609
SiR,—Ifind it very hard
to
believe that the symptoms
com-
by the industrial workers reported on by Dr McGuire (Feb. 18, p. 376) can be ascribed to psychological causes, especially since there was visible evidence of dermatitis. Was any attempt made to discover if a new toilet product (e.g.,
plained
of
soap) had been introduced in the factory or the locality?I have seen several patients during the past two years with severe symptoms, including blepharitis, weeping eczema, and extensive bullous eruptions, following the use of a well-known "bactericidal" soap which had been on special offer in local supermarkets. Was there any attempt to patch test the workers concerned against sensitising products which might be incorporated in a soap of this type? Basildon Hospital, Basildon, Essex SS16 5NL
***This letter has been shown lows.-ED. L.
ELIZABETH G. DOWSETT
to
Dr
Maguire,
whose
reply fol-
SiR,-Dr Dowsett states that there was visible evidence of dermatitis in the incidents I described. The term contact eczema is preferable to dermatitis, a term which has no meaning. There was no evidence of a contact eczema either of the contact hypersensitivity type or of the contact acute irritant variety in any of the persons involved. In the first epidemic the two male outdoor workers each had a winter eczema of the hands of ,two or three days’ duration, due to the prevailing east wind. The woman at the centre of this epidemic had cholinergic urticaria with subsequent impe-
tigo contagiosa. In the second epidemic one of the two central figures was a woman, without any visible evidence of contact hypersensitivity or irritant eczema, who nevertheless was later found to have a true hypersensitivity to aniline dye when patch tested. In all probability, however, each time she dyed her hair she would have suffered from subjective irritation and possibly eczematous vesiculation, certainly of the scalp. The man had a chronic non-specific blepharitis of many years’ duration. There was no evidence of eczema of any description amongst the others--merely transient erythema with subjective irri-
tation, also ephemeral. The possibility disposed of at the
that soap might explain the incidents outset since there was no evidence of a
was
true
contact irritant eczema.
The value of patch testing in dermatological diagnosis is illustrated by the correct diagnosis of subjective irritation in the woman at the centre of the second epidemic. Non-dermatological physicians may find it difficult to accept psychological aetiology in the pathogenesis of skin disorders, but the dermatologist’s experience will allow him to segregate the organic from the non-organic. As soon as the cause was explained both epidemics stopped immediately. This was observed by everyone involved, notably the -workers themselves. Psychic contagion is real enough and it carries danger for the individual. The clinician, by being aware of the possibility, retains objectivity and does not thus fall with his patients into participation mystique. 17 Wellington Street, St Johns, Blackburn BB1 8AF
ANNE MAGUIRE
SiR,-Dr Maguire attributes industrial epidemics of rashes individuals with organic disease influencing their colleagues by psychic contagion. Other epidemics attributed to hysteria include abdominal pain in a brass band and fainting at school.
to
I wish
to
add
a
further report and suggest
explanation.2 1. Smith, H. C., Eastham, E. J. Lancet, 1973, ii, 956. 2. Hocking, B. Papua New Guinea med. J. 1976, 19, 79.
an
workers, constructing a hydroelectric scheme in the Highlands of Papua New Guinea, and their families were served by one aid post. In May, 1974, after a motorcar accident, a Korean employee was beaten by local villagers and 514
PSYCHIC POSSESSION OR SOAP SENSITIVITY?
alternative
died. This resulted in much fear in this isolated community. Weekly attendances at the aid post had averaged 216 (range 151-242) but in the week after the accident attendances rose 40% above average, to 307, and then returned to normal. The increase in attendances was associated with no particular diagnosis or racial group. Such an epidemic can be explained in at least two ways which are not mutually exclusive. The first is the psychosomatic one (akin to hysteria) whereby, in reaction to stress, neurological and endocrine pathways produce symptoms. The second explanation is a mixed epidemiological and sociological one Household surveys suggest that many people have symptoms which they cope with by themselves. However, given a range of social pressures, such as Mechanic3 has described, help is sought for socially "acceptable" symptoms by adoption of a "sick role" which obtains for the person social privilege and sympathy as well as possible relief of symptoms. An analogy can be made using the iceberg of disease in the community concept. The psychosomatic explanation suggests that the iceberg gets bigger whereas the sociological explanation suggests the density of the surrounding water changes so the iceberg rises. The outbreak of abdominal pain in a brass band is probably an example of the psychosomatic mechanism but Maguire’s and the Papua New Guinea epidemic may have had more mixed causes. Detailed examination of such epidemics may yield useful information about the reasons people use and "abuse" health services. Telecom Australia, Melbourne, Victoria 3000, Australia
B. HOCKING
SiR,—The syndrome Dr Maguire describes is well known doctors
to
in industry; fortunately the symptoms are usually mild. Some years ago I was summoned because ten women had collapsed at work. They had been under considerable stress, and when I went to the works surgery they were lying on improvised couches, on the floor, sitting in chairs, twitching and weeping. There was little doubt about the psychogenic nature of the illness. The problem on these occasions is to identify the "group leader", and this may be far from obvious. In this instance the group leader was not affected by the illness; she was present in the room and overoccupied with caring for the others. Once she had been identified and separated the other women could be dealt with. 18 months later, in the same department, we had an outbreak of vandalism in the toilets. It could only have been done by an employee. On my advice the management announced that there would be no punishment to any individual concerned, but that on a certain day and between a certain period of hours it would be possible for the employee to consult me in strictest confidence without an appointment, the day and the hours being selected so that the employee could attend without being noticed to be absent from work. On that day a patient presented with mild tinea pedis. She was the woman I had identified as being group leader on the previous occasion. We had a long discussion about her feet and moved from that to certain personal marital problems. The vandalism was only briefly mentioned, but there was no further damage. More usually these syndromes are less dramatic--outbreaks of headache and eye strain. They are more common in female employees but do occur among men, especially if there has been some disaster, such as a fatal or otherwise severe heartattack in a fellow worker. Often, as in the cases mentioned by Maguire, the group leader may have a physical illness. We had an outbreak of "influenza and headaches" which was provoked by ventilation of the room; the supervisor insisted that
working
3. Mechanic, D. Medical Sociology. New York, 1968.
610 it
hot and she turned down the heat and the windows in winter. Later she had short-term absences from work and was treated for psychoneurosis and anxiety state. 6-9 months later thyrotoxicosis was diagnosed, after treatment for which her personality problems cleared up, and so did those in her department. In dealing with these disturbances an occupational health nurse is valuable if she can establish a good relationship with the employees. As Maguire noted, those affected are reluctant to consult a doctor; they are much more likely to consult a nurse. Maguire states that the employees did not make use of the factory’s own ambulance room; this suggests that the occupational health services in the factory were inadequate. The occupational health nurse must not stay in the ambulance room all the time but must make herself seen and known round the factory or department. Most of my consultations take place in the corridor or in the car park, and the same’ applies to the occupational health nurse. was
intolerably
opened
East Midlands Gas, Leicester LE1 9DB
A. R.
BUCKLEY,
Chairman, British Gas Medical Officers’ Committee
ACCIDENTS TO CHILDREN
SIR,-Professor Brown and Susan Davidson (Feb. 18,
p.
show that the risk of accidents to children is associated with the mother’s psychiatric disorder and social difficulties in the home. These associations are similar to those in primary schoolchildren who have difficulty in reading.’ Both accidents and backward reading may thus be indices of a family’s social pathology and psychopathology. Brown and Davidson also show that accidents are associated with threatening life-events. Other life-events, not normally regarded as threatening may also lead to disorder in the child, as with maternal pregnancy and onset enuresis.2 It would be interesting to know whether there is a similar association with accidents.
378)
27, Halfway Street, Sidcup, Kent, DA15 8LQ
E. TUCKMAN
IF I WERE A DEAN
SiR,-Dr Smith clearly has a high regard for the work of Liam Hudson, and to judge from his latest epistle (Feb. 18, p. 395) he accepts it without question. It was, I believe, not Hudson but Guilford3 who in 1950 first used the expressions "convergent" and "divergent," but these are concepts which are still by no means universally accepted by psychologists. The subject was critically reviewed by Heim4 who noted, by way of example, that Hudson had decided that for his purpose classics was a science but that chemistry and biology were nonsciences. It seems to me we may be in danger of erecting an edifice of dogma on unsubstantial ground. University Health Service, The University of Newcastle upon Tyne Newcastle Upon Tyne NE1 7RU
GRAHAM GRANT
SIR,—Most students accepted by medical schools are young, and their A levels are gained after many years of study and preparation. Their education is usually free, they have no domestic commitments, and they have parents to provide a home, and all that goes with it, and finance for books, equipment, and leisure. I would agree with Dr Barley (Feb. 11, p. 320) that for such students the setting of educational stan1. Tuckman, E. Proc. R. Soc. Med. 1965, 58, 234. 2. Paulett, J. D., Tuckman, E. Br. med. J. 1958, i, 1266. 3. Guilford, J. P. Am. Psychol. 1950, 5, 444. 4. Heim, A. Intelligence and Personality; p. 37. Harmondsworth, 1970.
dards followed by the random choice of names of successful applicants is a fair system. For other candidates the system is inadequate and unfair. What of those with only one parent or no parents to provide for them? There are bound to be financial problems. And what of the mature student, a recurring theme in your series If I were a Dean? Is the application from a 30-year-old to be dismissed because he is 12 years too late? I am a bus driver, now aged 31. My desire to become a doctor has spanned most of my thinking life. Some boys want to be engine drivers and some soldiers; I wanted to be a doctor. I was brought up with two brothers in a one-parent family on National Assistance, and received only a basic secondary education. In January, 1970,left my job as a bus driver and enrolled in an 0 level G.C.E. course. I had one specific aim. My local education authority would not give me a grant, and our only income was from my wife, who has supported us both and financed the fees and materials for seven 0 levels and four A levels. The course ran for 2 years and I had missed the first 3 months’ study. Yet after only a year I obtained 0 level passes in chemistry, physics, and English language. I was well on the way to becoming a doctor. My vacations were spent as a porter in the local accident hospital and, later, as an attendant in the operating-theatre of the eye hospitaldiathermy, cryoscopy, strabismus corrections, rhinostomies, a cyclectomy for suspected right melanoma, and laser therapy, and that unique euphoria and warm satisfaction found in help-
ing and caring for people. Unable to afford the rent on our modern council flat we moved into two rooms as the downstairs neighbours of a burglar. I had to take part-time jobs and for 3 months I went back to full-time employment as a bus driver, the shift system permitting me to attend college for a few hours each day. In a state of near poverty I was studying for four A levels (physics, chemistry, and biology over 2 years, and an intensive 1-year course in geology). In June, 1972,passed A level geology with a C grade.. The final year was chaotic. My wife and I were depressed and very, very tired. The gas was cut off--so was the electricity. We heated meals on a camping stove and went to bed when it was too dark to see. I made tentative inquiries of several medical schools, setting out my history, experience, and qualifications, and I was disappointed with the replies. Two London teaching hospitals said that since they received many thousands of applications from well-qualified 18-year-olds they did not envisage my application being successful. I applied, via U.C.C.A., to five medical schools, writing separately to each to explain my financial stress and the effect that this could have on my examination results. I received a conditional offer from only one (Liverpool) specifying grades B,B,C, and the month of June rushed headlong at me. Nothing could be done to alleviate our financial circumstances. I persevered with my studies as best I could and
hoped. shocked when I received the results-a D in chemisE in biology, and complimentary 0 level in physics. try, The battle had been lost. I (we) did all this to achieve one goal. It was the most important thing in our lives. We sold personal effects and furniture. Our health, both physical and mental, suffered. I would have taken the examinations again-if it had been possible. Medicine, surgery, and obstetrics still influence me. The Lancet, Samson Wright’s Applied Physiology, Gray’s Anatomy, and many other medical textbooks occupy some of my time. I still have the yearning and the will. I still have the capability. Most importantly, I believe that I have shown that I have the makings of a good doctor. Some would diagnose obsessional neurosis, for which E.C.T. may prove beneficial. I would diagnose "passionate keenness" for which 5 or 6 years in a medical school is not contraindicated. Any offers? I
was
an
7 Station Terrace,
Washington, Tyne
&
Wear NE37
3AJ
JOSEPH EDWIN DODDS
SiR,—Ifind it very hard
to
believe that the symptoms
com-
by the industrial workers reported on by Dr McGuire (Feb. 18, p. 376) can be ascribed to psychological causes, especially since there was visible evidence of dermatitis. Was any attempt made to discover if a new toilet product (e.g.,
plained
of
soap) had been introduced in the factory or the locality?I have seen several patients during the past two years with severe symptoms, including blepharitis, weeping eczema, and extensive bullous eruptions, following the use of a well-known "bactericidal" soap which had been on special offer in local supermarkets. Was there any attempt to patch test the workers concerned against sensitising products which might be incorporated in a soap of this type? Basildon Hospital, Basildon, Essex SS16 5NL
***This letter has been shown lows.-ED. L.
ELIZABETH G. DOWSETT
to
Dr
Maguire,
whose
reply fol-
SiR,-Dr Dowsett states that there was visible evidence of dermatitis in the incidents I described. The term contact eczema is preferable to dermatitis, a term which has no meaning. There was no evidence of a contact eczema either of the contact hypersensitivity type or of the contact acute irritant variety in any of the persons involved. In the first epidemic the two male outdoor workers each had a winter eczema of the hands of ,two or three days’ duration, due to the prevailing east wind. The woman at the centre of this epidemic had cholinergic urticaria with subsequent impe-
tigo contagiosa. In the second epidemic one of the two central figures was a woman, without any visible evidence of contact hypersensitivity or irritant eczema, who nevertheless was later found to have a true hypersensitivity to aniline dye when patch tested. In all probability, however, each time she dyed her hair she would have suffered from subjective irritation and possibly eczematous vesiculation, certainly of the scalp. The man had a chronic non-specific blepharitis of many years’ duration. There was no evidence of eczema of any description amongst the others--merely transient erythema with subjective irri-
tation, also ephemeral. The possibility disposed of at the
that soap might explain the incidents outset since there was no evidence of a
was
true
contact irritant eczema.
The value of patch testing in dermatological diagnosis is illustrated by the correct diagnosis of subjective irritation in the woman at the centre of the second epidemic. Non-dermatological physicians may find it difficult to accept psychological aetiology in the pathogenesis of skin disorders, but the dermatologist’s experience will allow him to segregate the organic from the non-organic. As soon as the cause was explained both epidemics stopped immediately. This was observed by everyone involved, notably the -workers themselves. Psychic contagion is real enough and it carries danger for the individual. The clinician, by being aware of the possibility, retains objectivity and does not thus fall with his patients into participation mystique. 17 Wellington Street, St Johns, Blackburn BB1 8AF
ANNE MAGUIRE
SiR,-Dr Maguire attributes industrial epidemics of rashes individuals with organic disease influencing their colleagues by psychic contagion. Other epidemics attributed to hysteria include abdominal pain in a brass band and fainting at school.
to
I wish
to
add
a
further report and suggest
explanation.2 1. Smith, H. C., Eastham, E. J. Lancet, 1973, ii, 956. 2. Hocking, B. Papua New Guinea med. J. 1976, 19, 79.
an
workers, constructing a hydroelectric scheme in the Highlands of Papua New Guinea, and their families were served by one aid post. In May, 1974, after a motorcar accident, a Korean employee was beaten by local villagers and 514
PSYCHIC POSSESSION OR SOAP SENSITIVITY?
alternative
died. This resulted in much fear in this isolated community. Weekly attendances at the aid post had averaged 216 (range 151-242) but in the week after the accident attendances rose 40% above average, to 307, and then returned to normal. The increase in attendances was associated with no particular diagnosis or racial group. Such an epidemic can be explained in at least two ways which are not mutually exclusive. The first is the psychosomatic one (akin to hysteria) whereby, in reaction to stress, neurological and endocrine pathways produce symptoms. The second explanation is a mixed epidemiological and sociological one Household surveys suggest that many people have symptoms which they cope with by themselves. However, given a range of social pressures, such as Mechanic3 has described, help is sought for socially "acceptable" symptoms by adoption of a "sick role" which obtains for the person social privilege and sympathy as well as possible relief of symptoms. An analogy can be made using the iceberg of disease in the community concept. The psychosomatic explanation suggests that the iceberg gets bigger whereas the sociological explanation suggests the density of the surrounding water changes so the iceberg rises. The outbreak of abdominal pain in a brass band is probably an example of the psychosomatic mechanism but Maguire’s and the Papua New Guinea epidemic may have had more mixed causes. Detailed examination of such epidemics may yield useful information about the reasons people use and "abuse" health services. Telecom Australia, Melbourne, Victoria 3000, Australia
B. HOCKING
SiR,—The syndrome Dr Maguire describes is well known doctors
to
in industry; fortunately the symptoms are usually mild. Some years ago I was summoned because ten women had collapsed at work. They had been under considerable stress, and when I went to the works surgery they were lying on improvised couches, on the floor, sitting in chairs, twitching and weeping. There was little doubt about the psychogenic nature of the illness. The problem on these occasions is to identify the "group leader", and this may be far from obvious. In this instance the group leader was not affected by the illness; she was present in the room and overoccupied with caring for the others. Once she had been identified and separated the other women could be dealt with. 18 months later, in the same department, we had an outbreak of vandalism in the toilets. It could only have been done by an employee. On my advice the management announced that there would be no punishment to any individual concerned, but that on a certain day and between a certain period of hours it would be possible for the employee to consult me in strictest confidence without an appointment, the day and the hours being selected so that the employee could attend without being noticed to be absent from work. On that day a patient presented with mild tinea pedis. She was the woman I had identified as being group leader on the previous occasion. We had a long discussion about her feet and moved from that to certain personal marital problems. The vandalism was only briefly mentioned, but there was no further damage. More usually these syndromes are less dramatic--outbreaks of headache and eye strain. They are more common in female employees but do occur among men, especially if there has been some disaster, such as a fatal or otherwise severe heartattack in a fellow worker. Often, as in the cases mentioned by Maguire, the group leader may have a physical illness. We had an outbreak of "influenza and headaches" which was provoked by ventilation of the room; the supervisor insisted that
working
3. Mechanic, D. Medical Sociology. New York, 1968.
610 it
hot and she turned down the heat and the windows in winter. Later she had short-term absences from work and was treated for psychoneurosis and anxiety state. 6-9 months later thyrotoxicosis was diagnosed, after treatment for which her personality problems cleared up, and so did those in her department. In dealing with these disturbances an occupational health nurse is valuable if she can establish a good relationship with the employees. As Maguire noted, those affected are reluctant to consult a doctor; they are much more likely to consult a nurse. Maguire states that the employees did not make use of the factory’s own ambulance room; this suggests that the occupational health services in the factory were inadequate. The occupational health nurse must not stay in the ambulance room all the time but must make herself seen and known round the factory or department. Most of my consultations take place in the corridor or in the car park, and the same’ applies to the occupational health nurse. was
intolerably
opened
East Midlands Gas, Leicester LE1 9DB
A. R.
BUCKLEY,
Chairman, British Gas Medical Officers’ Committee
ACCIDENTS TO CHILDREN
SIR,-Professor Brown and Susan Davidson (Feb. 18,
p.
show that the risk of accidents to children is associated with the mother’s psychiatric disorder and social difficulties in the home. These associations are similar to those in primary schoolchildren who have difficulty in reading.’ Both accidents and backward reading may thus be indices of a family’s social pathology and psychopathology. Brown and Davidson also show that accidents are associated with threatening life-events. Other life-events, not normally regarded as threatening may also lead to disorder in the child, as with maternal pregnancy and onset enuresis.2 It would be interesting to know whether there is a similar association with accidents.
378)
27, Halfway Street, Sidcup, Kent, DA15 8LQ
E. TUCKMAN
IF I WERE A DEAN
SiR,-Dr Smith clearly has a high regard for the work of Liam Hudson, and to judge from his latest epistle (Feb. 18, p. 395) he accepts it without question. It was, I believe, not Hudson but Guilford3 who in 1950 first used the expressions "convergent" and "divergent," but these are concepts which are still by no means universally accepted by psychologists. The subject was critically reviewed by Heim4 who noted, by way of example, that Hudson had decided that for his purpose classics was a science but that chemistry and biology were nonsciences. It seems to me we may be in danger of erecting an edifice of dogma on unsubstantial ground. University Health Service, The University of Newcastle upon Tyne Newcastle Upon Tyne NE1 7RU
GRAHAM GRANT
SIR,—Most students accepted by medical schools are young, and their A levels are gained after many years of study and preparation. Their education is usually free, they have no domestic commitments, and they have parents to provide a home, and all that goes with it, and finance for books, equipment, and leisure. I would agree with Dr Barley (Feb. 11, p. 320) that for such students the setting of educational stan1. Tuckman, E. Proc. R. Soc. Med. 1965, 58, 234. 2. Paulett, J. D., Tuckman, E. Br. med. J. 1958, i, 1266. 3. Guilford, J. P. Am. Psychol. 1950, 5, 444. 4. Heim, A. Intelligence and Personality; p. 37. Harmondsworth, 1970.
dards followed by the random choice of names of successful applicants is a fair system. For other candidates the system is inadequate and unfair. What of those with only one parent or no parents to provide for them? There are bound to be financial problems. And what of the mature student, a recurring theme in your series If I were a Dean? Is the application from a 30-year-old to be dismissed because he is 12 years too late? I am a bus driver, now aged 31. My desire to become a doctor has spanned most of my thinking life. Some boys want to be engine drivers and some soldiers; I wanted to be a doctor. I was brought up with two brothers in a one-parent family on National Assistance, and received only a basic secondary education. In January, 1970,left my job as a bus driver and enrolled in an 0 level G.C.E. course. I had one specific aim. My local education authority would not give me a grant, and our only income was from my wife, who has supported us both and financed the fees and materials for seven 0 levels and four A levels. The course ran for 2 years and I had missed the first 3 months’ study. Yet after only a year I obtained 0 level passes in chemistry, physics, and English language. I was well on the way to becoming a doctor. My vacations were spent as a porter in the local accident hospital and, later, as an attendant in the operating-theatre of the eye hospitaldiathermy, cryoscopy, strabismus corrections, rhinostomies, a cyclectomy for suspected right melanoma, and laser therapy, and that unique euphoria and warm satisfaction found in help-
ing and caring for people. Unable to afford the rent on our modern council flat we moved into two rooms as the downstairs neighbours of a burglar. I had to take part-time jobs and for 3 months I went back to full-time employment as a bus driver, the shift system permitting me to attend college for a few hours each day. In a state of near poverty I was studying for four A levels (physics, chemistry, and biology over 2 years, and an intensive 1-year course in geology). In June, 1972,passed A level geology with a C grade.. The final year was chaotic. My wife and I were depressed and very, very tired. The gas was cut off--so was the electricity. We heated meals on a camping stove and went to bed when it was too dark to see. I made tentative inquiries of several medical schools, setting out my history, experience, and qualifications, and I was disappointed with the replies. Two London teaching hospitals said that since they received many thousands of applications from well-qualified 18-year-olds they did not envisage my application being successful. I applied, via U.C.C.A., to five medical schools, writing separately to each to explain my financial stress and the effect that this could have on my examination results. I received a conditional offer from only one (Liverpool) specifying grades B,B,C, and the month of June rushed headlong at me. Nothing could be done to alleviate our financial circumstances. I persevered with my studies as best I could and
hoped. shocked when I received the results-a D in chemisE in biology, and complimentary 0 level in physics. try, The battle had been lost. I (we) did all this to achieve one goal. It was the most important thing in our lives. We sold personal effects and furniture. Our health, both physical and mental, suffered. I would have taken the examinations again-if it had been possible. Medicine, surgery, and obstetrics still influence me. The Lancet, Samson Wright’s Applied Physiology, Gray’s Anatomy, and many other medical textbooks occupy some of my time. I still have the yearning and the will. I still have the capability. Most importantly, I believe that I have shown that I have the makings of a good doctor. Some would diagnose obsessional neurosis, for which E.C.T. may prove beneficial. I would diagnose "passionate keenness" for which 5 or 6 years in a medical school is not contraindicated. Any offers? I
was
an
7 Station Terrace,
Washington, Tyne
&
Wear NE37
3AJ
JOSEPH EDWIN DODDS
