necessary for Mr. Clarke, whose article appeared in your issue of Aug. 17, to take 3 radiographs of a patient to demonstrate what has clearly been indicated by the article by Ardran which he quotes? Was it not
unnecessary irradiation*! If the propaganda about the dangers of irradiation continues with its exaggerations we shall soon find it. difficult to get any workers in X-ray departments ; but if that leads to an improvement in clinical methods it could be claimed to have done a good service. The criticism which Dr. Thomas Addison made of the stethoscope can be much more truthfully applied to the X ray, as I have indicated.! JAMES F. BRAILSFORD.
to suicide only when alcohol intoxication fails to blot out the undesirable aspects of life.7 The relative frequency of suicidal attempts among alcoholics is easily understandable in the light of those hypotheses which regard social isolation 8 and the loss of the inner feeling of identity will) a recognised social grouping (" subjective excommunication ") 9 as highly important factors in the genesis of suicidal attempts. Such experiences must be very common and severe in the case of alcoholics, whose behaviour leads to " a progressive withdrawal from the social environment and to a system of isolation." 10
turning
"
to a recent American review of alcoholism and those who are psychopaths or depressives are more likely to try this way out."2 A third of Dr. Epps’s series of 24 alcoholics were " psychopathic." Among the W.P.H. alcoholics a history of suicidal attempts was relatively more common in psychopaths (33% of 86 men and women) than in nonpsychopaths (21% of 182 men and women), younger agegroups (21-40 years) predominating among the suicidal psychopathic alcoholics, older ones among the non-psycho-
‘
CONSULTANT AND SPECIALIST
SIR,-" Senior Registrar"
asks (Aug. 17) if the of Health has rejected any applications for the creation of a new consultant appointment. I can report two happenings at one teaching hospital. A special reference clinic was proposed. I was told I could have a room and a nurse but it would be no good asking to be paid for the extra session a month. (The need for such a clinic is shown by one having developed a waiting-list of 5 months, despite having 2 consultants and doing 2 or 3 sessions a month.) Two years ago the medical committee recommended a new consultant appointment for 4 sessions a week. After about a year the Ministry approved such an appointment but said they would make no extra allotment of moneys to pay him (which seems to me rathei
Ministry
According
suicide,
paths.
Of
dishonest behaviour). TEACHING-HOSPITAL CONSULTANT. WOMEN IN PRISON ON "ATTEMPTED SUICIDE " CHARGES SIR,—Dr. Epps (July 27) touches on the problems
presented by suicidal alcoholics. " " She found 24 chronic alcoholics among 100 women on This is a slightly higher pro"attempted suicide charges. portion than usually reported among suicidal women, where the percentage of alcoholics has been said to range between 3 and 12 (average 8) ;among suicidal men, alcoholics formed a proportion of between 25 and 40% (average 30).2 Figures also seem to vary a great deal if, instead of asking for the frequency of alcoholics among attempted suicides," one investigates the question of how many alcoholics have made suicidal attempts. Thus, in a large German study, of the alcoholics admitted to a university clinic, about 4% of the men and 4’5% of the women had attempted suicide.3 Figures in recent years in this country seem to show that suicidal attempts are not uncommon among alcoholics of all social classes. Thus, a quarter of the middle-class alcoholics (predominantly occupational groups i and II) seen at Warlingham Park Hospital had a history of suicidal attempts (24% of 200 men, 265% of 68 women). Among a series of 56 male and female alcoholics recently admitted to a London observation ward-the majority belonging to occupational groups III-V—12 (24%) had attempted suicide in the past.4 finally, among homeless men admitted to a London observation ward-mostly occupational groups iv and v-out of 40 in whom alcohol consumption had been excessive, 13 (33%) gave a history of suicidal attempts, as against only 11% among 90 men who had not been heavy drinkers. Of the 40 heavy drinkers, 15 were classified as alcoholics ;4 of them "
"
had attempted and 4 threatened suicide.5 Alcoholism is regarded by some as chronic suicide,"6 "
by
others
as an
" avoidance of suicide," the alcoholic
1. 2. 3. 4.
Radiography, June, 1957, p. 157. Conn. Rev. Alc. 1955, 7, 14. Graute, P. Allg. Z. Psychiat. 1939, 111, 47. Fleminger, J. J., Glatt, M. M. To be published. Mschr. Psychiat. Neurol. 1956, 5. Glatt, M. M., Whiteley, J. S. 132, 1. 6. Menninger, K. A. chapter 3.
Man Against Himself.
"
New York, 1938 ;
the suicidal women described by Dr. Epps, most had gone to a general hospital after their suicidal attempt but had stayed there for only a very short time. One reason for this, according to Dr. Epps, is that " some of them-usually the alcoholics and psychopaths-can be a nuisance to those around them, and may be unwelcome in both general and psychiatric wards." According to Dr. Epps the non-psychotic alcoholics In general seen by her " might or might not be treatable." it would probably be fair to say that at least some of the 10 psychoneurotic alcoholics in her series-seeing that the great majority were of at least average intelligence-should have some chance of improving under treatment, and that if treated in the setting of an alcoholic group within the hospital, these (neurotic) patients would not prove a nuisance. "
"
The problem of the treatment of alcoholic offenders is also touched upon in your annotation (July 27) on a report on some recent suggestions by the Advisory The council Council on the Treatment of Offenders. agreed that in the case of the " chronic alcoholics " their offence suggests that prison is prima facie unsuitable and useless " ; but it could see no alternative at present to imprisonment, though occasionally probation and residential treatment might be tried. The council reports that very few of the alcohol addicts seen in prisons are of suitable character and intelligence for psychotherapy. But occasionally a more intelligent type of alcoholic, responding to psychotherapy, must turn up in prisons, as is evident from the fact that more than a fifth of the W.P.H. alcoholics had been in prison (and another third before the courts) at some time before hospital admission. Anyhow, facilities for the residential treatment of alcoholics outside prisons are very scarce, and, where present, their permissiveness makes them not very suitable for the treatment of aggressive psychopathic alcoholics. As the council did not suggest any alternative to imprisonment, the question arises whether more could not be done for these people while in prison. The council reports that prisoners are allowed to make contact with Alcoholics Anonymous, but (in contrast to the United States) there are as yet apparently no A.A. prison groups in this country. A great number of the prison alcoholics must be psychopaths who may easily disrupt such a group 11 12 though it might be expected that the group " would be able to carry " a few psychopaths. It might, therefore, be more advisable to have the alcoholic prisoners " screened " by a psychiatrist and to create separate (and perhaps psychotherapeutic) groups for non"
Haggard, H. W., Jellinek, E. M. Alcohol Explored. New York, 1950 ; p. 162. 8. Sainsbury, P. Suicide in London. Maudsley Monographs No. 1. London, 1955. Brit. med. J. 1956, ii, 818. 9. Strauss, E. B. 10. Alcoholism subcommittee (2nd report). Wld Hlth Org. tech. Rep. Ser. 1952, 48, 34. 11. Slavson, S. R. (editor). The Fields of Group Psychotherapy. New York, 1956 ; chapter 1. 12. Pfeffer, A. Z., Friedland, P., Wortis, S. B. Quart. J. Stud. Alc. 1949, 10, 198. 7.