Dear Ann Landers,
his is for the crazy lady who wrote to say she loves to watch her husband sleep at night because he looks so much like a little boy. Then she added, "I adore lis-tening to him snore. It's such a com-fort to know he's right there beside me." (That broad must sleep in the daytime.) For 24 years I have been married to a man who snores. If I turn on the light to look at him I'm sure the only thought that would come to my mind is murder. His snoring, under ordinary circumstances, is enough to shake the fixtures, but when he's had a few drinks he makes such a racket the peo-ple in the next apartment bang on the floor with what must be a sledge ham-mer. Several years ago we took The City of San Francisco (a great train) to the west coast. The people in the next compartment knocked on our door and asked if I could do something to quiet my husband. I said, "Yes, but it's against the law." Last year our family doctor suggested either a sedative for me, ear-plugs or separate bedrooms. I am now using all three. Pass the word to my sister sufferers, Ann. PEACE IT'S WONDERFUL

DEAR PEACE,
Consider it passed. I can't imagine worse punishment than being up all night, while the mate is snoring up a storm, depriving you of a night's sleep. Your suggestions all sound good. Too bad it took you so long to get relief. Sterilization Emotional Impact of Voluntary Sterilization In most discussions pertaining to voluntary sterilization, the thoughts, mo-tives and feelings of the patient are extremely important. I would like to stress that any surgical procedure involves two people-the patient and the doctor. No generalizations should be made about why a person chooses sterili-zation. Reasons for the choice have changed over the years along with changes in public information and attitudes. The decision "to be or not to be" is based on thinking that is both rational and emotional. The rational factors vary. To mention a few: age, economic circumstances, careers and lifestyle, health, degree of enjoyment of children. (Some women look upon having children as a disaster. Others view it merely as an incon-venience.) How does a person perceive the possibility of later regret? For some, it would be very sad indeed not to be able to have a child in a second marriage, for others it would be a blessing. Some couples look forward to adopting interracial or otherwise unwanted children. Others wouldn't con-sider it. What are the feelings about contraceptives? Fears of side effects of the pill are mounting. Millions of women have gone off the pill within the last two years. On the other hand, the discomfort or inconvenience of using a condom or diaphragm is a factor that must be reckoned with also. Feelings about abortion run to both extremes. Some women have no guilt whatever about the procedure and are therefore willing to risk pregnancy. These women tend to steer clear of sterilization. Others feel that abortion is murder and need more certainty in their con-traceptive method. They tend to favor sterilization-when they can get an okay from their clergyman, which is often not easy. A woman may be more or less aware of her own ambivalence about having another baby. Dr. Hans Leyfeldt has described the syndrome he calls "Will-ful Exposure to Unwanted Pregnancy," in which a woman unconsciously for-gets her pill or her diaphragm. She may enjoy pregnancy, but not children. She may be afraid of no longer having babies to keep her busy. She may feel the need of a pregnancy, to hold her husband. In agreeing to a sterilization for either herself or her husband, a woman may be unwittingly protecting herself from her irrational thinking. To turn to less rational motives for sterilization, especially among young people, there may be fear of the responsibilities of raising children, or an overconcern with money. A fairly common motive is the hope of improving sexual pleasure, and this also has its rational and irrational sides. It is per-fectly true that the fear of pregnancy may inhibit enjoyment of sex and re-duce its frequency. But any hope of a magic cure for sexual problems must be extinguished by the doctor before surgery. In theory, other unconscious irrational motives may be imagined: hostility to the spouse and a wish to deprive him or her of a baby, self-punishment and so on. A number of psychiatrists have let their fantasies roam widely, be-cause of their high index of suspicion, and possibly because of their own feel-ings. The patient may also have both rational and irrational reasons to be reluc-tant to have a sterilization. There may be a possible worry about a later change of heart in wanting a baby. Sometimes there are anxieties-the most common mentioned in surveys is pain. In the most recent survey of men having vasectomies, about one third of the men spoke of some worry about "less sex drive" and one sixth about less masculinity. Clearly, any surgery interferes to some extent with body image, and surgery on the reproductive organ is even more significant. But this im-pact varies in degree, and cannot be assumed to be important in all cases. I will turn now to the decision by the doctor. After a patient requests a sterilization, the doctor of course goes through the same process of weighing the factors. Since he is taking some risks, however small, and since his sup-port is important to the patient, he has the right to refuse to perform the pro-cedure. He should not, however, project onto the patient his own feelings about having children, his own sexual anxiety or his own satisfaction with other contraceptive methods. He should be so well informed that he recog-nizes whether his fears are irrational. This includes the fear of lawsuits, the fear of being held responsible for some neurotic problem in the patient, or for later regret. A doctor generally asks himself: What could go wrong if I do this? The chances of something going wrong are well under 5 percent. He should ask himself: What could go wrong if I don't do this? The chances are far greater. They include continued discontent with present contraceptive methods, chronic anxiety about their failure, possible side effects of the pill or IUD and of course the chance of an unwanted child or abortion. The doctor can-not avoid a responsibility for saying no any more than for saying yes. If a doctor does not feel good about the procedure, he should send the patient to another physician. Various papers about vasectomy clearly reveal the prejudices of many doc-tors..In some the writer assumes that all men will confuse vasectomy with castration. Another writer assumes that the motives are always neurotic. I read one paper in which the doctor deplored the performance of surgery on the man for the benefit of the wife. He stated, "In the male mind an un-wanted pregnancy is still woman's misfortune alone." The erroneous assump-tion is often made that vasectomy must inevitably lead to lower self-esteem, and that the low incidence of regrets indicates overcompensation and denial. In the case of tubal ligation for women (having tubes tied), the decision is complicated by the frequent addition of medical reasons, sometimes increas-ing conflict in the patient. An occasional doctor, unfortunately, has been influenced in his decision by emotions such as resentment against the cost of welfare. I should perhaps add sexism as well; for example, who ever heard of a male doctor advocating compulsory vasectomy for men who have fathered too many children? I will briefly discuss what has been reported about the results of sterili-zation, as they affect attitudes and decisions. The results of vasectomy have been described in many surveys which have been taken after the operation, generally by questionnaires and occasionally by interviewers. I will simply mention the two largest and most recent reported studies, one of 1,012 men in England done by the Simon Population Trust in 1969, and the other of 401 men in Canada done in 1970. In England, 99.4 percent of the men had no regrets, 73 percent enjoyed increased sex pleasure and 1.5 percent decreased pleasure. In the latter group, many of these men still had no regrets. This important point has been made in other surveys also. In the Canadian study, the figures are very similar: 98 percent of the men would have the operation again, the same 73 percent had increased sexual pleasure, and 2 percent decreased. The health and sexual enjoyment of the wives im-proved even more than the husbands'. Very rarely a wife will report a new sexual problem for her after her husband's vasectomy. The work done by Drs. Ziegler and Rodgers covered a period of four years, and compared forty-two couples choosing vasectomy with forty-two couples choosing the pill. After one year, psychological tests revealed increased unconscious dis-turbance in the vasectomy men, though they were consciously very satisfied. Later this difference disappeared. Two of the vasectomy couples regretted their decision, but nearly half the women who were on the pill stopped taking it and chose another form of contraception. We turn now to the results of female sterilization. Some sterilizations were by hysterectomy, some by tubal ligation. Many of the women were sterilized because of medical reasons, which rarely are an indication for vasectomy. In some cases the sterilization of women was combined with abortion, and it would be difficult to sort out the results. If a group has a high proportion of women for whom sterilization is recommended for psychiatric reasons, the results will probably be different. A well-educated person would undoubtedly respond differently than an ignorant one. To get down to figures: When asked, "Do you regret the operation?" the "yes" responses ranged from 1 to 10 percent, except for one study in Sweden where the sterilizations were done mostly with abortions, and many for psy-chiatric reasons. Generally, regrets were higher after a hysterectomy. One possible explanation is that then there is no opportunity to fantasize a rever-sal, which many women otherwise do, and the absence of a menstrual period may increase a feeling of damage. It's important to recognize that a women may regret her inability to have a child, but she still may not want more children. The survey with the lowest incidence of regret, 1 percent, was of one thousand women in Hong Kong studied by Lu. Apparently in Hong Kong sterilization is supposed to affect your temper and your memory, and 18 percent of them said that their tempers and memories and general health were worse, but this was a price they seemed willing to pay. As far as sexual activity among women is concerned, diminished enjoy-ment in one form or another ran from about 3 percent to 24 percent. This rate was much higher than that in men. This seems to contradict a popular conception that males are more threatened by sterilization, and supports the assumption that the childbearing function is more important to women. In general, the large majority of women report improved health, better sex life and happier marriages. In any couple, which partner should be sterilized should be determined by individualized counseling, and the role relationships in the family also should be taken into consideration. Any pressure by spouse or doctor must be avoided. Psychological aspects are as important as medical or practical ones. credit: Helen Edey, M.D., treasurer of the Association for Voluntary Sterili-zation, New York, New York, also former Staff Psychiatrist at the Margaret Sanger Research Bureau, now retired. Stomach The Nervous Stomach The nervous stomach is more properly called irritable bowel syndrome. It is also known as "spastic colon," "spastic colitis," "mucous colitis" and "func-tional dyspepsia." This is not a diseased bowel but it can cause worrisome and even frightening symptoms. Fortunately, this condition is not life-threat-ening nor is it a sign that you are coming down with a serious illness. In spite of the fact that all tests show the patient to be normal, he may have some very distressing symptoms. These symptoms are real and not "all in the head." If the upper intestinal tract is especially involved in the "nerv-ous stomach" the individual may vomit or belch excessively. If the small bowel seems to be chiefly involved, the pain can be cramp-like or of almost any character, but often moves from one area of the abdomen to another. If the lower bowel is involved with the irritable bowel symptoms (no dis-ease) the individual may have loose and watery stools. These often occur soon after meals and perhaps may even interrupt a meal. In other instances, however, the patient may be constipated. Individuals who suffer excessively from these problems may need treatment by a trained physician if the pain becomes severe and interferes with the person's ability to work or enjoy life. While the cause is not known, possible explanations are reasonable. The body is controlled by two types of nerves: (1) The conscious nervous sys-tem causes specific actions; for example, if one picks up a pencil from a table it may require the use of fifty muscles. The act is consciously performed. This is a function of the conscious nervous system. (2) The unconscious nervous system is just as important in the functions of the body and yet the individual can't control this nervous system. For example, if you should go to a funeral and the sermon is sad, you may weep. If you give a speech before a thousand people, your heart may beat fast, your hands may become moist and the paper might shake. You may even need to empty your bladder before going on the podium. The gastrointestinal tract from our mouth to our rectum is controlled by the unconscious nervous system. We consciously have a little to do with chewing and swallowing our food. Actually, even this is for the most part un-conscious, for we don't have to wonder where our tongue is while chewing. We do have a little control over emptying the bowel, but not total control. We have all heard the vulgar expression "It scared the out of me." During World War II, pilots and crews of bombers on the way home from bombing Berlin often had diarrhea to such a degree that they would soil their clothing. Yet these men were chosen because they were considered the most emotionally stable individuals in our armed services. At the other extreme it is not unusual to go on a trip and become con-stipated for a few days. The constipation was likely the result of the worry and tension of arranging the 101 little details that must be managed prior to leaving home, and after a few days, the bowel rights itself. Another example: A perfectly healthy person may suddenly vomit if he comes upon an accident and sees blood and brains scattered over the side-walk. Again-the body behaves in an "unusual way," but this does not repre-sent disease. It is important to know that these things can and do occur at times to all individuals. When, however, troublesome symptoms persist the patient has an irritable bowel syndrome. Sometimes this in inaccurately called spastic colitis. The treatment of the irritable bowel syndrome is difficult and varies with the way the unconscious nervous system is having its effect. First, and per-haps most important, is that the patient understand and be assured that the problem is not due to disease. This is usually the major helpful factor and can be convincingly done after a thorough examination with history, physical examination, laboratory tests and X rays have proved normal. Second, every-thing possible must be planned to help the bowel perform normally. The indi-vidual should eat slowly, chew his food well, avoid eating when nervous, tense or tired, and eat three moderate-sized meals each day, at approximatly the same time. This helps give the intestinal tract a regular and consistent amount of work to perform. The type of food is usually not important. One day any food may cause trouble while the next the patient can eat anything without difficulty. Six to eight glasses of water should be drunk each day, not more than one glass of liquid with each meal, so that the digestive juices will not be unduly diluted. The water should be drunk between the meals and not after 6 p.m. or the patient will have to get up to empty the bladder. The patient should plan to sit on the toilet each day at a regular time, preferably fifteen to thirty minutes after a meal. The patient should be encouraged never to try to belch. The "belcher" will usually swallow consciously or unconsciously three times or so before belching. When he belches two swallows of air come up, but he is actually re-taining one swallow. This occurs each time he belches and eventually the pa-tient becomes distended, bloated and very uncomfortable from the swallowed air. This is called aerophagia. It is very important for the individual with the irritable bowel syndrome to recognize that he is not very different from other individuals. If he is worried about his nervous stomach, the symptoms tend to increase. They do not, however, develop into cancer or any other serious disease. A word of warning, however. While these symptoms do not turn into dis-ease, the patient must be aware that he is not immune from getting something serious. If his symptoms change noticeably, he should consult a well-trained physician, preferably a gastroenterologist. credit: James C. Cain, M.D., Gastroenterology and Internal Medicine, the Mayo Clinic, Rochester, Minnesota. Stress Like death and taxes, everyone complains about the stress in their lives, yet few people understand what it is; much less do they attempt to reduce its rav-ages. Dr. Hans Selye, a Vienna-born endocrinologist, is perhaps the world's foremost authority on stress-in fact, he is called "Dr. Stress." According to this renowned authority, the only way to avoid stress completely is to be dead. "Stress," he claims, "is part of the human condition." The most frequent causes of stress are psychological, though our primitive ancestors had stress from physical causes and nature-like the fear of being eaten or carried away in a flood. Modern stress comes from an inability to adapt to our surroundings and the demands of work or family. It can also come from setting up for our-selves standards which are unrealistic-impossible to attain. When we don't "measure up" we feel inadequate and even depressed. Stress is often associated with the jobs of high-powered executives and pro-fessionals. As more and more women move into these roles, it is already evi-dent that they will begin to suffer the same consequences as men, in terms of ulcers and coronary problems. Stress itself is not a bad thing, but too much stress can shorten your life. The secret of coping with stress is not to avoid it but to alleviate it. Drugs can help if the stress is caused by a temporary problem or life change (divorce, death of a loved one, the loss of a job), but drugs can create additional stress if used as a cop-out. In some instances, the answer may be change jobs-or careers. Too many people are doing things they really don't want to do or aren't equipped to do -simply because it makes sense economically or because they think it is ex-pected of them by parents, spouses or peers. Physical activity-tennis, swimming, squash, handball, bicycling, etc.-can help relieve stress, but it is seldom a solution to the problem. "The most im-portant thing," says Dr. Selye, "is to have a code of life, to know how to live. Find yourself a port of destination-and practice what I call altruistic ego-ism." This means-set up goals which please your ego and yet have a redeem-ing or worthwhile element. Then go after goals that make you happy and perhaps help others as well. When you're sure of what you want, avoid dis-tractions, detours and frustrations. Keep your eye on your goal and don't let anything sidetrack you. Dr. Selye admits to being an egoist in this sense, but his altruistic goal is to acquire "as much goodwill and as many friends as possible." Too many peo-ple today measure their worth and self-esteem on making money. Conse-quently, they find themselves in stressful situations in pursuit of a goal that may be rubbing them the wrong way almost all of their lives. But "you can invest in goodwill and friendship, too," says Dr. Selye. "If you are desired, if you are necessary, then you are safe." Asked what he would say if he had to give a single piece of advice to peo-ple about stress, he replied: "I would offer the wisdom of the Bible translated into terms a scientist can easily accept today: 'Earn thy neighbor's love.' " credit: Eugene Kennedy, Ph.D., Loyola University, Chicago, author of Living with Everyday Problems, Chicago, Illinois: Thomas More Association. Stretch Marks The medical term for stretch marks is striae distensae-but no matter how fancy the handle, millions of women (and some men) hate the sight of the darned things and are willing to do almost anything to get rid of them. There is no known way to get rid of stretch marks, but it might be of some comfort to know that time can be a friend. When they first appear they are purplish in color or pink-but after a few months the marks become lighter and lighter and eventually they are faint whitish streaks that can scarcely be seen. Stretch marks can develop on the stomach (especially during and after pregnancy). They can show up on the breasts of nursing mothers, the but-tocks, thighs and sometimes across the lower back, knees and elbows. They sometimes appear after a sudden weight gain or rapid growth and with the onset of Cushing's syndrome (a glandular problem). Any illness for which cortisone is used might produce this much dreaded "scarring." About one out of three adolescents between ten and sixteen years of age develop stretch marks on the thighs, hips or stomach. Approximately three times as many girls get them as boys. No one knows exactly how stretch marks are formed. The loss of the skin's elasticity has something to do with it. Hormones must also be a factor be-cause of the frequent connection with pregnancy, puberty and cortisone. He-redity undoubtedly figures in somewhere. If stretch marks run in your family, you'll probably have them. A common misconception is that you have to be fat and put tension on the skin to develop stretch marks. This is not true, witness the fact that many thin people have them also. credit: Harry J. Hurley, M.D., Upper Darby, Pennsylvania. Stroke Stroke and heart attack have much in common. The immediate cause of each is the same: The blood supply is reduced or cut off. If this occurs in the area of the heart, it's a heart attack. If it occurs in the head, it's a stroke. A stroke may occur when the blood supply to a part of the brain is re-duced or cut off for any reason-such as a blood clot, or a blood vessel becoming clogged or bursting. The brain controls all bodily functions, from walking and talking to think-ing and feeling. Therefore, a stroke can affect any part of the body, depend-ing on the area of the brain deprived of an adequate supply of blood. Common results of a stroke are paralysis of one side of the body and/or loss of speech. These and other effects may vary according to the individual and the kind of stroke. The problems resulting from stroke may be slight or severe, temporary or permanent. Stroke is a major killer and an even more serious crippler. It is estimated that about 700,000 persons in the U.S.A. suffer serious new strokes each year. About one third of these people die, and about half of those who sur-vive suffer aftereffects that limit their lives. Fortunately, new treatments and preventive treatments in recent years have reduced some of the serious af-tereffects and modern research promises even more hope for stroke victims in the future. TYPES AND CAUSES OF STROKE Strokes are of two main types, medically called ischemic and hemorrhagic. Ischemic strokes are two or three times more common than hemorrhages. Ischemia means that the blood supply to the tissue becomes insufficient to meet the tissue's need for oxygen. When this occurs, the tissue dies. With ischemia, the individual usually suffers only a temporary neurological loss from which he may recover. This explains the improvement some people may show following a stroke. Global ischemia results when the heart stops or the blood pressure falls to very low levels so that the circulation drops below what the whole brain needs to function. Although with a duration too brief to produce stroke, this is what happens when a person faints. To put it simply the blood pressure falls suddenly after an emotional or painful crisis and he loses consciousness. Because some circulation always continues during a fainting spell, the circu-lation to the brain almost immediately restores itself as soon as the patient becomes horizontal. More serious global ischemia occurs, however, during temporary standstill of the heart due to heart attacks, during severe blood loss or injury causing profound shock, or in the course of certain rare blood diseases where small clots plug the majority of blood vessels leading to the brain. Regional ischemia to the brain occurs when one or more of the larger blood vessels become plugged and no longer can carry the brain's vital nour-ishment or drain its waste products. Trauma, inflammation or clotting abnor-malities can sometimes cause such obstructions. Much more commonly, how-ever, such closures result from arteriosclerosis, also known as hardening of the arteries, a process which thickens the arterial wall and piles up choles-terol and other chemicals in plaques on the inside of the wall so as to narrow and eventually close the opening. Blood products normally designed to pro-vide for the healing of wounds fasten themselves onto the area of ar-teriosclerotic plaques and sometimes contribute the final step in closure. In this special instance, the intent on healing actually makes matters worse: The vessel itself can completely close off or a piece of the plaque plus the repair products can break off. Such pieces can then wash downstream to a smaller artery and plug it off. These fragments drifting through the arterial stream to a distant artery are called emboli. The most common source of emboli caus-ing stroke probably is from these plaques in the large arteries in the neck that lead to the brain. Removal of such plaques reduces the risk of such emboli and stroke. Cerebral hemorrhage occurs mainly in older persons and results when a once normal artery in the brain ruptures. Such arteries gradually lose their re-sistance as the result of years of wear and tear caused by arteriosclerosis, hy-pertension and aging. As the artery leaks, blood escapes into the brain under more or less pressure, depending on the size of the hole in the artery and the efficiency of local repair factors. Occasionally, as in hemophilia or leukemia, abnormalities in the blood it-self may cause a hemorrhage. Less often, such hemorrhages can result from inborn abnormalities in the arteries, called aneurisms. The seriousness of the accompanying stroke depends on where the hemorrhage occurs, that is whether it damages critical neurological centers such as those controlling speech, movement and consciousness and how big it becomes. Large cerebral hemorrhages often are fatal. Although hemorrhages into the brain sometimes are treated surgically, there is little evidence that such procedures are helpful. Cause of stroke. Most strokes occur in persons over fifty years of age and are due to the interrelated disorders of atherosclerosis and hypertension. Atherosclerosis is caused by diabetes, certain inherited abnormalities of fat metabolism, and some mysterious factors which may cause the blood vessels to overreact to infections and aging. High blood pressure also produces its own special damaging effects on blood vessels, since the arteries must gradu-ally thicken to meet the higher pressure and this thickening can eventually lead to closure. As one might expect, hypertension accelerates the time when weak vessels blow out. Both cigarette smoking and the use of contraceptive pills contribute in a small but important way to the risk of stroke. These risks are substantially accentuated in persons with a history of diabetes, heart at-tack, high blood pressure or migraine headaches. There are many less frequent causes of stroke including congenital and acquired heart disease, diseases of the blood cells or blood coagulation mech-anisms, inflammation of the arteries and, rarely, even severe migraine. BEHAVIORAL CHANGES A patient who has had a recent stroke will often show partial loss of his emotional control. He may switch from laughing to crying without apparent reason. The most frequent problem seems to be crying. Sometimes the stroke patient will cry because he is depressed. Certainly most stroke patients will have considerable reason to be de-pressed. Depression is a natural response to loss of ability or any abrupt change in life. Often excessive crying by the stroke patient is due to the brain damage he has experienced and is not directly connected with his perceived losses. It is usually possible to tell the difference between loss of emotional control due to brain damage and sadness due to depression. When brain damage is the cause, the patient may begin weeping for no reason whatsoever. He will stop weeping abruptly if his attention is diverted. Diversion can be accom-plished by snapping the fingers and calling his name-or asking him a simple question. Unexpected laughter, flares of angers or moaning usually can be in-terrupted by using the same tactics. On the other hand, crying caused by depression is not easy to interrupt. Do not make the mistake of thinking that when the stroke patient is crying he is terribly sad or when he is laughing he is particularly happy. Even pa-tients who behave as if they were angry will later express surprise that they "flew off the handle." HOW YOU CAN HELP Some memory problems can be expected in most stroke patients. When working with memory deficits, you can often increase the patient's ability to perform if you: Establish a fixed routine whenever possible. Keep messages short to fit his retention span. Present new information one step at a time. Allow the patient to finish one step before proceeding to the next. Give frequent indications of effective progress; he may forget his past "successes." Train in settings that resemble, as much as possible, the setting in which the behavior is to be practiced. Use memory aids such as appointment books, written notes and sched-ule cards whenever possible. Use familiar objects and old associations when teaching new tasks. TREATMENT Treatment of acute stroke is based on three principles: (1) prevent the stroke from enlarging or recurring; (2) correct or prevent complications; (3) aid in the restoration of neurological function. Preventing strokes from enlarging is largely a matter of medical therapy. Appropriately selected patients with evolving strokes are given intravenous anticoagulants to stop the progress of the thrombotic process. The same treatment generally is employed for patients with progressive vertebro-basilar strokes. If the blood pressure is high, it should be brought to ranges more near normal. When transient ischemic attacks are present, oral anticoagulants usually help, assuming no complicating illness sets in. Drugs that counteract the aggregation of platelet cells in the blood also may be useful. Most pa-tients with acute stroke receive oxygen to aid the threatened brain. Few, if any, acute strokes can be treated surgically. Prevention. The single most important measure in preventing stroke is to treat hypertension. At all ages, the presence of hypertension correlates with an increased incidence of stroke and, usually, the higher the pressure the greater the risk. Effective treatment that reduces the blood pressure back to-ward normal reduces this risk, no matter at what age the treatment is begun. Some evidence even suggests that lowering the blood pressure after the first stroke prevents against future strokes. Obesity is a risk almost equal to hypertension. For one thing, being over-weight brings on both high blood pressure and diabetes prematurely. Put an-other way, how many healthy fat old people do you know? Those who smoke face an increased risk of stroke at all ages as opposed to those who do not. Women taking contraceptive pills, especially if there is a history of migraine, should recognize that if they also smoke their risk of stroke is four to six times higher than that of their contemporaries who avoid these risks. Other risk factors are harder .to counteract. Evidence is controversial, but other than keeping the weight down and exercising regularly there probably is little one can do to stave off the ravages of diabetes and inherited diseases of fat metabolism. Nevertheless, even these steps are important, and together with attention to the ones above they have already begun to reduce the inci-dence of stroke in this country. credit: Fred Plum, M.D., Department of Neurology, New York Hospital-Cor- nell Medical Center, New York. Stuttering is the act of speaking with involuntary, spasmodic halts, breaks, repetition of syllables and sounds. Over two million people in the United States stutter-approximately 1 percent of the population. The stutterer is often embarrassed by his inability to get his words out smoothly, and for this reason, some stutterers are reluctant to speak. This handicap can create serious employment problems as well as social problems. According to Dr. Dorvan Breitenfeldt, a speech pathologist at Eastern Washington State College in Cheney, Washington, Winston Churchill, one of the greatest orators of our time, was once a stutterer. So was Moses, Aristotle and Demosthenes. Historically, stutterers come from all social and economic classes. Dr. Breitenfeldt claims that 85 percent of all stutterers can conquer the handicap for life. The major determinant is the stutterer's wish to do so. (Dr. Breitenfeldt himself is a former stutterer.) The cause of stuttering has been a matter of continuing controversy among the specialists for a long time. Some say it is the result of an organic brain disease or a psychological defect. Others say it is a psychic condition pro-duced by anxiety or the fear of not being permitted to speak one's mind. It occurs more frequently in males, in individuals who are twins and in those who are left-handed. According to Linda Swisher, Ph.D., director of Northwestern University Speech and Language Clinics in Chicago, many children go through a normal stage of stuttering when they first learn to speak. They often outgrow it as they acquire better speaking skills. During this time, parents and siblings should treat the stutterer naturally and wait for him to complete his sen-tences. Dr. Swisher added that brothers and sisters should be prohibited by their parents from laughing at a stutterer. It should be viewed as a handicap, and not funny. The stuttering child should not be told, "Stop stuttering," or "Start again and speak more slowly." No notice should be taken of his stuttering. He should be protected against interruption by others, especially in school and at the dinner table. The teacher or parent should say, "Please let Johnny finish what he is saying." If, however, a child (as early as age three) begins to exhibit symptoms of serious frustration, he should be taken to a speech therapist. The goal of the therapist would be to decrease the stuttering behavior before secondary char-acteristics develop. Secondary characteristics are blinking of the eyes, or a re-fusal to look at the person to whom he is speaking, stamping of feet and the failure to properly control breathing. If a child's stuttering persists beyond twelve years of age, he needs speech therapy. The best way to contact a speech therapist is by calling the speech department of the nearest college or university. If there is no college or university in your vicinity, write to: American Speech and Hearing Association, 9030 Old Georgetown Road, Washington, D.C. 20014. The telephone number is: (301) 530-3400. credit: Ann Landers Success Success is a word for which there could be a thousand definitions. A great many people equate success with money. Almost always, these people are of modest means. My mail bears strong testimony to the fact that there are mil-lions of affluent "failures" and an equal number of "successes" who have nothing in the bank. This definition for success was written in 1904 by Bessie Anderson Stanley from Lincoln, Kansas. She was paid $250 for this prize-winning essay. "He has achieved success who has lived well, laughed often and loved much; who has enjoyed the trust of pure women, the respect of intelligent men and the love of little children; who has filled his niche and accomplished his task; who has left the world better than he found it, whether by an im-proved poppy, a perfect poem or a rescued soul; who has never lacked appre-ciation of earth's beauty or failed to express it; who has always looked for the best in others and given them the best he had; whose life was an inspiration; whose memory a benediction." credit: Ann Landers. Suicide Among Adults Each year twice as many Americans kill themselves as kill each other. Cur-rently suicide is listed as the tenth most common cause of death. Experts esti-mate the number of deaths caused by suicide to be approximately 25,000 a year. They say, however, that the incidence is undoubtedly far higher because it is so difficult to obtain accurate data. For a suicide to be recorded, there must be undeniable evidence that the person intentionally killed himself. It is well known, however, that numerous "accidents" have earmarks of at least unconscious self-destruction. Many experts estimate that the actual figures for suicide may be more than twice the number recorded. The World Health Organization places the United States far behind world suicide leaders-Hungary, Austria, Czechoslovakia, Sweden, Finland, Den-mark and West Germany. The WHO qualifies this placement by noting that these countries may simply be keeping the most unbiased and accurate rec-ords. There are certain trends in the statistics that should be mentioned. For many years, it was noted that men were three times more likely to commit su-icide than women. Recent research indicates that this trend may be changing, moving toward a more equal proportion between the sexes. The suicide rate rises steadily with men as they increase in age, while the rate for women levels off by about age seventy. Another particularly vulnera-ble age group is those fifteen to twenty-four years of age. In the past the rate of Caucasian suicides far outnumbered the Negro, and Gentiles far outnum-bered Jews, but again, there is evidence that these groups seem to be moving closer together in this regard. In our society, it is the most affluent, and presumably most "successful," who show the highest suicide rates. They are professional and managerial people, businessmen and executives. Doctors and dentists have more than double the rate of the general population (no doubt in part because they have easier access to large doses of fatal drugs). The rate for married people is far lower than for single, widowed or divorced-in fact, one fourth of all suicides had been living alone, compared with only 7 percent of the general population who live alone. Contrary to popular belief, about 70 percent of persons who threaten sui-cide actually make the attempt; the warning is a cry for help, and not merely a bid for attention. Only about 15 percent leave suicide notes. In most cases, these notes express love or hate, the desire for revenge and the wish to be loved after death. Suicide which is disguised and attributed to some other cause can take many forms. Self-destructive behavior can be manifested through starvation, excessive eating, excessive smoking, alcoholism and refusal to take prescribed medication. It is often impossible to tell whether a person fell or jumped from a high place. In this same category are drowning, reckless automobile driving, unskilled use of potentially dangerous tools, failure to carry out lifesaving medical procedures, inviting murder in any number of bizarre ways, burning to death in a fire and inviting lethal bites by poisonous snakes or spiders. Most people who try to kill themselves are rescued by friends and treated by the family doctor, if at all. They return to their routines hoping to avoid the public record-with good reason. Suicide is still a crime in eight states; and the religious still regard taking one's life as a sin against God; and whether or not suicide can occur among mentally healthy persons is still a debate within the medical profession. Helen Epstein, a member of the journalism faculty at New York Univer-sity, wrote in the New York Times Magazine in a piece titled "Suicide-A Sin or a Right?":* "The traditional profile of the American suicide has been ... a relatively successful, white, middle-aged man with a wife and children whose chances of killing himself rose gradually through middle age and then precipitously after the age of sixty. This kind of man committed suicide in droves in 1933 and set the all-time American record. But, like all composites, the profile ob-scured a more complex reality. The incidence of suicide has always been greatest among people of any sex, age or racial group who have made previ-ous attempts on their lives. Women (using drugs, poisons, gas) have tradi-tionally attempted suicide three times as often as men. Men (using violent means like hanging, jumping or shooting) have actually died by suicide three times as often as women. Traditional explanations for the 3 to 1 ratio of male to female suicides have centered around the theme of men being both more decisive and more efficient than women. The highest-risk age group has been the elderly, who account for about 25 percent of all suicides in the United States. Among ethnic groups, the American Indian has led all others with a rate that is twice the national average, and on some reservations, five or six times that. * Copyright � 1974 by The New York Times Company. Reprinted by permission. "These trends have not been difficult for researchers to explain. Suicide among the elderly has been attributed to decline in status, income, power, health and mobility in a culture which glorifies all these qualities. The desire to end a serious illness, or to die before succumbing to one, swells the ranks of elderly suicides." Because suicide is a complex human act and because it can touch every-one's life at one time or another, both laymen and professionals constantly search for understanding. No one really knows why human beings commit suicide. They have been doing so for as long as history has been recorded. Edwin Shneidman, Ph.D., one of the foremost suicidologists in the country, has noted, "A dozen people can shoot themselves through the head and subsequent psychological autop-sies would reveal that they participated in a dozen different descriptive events. One was escaping from pain, another was afraid of going insane, a third acted on impulse after a quarrel, a fourth hoped to join a loved one in the hereafter, a fifth was punishing his parents and so on. But every case of overt self-destruction involves the presence of unbearable anguish." Some of the more familiar psychological theories regarding suicide have been listed by Herbert Hendin, M.D. These include: Death as retaliatory abandonment. In such instances, the suicide is a way of getting back-the suicide "leaves" or abandons the loved or cherished person in order to pay back a felt rejection by that person. "You leave me, I'll leave you by killing myself. Then you'll be sorry." Death as retroflexed murder. This involves situations where the per-son says, "I'm so angry at you I could kill you. However, that's unacceptable so I'll kill myself." Then he or she does. Death as a Reunion. Here the emphasis is not so much on dying, but on how pleasant the reunion with the deceased loved one will be after death is accomplished. Fantasies of this kind are often verbally expressed by psy-chotic individuals and should be taken very seriously. Death as rebirth. One's life may be so tragic and miserable that dying may be seen as a way to "start over with a new life." Death as self-punishment. This occurs when a person fails to achieve a goal or level of success which he considers extremely important in his life's plan. The person feels like a failure, and decides that he or she needs to be punished. The ultimate punishment is death. How do average laymen deal with the possibility that one of their associ-ates or close family members may be experiencing such thoughts? There are a few basic principles that are well known among professionals and others who have worked with suicidal persons. The first is that (1) some people who commit suicide (they are a small percentage, but they cannot be ig-nored) do not give off any signals that they are contemplating suicide; and if a person truly wants to kill himself he will find a way to do it despite the efforts of those around to save him. There are specific clues to a potential suicide with which the average per-son should have some familiarity. The professional evaluates suicidal risk in terms of a number of factors. As these factors weigh more heavily, the risk is thought to be greater. Age and sex. The potential is greater for men than women and greater over age fifty. Marital status. The potential is greater for divorced, widowed and sin-gle persons than for married, especially those married who have children. In other words, the less interpersonal support, the greater the potential. Symptoms. The potential is greater if the person is depressed, has se-vere insomnia, is alcoholic or has homosexual conflicts. Stress. The potential is greater if the person is under severe stress. Acute versus chronic. The potential is greater if there is a sudden onset of specific symptoms. Suicidal plan. If the person has a detailed plan, the potential is greater than if the suicidal thoughts are vague. Previous suicide attempt. The risk is greater if the person has acted on suicidal impulses previously. Medical status. If the person is suffering from a chronic disease or has the potential of a chronically debilitating illness, the risk is greater. Communication aspects. If the person feels rejected by others or feels there is no outlet for his distress, the potential is higher. Family history. If there is a history of suicide in the family- especially a same-sexed parent-the risk increases. The evaluation of suicidal potential is a risky business for even the experi-enced professional. The basic principle is that if a person has serious reason to suspect that someone may commit suicide, he or she should attempt to get the person to accept professional help during the critical period. Since most people are ambivalent about taking their own lives, strategic care can be most helpful and even lifesaving. A certain few will say no to any efforts to help them, and this also must be recognized. This is the most frustrating aspect of dealing with suicidal persons. Moreover, suicide can occur even among those who get help. It is for most people literally unthinkable that someone close to them would feel the need to take his own life. It is, in fact, difficult for most people even to acknowledge that they themselves have had suicidal thoughts. How then can one comfort oneself and those persons who are close after a suicide has occurred? The natural response to any major life event, whether it is failing an examination, experiencing a divorce or suffering a severe busi-ness loss, is to go over in one's mind again and again the particulars of the event, in an attempt to make sense out of it, and make it a "part" of one's self. Negative events are far more difficult to integrate because the pain is so great. The most difficult and painful emotion subsequent to a suicide or suicidal attempt is the feeling of guilt engendered in those who are left. It is generally an irrational feeling. A survivor may have read some of the signs, consulted, urged treatment and, in fact, may have seen that the person was hospitalized in a protected environment, but the suicide occurred anyway. At this point, survivors must strive to be more kind and less self-punishing toward them-selves. This is, in fact, the most reasonable and constructive response to a suicide. A great many spouses, parents and siblings suffer tremendous guilt when a suicide occurs, believing that they were insensitive to the "signs." They tor-ture themselves with the thought that had they been more caring or alert, they could have prevented the loved one from committing suicide. When these individuals find life joyless-when they isolate themselves from others, refuse social invitations and avoid seeing persons who remind them of the deceased-in other words, when depression hangs on and cannot be shaken, professional help should be sought. Survivors often need outside counseling so that they can verbalize their feelings and obtain emotional support that comes from ventilation. More-over, the feedback from the professional, hopefully, will help them under-stand that they were not responsible for the tragedy, and that life is for the living. credit: Sara Charles, M.D., Assistant Professor of Psychiatry, Abraham Lin-coln School of Medicine, University of Illinois in Chicago. SUICIDE AS FAST RELIEF . . .