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132 (47%) did not attend. This was a highly significant difference (P < 0.01) and suggests that there is agreat deal of reluctance for people to becomeassociated with psychiatric hospitals.

The drive towards community-based care in theform of community health teams we would hope tobe an important factor in eliminating this stigmaby making the services more accessible and lessintimidating for the people who may require theirhelp.

In addition, patient access to medical records mayhave an important part to play in de-stigmatisingpsychiatry. Psychiatrists could take this opportunityto improve doctor/patient communication and showthat psychiatry is not the secretive and sinisterprofession it is often portrayed to be.

T. N. EVANSA. IWANCZYK.

Cefn Coed HospitalCockeit, Swansea SA20GM

Observation of the suicidal in-patientDEARSIRSThere is substantial psychiatric literature concerning the assessment of suicidal risk. There is littleempirical assessment of observation of the suicidalin-patient. It has been suggested that a code of practice might be formulated (Morgan, 1988). We felt itmight be helpful to construct a picture of day-to-dayclinical practice on a nation-wide basis.

A postal questionnaire concerning this subjectreceived a disappointing response rate (55%) whichprecludes meaningful statistical analysis. We feel,however, that the findings merit some discussion.The vast majority of units who responded had awritten policy concerning observation. Two-thirdsutilised constant surveillance of the patient. Inthe majority of units the level of observation was amultidisciplinary decision. In four, nursing staffalone made this decision.

A clear majority of respondents felt that a controlled trial of observation would be unethical. Wewould suggest that this probably reflects a highdegree of confidence in this regime.

Our experience is that patients find this practiceintrusive and often resent it. Conversely, relativesappear grateful for it. We do wonder, however, giventhe loss of privacy involved, whether there is a casefor its being included as a treatment requiringinformed consent or a second opinion from apsychiatrist approved under Part IV of the MentalHealth Act 1983.

The final issue concerns the prison system. Despitecalls for prison reform, there have so far been nomoves to implement this regime for the suicidalpatient within the prison system. The obvious difficulty here is the resource implications for over-

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stretched prison hospitals. Given that the option is aform of seclusion ("unfurnished accomodation") we

would suggest that this issue should be urgentlyaddressed.

N. M. J. KENNEDYReaside ClinicBirmingham B45 9BE

N. S. BROWNLyndon Clinic, Hobs MeadowSolihull, West Midlands B928PW

ReferenceMORGANH. G. (ed) (1981) Proceedings of Conferenceon the

Clinical Management of Suicide Risk. London: TheRoyal Society of Medicine, Chapterhouse Codex.

A irfreshener perfumesDEARSIRSOver the last 12 years, I have collected 51 cases whoappear to be adversely affected by the presence ofso-called 'fresh' perfumes in their environment.

They present with symptoms of tiredness, nausea,headache and mild derealisation. A minor subgroupsuffer irritation of the nose, chest or eyes and three ofthe cases were severely disturbed emotionally, withtearfulness and inability to cope. One young man wascontemplating suicide. Signs of fine tremor, intentiontremor, nystagmus and an unsteady Rombergs testwere present in most (Lawson, 1985). In all cases,symptoms resolved completely when they clearedsources of'fresh' odourants from their environment.

None of the cases went on to develop anxiety ordepression needing treatment in its own right.

'Fresh' perfumes, like traditional perfumes, are a

mixture of many different odourants, but a greaterproportion of the constituents are synthetic in thecase of the 'fresh' variety. There is also the possibilitythat a new agent - the 'Malodour Counteractant' -

discovered by A. Schleppink in 1968 and developedby Monsanto, has a specific mode of action inblocking the exchange of protons, which is a leadingfeature of unpleasant odourants (Schleppink, 1981).

It is thought that fresheners act by stimulating theolfactory nerve so strongly that unwanted odoursare not perceived. The theoretical consequences ofstrong stimulation of the olfactory nerve are interesting. There is no doubt that the major input is to therhinencephalon, now termed the limbic lobe,and thought to mediate emotion. There are alsoconnections between the olfactory nerve and thehypothalamus and the caudate nucleus. There istherefore some theoretical basis for the observedeffect on emotions and on muscle tone. Further cor-roboration of the likelihood of perfumes affectingmood comes from the work of Dodd, who has usedperfumes to induce beneficial mood changes (Dodd& Van Toller, 1983).

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Although these clinical observations are 'mereanecdotes', I believe they are now numerous enoughto support the hypothesis that 'fresh' perfumes maysignificantly affect the well-being of some individuals. A crude extrapolation from this study wouldsuggest that some 50,000 people a year in the UKmight be adversely affected by air freshener perfumes. I believe that the onus of proof now rests withthe regulatory authorities and the perfume industrywho should put forward resources to enable thishypothesis to be tested.

RICHARDLAWSONThe Old School HouseSlat ion Road, Congresburv,AvonBS195BX

ReferencesDODD G. & VAN TOLLER,S. ( 1983) Perfumer and Flavorisl,

8, No. 4.LAWSON,R. H. (1985) Is there an air freshener syndrome?

Bristol Médico-Chirurgical Journal, 100, 10-13.SCHLEPPINK,A. A. (1981) Structure recognition as a peri

pheral process in odor quality coding. ACS SymposiumSeries, No 148. Washington: American ChemicalSociety.

WisdomDEARSIRSI followed with great interest Larry Culliford's series' Reading About Wisdom' (Psychiatric Bulletin, 1991,15,638-639). But having studied the essays I was stillnot sure what the series was about and would welcomeDr Culliford's clarification on what wisdom is?

IKECHUKWUO. AZUONYEThe Royal London HospitalS t Clement 's2a Bow Road, London E3 4LL

DEARSIRSThe recent series on Wisdom was something of asequel to an earlier piece in the Bulletin, (1984, 8,186-187). In this I attempted to answer the question,"What is Wisdom?".

Briefly I began with a conventional definition,acknowledging that it was not entirely satisfactory.("A recognisable attribute of human beings,reflected in their thoughts, words and actions,derived through intuition and through individualcontemplation of ideas, knowledge and experience ofall kinds"). I went on to mention Erik Erikson's workon Wisdom as the hoped-for outcome of the lifecycleand old age. I made comparisons between wisdom andknowledge, also wisdom and common sense, suggesting that these three are akin but distinguishable.

More recently I have had the thought that wisdomis that to which the heart and mind naturally aspirewhen one's self-seeking fades away.

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The Abbot of a Buddhist Monastery in Englandsaid not long ago, "Wisdom isn't something you get,it's something you use. It is not something that youdon't have and that you have to get. It's somethingyou start using because it's everywhere; it is here andnow. It may even be used in the little things; in juststanding, sitting, walking, lying down. It is contemplation, reflection. It is being alert while being anddoing.

You may not always feel wise when using wisdomin this way, but that is what it is."It is difficult to be definitive on the question of

what wisdom is. The 1984article and these ideas maynot be fully illuminating. They are simply offered forreflection. Where there is darkness, even the smallestflame may offer comfort.

LARRYCULLIFORDAldrington HouseHove Community Mental Health Centre35 New Church Road, Hove BN3 4AG

DEARSIRS'Reading about Wisdom' was a satisfying conclusionto a stimulating series (Culliford, 1991). It would beinappropriate to criticise the choice of materialrecommended in this particularly subjective area. Iwould, however, like to suggest three additionalsubjects that may have been included.

Firstly, among the ancient Eastern traditions considered in the series Sufism was largely neglected,despite the ready availability and interesting nature ofthe "teaching stories" of Idries Shah. Secondly, there isa considerable body of literature describing parallelsbetween psychotherapy and such Eastern theologies,an example being Erich Fromm's comparison ofZen Buddhism and psychoanalysis, which could beincluded in such a recommended reading list. Finally,the Judéo-Christiantradition should not, throughfamiliarity, be neglected as a source of Wisdom.

GARYHOSTYAll Saints HospitalBirmingham B18 5SD

ReferenceCULLIFORD,L. (1991) Reading about Wisdom. Psychiatric

Bulletin. 15, 638-639.

DEARSIRSI entirely accept Dr Hosty's suggested inclusions.My experience of Sufism is limited, but I have read

and enjoyed some of the Idries Shah stories.In positive comparison to the Fromm book I can

also recommend. Yoga and Psvchotherapv; TheEvolution of Consciousness on a similar subjectby Swami Rama, Rudolph Ballantine and SwamiAjaya, published in 1976 by the HimalayanInternational Institute, Honesdale, Pennsylvania.