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THE GEOGRAPHY OF DEATH
635 many of them with other drugs prescribed by have signally failed to help their depressed which doctors, It would indeed be a pity if these drugs, which patients. the simple treatment of the sort so revolutionised have and recent of depressions anxiety states so often seen in their value minimised because too general practice, had much attention is being focused on very rare or even theoretical complications.
year,
too
Department of Psychological Medicine, St. Thomas’s Hospital, London, S.E.1.
WILLIAM SARGANT.
THE GEOGRAPHY OF DEATH
SIR,-Dr. Howe’s 1 map shows the distribution of
compared with the national average, and he lists the areas where the mortality in 1960 was especially high or especially low. These lists made me wonder to what extent mortality as high or low as that of 1960 was mortality
a
as
permanent feature of the
areas
listed.
The first thing which became apparent from a study of the basic data was that although the 1465 areas for which separate figures were given had an average population of 31,200, they varied widely in size. At one extreme was the county borough of Birmingham with a population of over a million and the county boroughs of Liverpool, Manchester, and Leeds, each with over half a million inhabitants. At the other extreme were six areas, all in Wales, with less than 1000 inhabitants, the smallest having 710. The measure of comparative mortality used was the ratio of the local death-rates (adjusted for age and sex-structure, &c.) to the national rate and I have called this the mortality ratio. There are two principal reasons for the mortality ratio in any year differing from unity: (1) the average mortality of the area over a long period being different from the national average, and (2) the yearly fluctuations from the long-term average of the area. The smaller the population of the area the larger can be the yearly fluctuations. Of the 25 areas where the mortality ratio for 1960 was 1-40 or more, only Nelson municipal borough (M.B.) with a population of 31,470 was larger than the average size of 31,200, whereas 13 areas had populations less than 4000; hence yearly fluctuations would be expected to be large in many of these areas. The mortality ratios for these 25 areas for the five years 1956 to 1960 show that only five areas had ratios greater than 1-40 in any of the four years before 1960. 14 areas had a ratio less than 1-00 for one or more of these years. The largest average of the five mortality ratios for the years 1956-1960 for an individual area was 1-59 for Betws-y-Coed urban district (U.D.) with a population of 740 in 1960; only two other areas had a five-year average mortality ratio of 1 -40 or more. But the average of the 13 mortality ratios for 1948-60 for Betws-y-Coed was 1-35. Thus, of the areas having mortality ratios of 1-40 or more in 1960 not more than two or three seem likely to have a long-term average mortality ratio greater than 1 -40. In 1960 there were 22 areas with a mortality ratio less than 0.70; the largest population among these areas was 18,180 (not much more than half the average size), but all the others had populations of less than 10,000, and 13 had less than 4000 inhabitants. Thus, yearly fluctuations would again be expected to be large in many of these areas. Of these 22 areas, 13 had ratios of less than 0-70 in one or more of the four preceding years 1956-59. 11 areas had ratios of 1-00 or more in at least one of the years 1956-59. The only five-year 1956-60 average mortality ratio less than 0.70 was 0-63 for Wallingford M.B. (Berkshire) (population 4380); but if the mortality ratios are averaged for the 13 years 1948-1960 the result is 1-06.
From the
larger that nearly
areas
foregoing figures and from a study of the with high and low mortality ratios, it appears all, if not all, areas in England and Wales have 1.
Howe, G. M. Lancet, 1963, i, 818.
long-term mortality ratios lying between
about 0-75 and for an individual and that most values 1-35, year which are outside this range are merely due to the yearly fluctuations about the long-term average and will be confined almost entirely to areas with less than about 10,000 inhabitants. In any study of mortality ratios for one year the considerable yearly fluctuations in the smaller areas must always be borne in mind. R. H. DAW.
SCIENCE AND PSYCHIATRY SIR,-Dr. Barton’s interesting Pointof View (Sept. 14) raises important issues, some of which I have touched on elsewhere. 12 In sorting out the complex phenomena of mental function, it is necessary to distinguish between history-taking and examination. In psychiatry, as in other psychological fields, such as the investigation of suspected offenders (although for different reasons), much of the history may have to be taken or at least checked from sources other than the patient. Moreover, a history of subjective symptoms, whether psychic (e.g., mood change) or somatic (e.g., pain or discomfort), must be distinguished from a history of objective signs-for instance, how long a lump or a tendency to weep may have been present. History-taking from the psychiatric patient himself then tends to become part of examination, and far from inspection and auscultation being of no use in assessing the mental state, they are in fact the main avenues available since such assessment depends upon " observation " of behaviour (i.e., inspection) and listening to the stream of talk (i.e., auscultation). Dr. Barton appears able to evaluate the extent of a patient’s credulity in this way, but says he cannot measure the degree of a patient’s depression, whereas he can probably do so as accurately as a surgeon can measure the degree of rigidity or guarding of the abdominal wallsBoth surgeon and psychiatrist rely upon their experience of the " feel " of the situation. The psycho-palpation implied here depends upon the psychiatrist’s wide experience of what people say and how they behave in certain circumstances, and when he puts considered questions to a patient and awaits replies he is in a sense using psycho-percussion, for he develops a special skill in knowing what sort of question to put and which area of the psyche to sound in this fashion. His constant practice with thousands of patients also enables him to predict, with as much precision as the surgeon before laparotomy, what pathology (although in his case of the psychological variety) he will find.4 Finally, animals with brains sufficiently similar to our own probably experience much the same sort of consciousness as we do.5 Tail-wagging and purring may, for example, therefore be as informative of subjective experience as (and incidentally no more objectively ridiculous than) laughter.
J. P. CRAWFORD. TRANQUILLISERS
IN PREGNANCY
SIR,-May I comment on your interesting editorial of July 20 on Genes, Drugs, and Diets, regarding the genetically determined variations revealed solely by the effects of drugs ? The rare published cases of foetal abnormality 67 possibly attributed to the use of certain psychotropic drugs, apart from thalidomide, may be accounted for by genetic variations in drug response. Conversely, considering the effect on the emotional development of the offspring of rats fed chlorpromazine, reserpine, &c.,8 9 1. Crawford, J. P. Practitioner, 1954, 173, 696. 2. Crawford, J. P. Lancet, 1962, i, 591. 3. Crawford, J. P. Postgrad. med. J. 1955, 31, 180. 4. Crawford, J. P. Guy’s Hosp. Gaz. 1953, 67, 400, 451. 5. Fox, H. M. The Personality of Animals. London, 1952. 6. Smithells, R. Lancet, 1962, i, 1270. 7. Schire, I. ibid. 1963, i, 174. 8. Werboff, J., Kesner, R. Nature, Lond. 1963, 197, 106. 9. Werboff, J., Havlena, J. Exp. Neurol. 1962, 6, 263.
year,
too
Department of Psychological Medicine, St. Thomas’s Hospital, London, S.E.1.
WILLIAM SARGANT.
THE GEOGRAPHY OF DEATH
SIR,-Dr. Howe’s 1 map shows the distribution of
compared with the national average, and he lists the areas where the mortality in 1960 was especially high or especially low. These lists made me wonder to what extent mortality as high or low as that of 1960 was mortality
a
as
permanent feature of the
areas
listed.
The first thing which became apparent from a study of the basic data was that although the 1465 areas for which separate figures were given had an average population of 31,200, they varied widely in size. At one extreme was the county borough of Birmingham with a population of over a million and the county boroughs of Liverpool, Manchester, and Leeds, each with over half a million inhabitants. At the other extreme were six areas, all in Wales, with less than 1000 inhabitants, the smallest having 710. The measure of comparative mortality used was the ratio of the local death-rates (adjusted for age and sex-structure, &c.) to the national rate and I have called this the mortality ratio. There are two principal reasons for the mortality ratio in any year differing from unity: (1) the average mortality of the area over a long period being different from the national average, and (2) the yearly fluctuations from the long-term average of the area. The smaller the population of the area the larger can be the yearly fluctuations. Of the 25 areas where the mortality ratio for 1960 was 1-40 or more, only Nelson municipal borough (M.B.) with a population of 31,470 was larger than the average size of 31,200, whereas 13 areas had populations less than 4000; hence yearly fluctuations would be expected to be large in many of these areas. The mortality ratios for these 25 areas for the five years 1956 to 1960 show that only five areas had ratios greater than 1-40 in any of the four years before 1960. 14 areas had a ratio less than 1-00 for one or more of these years. The largest average of the five mortality ratios for the years 1956-1960 for an individual area was 1-59 for Betws-y-Coed urban district (U.D.) with a population of 740 in 1960; only two other areas had a five-year average mortality ratio of 1 -40 or more. But the average of the 13 mortality ratios for 1948-60 for Betws-y-Coed was 1-35. Thus, of the areas having mortality ratios of 1-40 or more in 1960 not more than two or three seem likely to have a long-term average mortality ratio greater than 1 -40. In 1960 there were 22 areas with a mortality ratio less than 0.70; the largest population among these areas was 18,180 (not much more than half the average size), but all the others had populations of less than 10,000, and 13 had less than 4000 inhabitants. Thus, yearly fluctuations would again be expected to be large in many of these areas. Of these 22 areas, 13 had ratios of less than 0-70 in one or more of the four preceding years 1956-59. 11 areas had ratios of 1-00 or more in at least one of the years 1956-59. The only five-year 1956-60 average mortality ratio less than 0.70 was 0-63 for Wallingford M.B. (Berkshire) (population 4380); but if the mortality ratios are averaged for the 13 years 1948-1960 the result is 1-06.
From the
larger that nearly
areas
foregoing figures and from a study of the with high and low mortality ratios, it appears all, if not all, areas in England and Wales have 1.
Howe, G. M. Lancet, 1963, i, 818.
long-term mortality ratios lying between
about 0-75 and for an individual and that most values 1-35, year which are outside this range are merely due to the yearly fluctuations about the long-term average and will be confined almost entirely to areas with less than about 10,000 inhabitants. In any study of mortality ratios for one year the considerable yearly fluctuations in the smaller areas must always be borne in mind. R. H. DAW.
SCIENCE AND PSYCHIATRY SIR,-Dr. Barton’s interesting Pointof View (Sept. 14) raises important issues, some of which I have touched on elsewhere. 12 In sorting out the complex phenomena of mental function, it is necessary to distinguish between history-taking and examination. In psychiatry, as in other psychological fields, such as the investigation of suspected offenders (although for different reasons), much of the history may have to be taken or at least checked from sources other than the patient. Moreover, a history of subjective symptoms, whether psychic (e.g., mood change) or somatic (e.g., pain or discomfort), must be distinguished from a history of objective signs-for instance, how long a lump or a tendency to weep may have been present. History-taking from the psychiatric patient himself then tends to become part of examination, and far from inspection and auscultation being of no use in assessing the mental state, they are in fact the main avenues available since such assessment depends upon " observation " of behaviour (i.e., inspection) and listening to the stream of talk (i.e., auscultation). Dr. Barton appears able to evaluate the extent of a patient’s credulity in this way, but says he cannot measure the degree of a patient’s depression, whereas he can probably do so as accurately as a surgeon can measure the degree of rigidity or guarding of the abdominal wallsBoth surgeon and psychiatrist rely upon their experience of the " feel " of the situation. The psycho-palpation implied here depends upon the psychiatrist’s wide experience of what people say and how they behave in certain circumstances, and when he puts considered questions to a patient and awaits replies he is in a sense using psycho-percussion, for he develops a special skill in knowing what sort of question to put and which area of the psyche to sound in this fashion. His constant practice with thousands of patients also enables him to predict, with as much precision as the surgeon before laparotomy, what pathology (although in his case of the psychological variety) he will find.4 Finally, animals with brains sufficiently similar to our own probably experience much the same sort of consciousness as we do.5 Tail-wagging and purring may, for example, therefore be as informative of subjective experience as (and incidentally no more objectively ridiculous than) laughter.
J. P. CRAWFORD. TRANQUILLISERS
IN PREGNANCY
SIR,-May I comment on your interesting editorial of July 20 on Genes, Drugs, and Diets, regarding the genetically determined variations revealed solely by the effects of drugs ? The rare published cases of foetal abnormality 67 possibly attributed to the use of certain psychotropic drugs, apart from thalidomide, may be accounted for by genetic variations in drug response. Conversely, considering the effect on the emotional development of the offspring of rats fed chlorpromazine, reserpine, &c.,8 9 1. Crawford, J. P. Practitioner, 1954, 173, 696. 2. Crawford, J. P. Lancet, 1962, i, 591. 3. Crawford, J. P. Postgrad. med. J. 1955, 31, 180. 4. Crawford, J. P. Guy’s Hosp. Gaz. 1953, 67, 400, 451. 5. Fox, H. M. The Personality of Animals. London, 1952. 6. Smithells, R. Lancet, 1962, i, 1270. 7. Schire, I. ibid. 1963, i, 174. 8. Werboff, J., Kesner, R. Nature, Lond. 1963, 197, 106. 9. Werboff, J., Havlena, J. Exp. Neurol. 1962, 6, 263.