A Doctor's Journal
Cultural Shock
By MILES HOWARD How does anyone who wants to keep track of advances in the various 'sectors' of medicine contrive to do it, along with an ordinary job? I haven't solved that one, and I wonder sometimes if there is a solution. Reading? A diligent man may read, say, three abstracting journals, and a selec- tion of the rest, and still miss important and valuable papers. Meetings? Many are dull and worth while only for the contacts with co-workers at the bar, before and after. Some medical Life- men, I notice, are seen at the bar, deep in talk, until the meeting is due to begin, and then vanish.
was reminded of this problem at lunch the other day with a comrade working in industry. He chanced to have with him a copy of industry and Tropical Health, Vol. III—from the Harvard School of Public Health. I asked to borrow it, and glanced through some of the papers in the Tube coming home. Here was a publication I would never have seen, perhaps even heard of, but for this encounter. There was a study of 'cultural shock' in Americans abroad, by Dr. Theodore Allen, which so held me that I read it right through—and that doesn't happen often.
The central symptom of this malady is a rejection, total or partial, of the new environment to which the temporary exile must adjust. John Doe feels bad, and so the new place must be to blame. At once, 'home in America' becomes unduly glorified, a Utopia with no faults; and Ruritania becomes a rat-hole : the food's lousy, the water dirty, the people dangerous. John falls to grousing, has fits of temper, complains about delay in the mails and about his own health— he goes sick with all kinds of minor illness, that betoken to him incurable disease, since they appeared 'just before I got to this damn place.' More grave than these is the symptom of hostility towards the Ruritanians, their customs, ways and culture. All John's discomforts then get much worse--due, as he thinks, to the country : he retreats to his own group, all American and doing American things, looking back to the mother country. This (says Dr. Allen) is a critical stage of the illness. Many victims admit defeat and go home; some stay longer, and then crack. Those who stay on, if they learn the language, can do well. With even a little direct communication, John begins to relax; he feels easier. He finds he can joke about things with the natives, and even joke about America with them—once that comes, he is 'over the hump.'
Much of Dr. Allen's thesis could be applied to us—the form of the illness differing, perhaps, but its nucleus the same. What proportion, I wonder, of 'breakdowns' abroad are essentially caused by 'shock symptoms' in the wife and not in the man himself? I imagine that some kind of preparation of Mrs. Doe for foreign service would be both a kindness to her and a prophylactic measure for the welfare of the husband-wife unit. Of course, Dr. Allen is right—communication is the key—and not only in Ruritania : how often, here in Britain. does one observe doctor and patient not 'speaking the same language'! The patient is trying to convey what is troubling him; the doctor pursues an image (in his mind) of an 'organic' disease he thinks the patient may have—and it is as though the two were marching in opposite directions; they make no contact at
all—the ill person goes away uncomforted, and the doctor sits back frustrated and perplexed. High time, then, for a new set of words and, indeed, of concepts and ways of thinking.
Odd how some men—and a few doctors—dis- like the notion of a biological rhythm in men. I wonder why?—after all, if it exists (as I'm sure it does) it's simply a fact of life and no blame to anyone.
Lately I saw X, who was much troubled by fatigue : he felt droopy, couldn't get through his work, and had to sit down; he had lost his zest and drive, and felt miserable about it. As he described it. fatigue was the central thing—but it was by no means the only symptom : when one came to add up, there were nine principal features of the illness, including a disturbance of sleep of the kind common in depressive states. In short, he was in the early phase of a depressive illness. He had cause to worry—a son was wayward and defiant, had been checked by the police—but this wasn't new: the lad had been a 'problem child' from the earliest days. Indeed, the pattern of X's life—so far as I could see —hadn't altered sig- nificantly for a number of years. The only change was the change of time—he was fifty-one. I con- cluded that this was a menopausal depression, and put that to him forthwith.
He wasn't put out—he didn't much mind what diagnosis I arrived at, so long as I could suggest a remedy. So I drew up a regime, with several constituents that had proved useful in similar cases, and started him off on it. Slowly, and with ups and downs (as one expects in all such recovery-curves), he got better, and everyone was pleased—everyone, that is, except his family doctor, who was nettled : in a well-mannered and good-humoured way, but nettled—that I should give the menopause as a contributory cause of illness in a man. I don't know if his own age had anything to do with it. At all events, the miniature storm has now passed; X has resumed his normal energetic habita—among them, tennis : which, I'm advised by H. D. Johns, the senior professional at Lord's, is a fine game in the autumnal years, since it is a game of skill more than animal force (I don't, of course, mean lawn tennis).
A 'menstrual' rhythm in men, with its peak every two-three weeks, and a menopause in the late forties or fifties—some of us, in the clinical field, may be convinced that these are universal : but I have heard of no study of them well enough controlled to be objective. Men with a disorder such as urticaria—attacks of it linked to a source of tension—will now and again point out that, apart from acute episodes, the illness as a whole shows a periodic fluctuation—the length of the cycle not close to twenty-eight days, as it is in most women, but anything from a fortnight to two months. The importance of this rhythm is, I think, in the understanding of an illness of the kind that X had—one that at first seems not fully explained, until the 'periodic factor' is brought in. The value of hormone preparations at the male menopausal epoch—here is a topii: I'd like to see more explored and written about. A 'field survey' of cyclic variation in men—in mood, well-being , and drive, as well as in illness—could be carried out quite simply by the family doctors, and per- haps their College will take it up.
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