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PERSONALITY AND LUNG CANCER
216
In A
England
Now
Letters
Running Commentary by Peripatetic Correspondents
HIGHER education is on the move. More than one senate has before it the report of its subcommittee on the taxonomy of degrees. One view is that it is the function of a degree to disguise: to provide a cloak for its holder’s class (both social and academic) and so convince him that all graduates are brothers as far as the skin; the other is that a degree should reveal, the label describing the goods, and the portion of the alphabet he uses making it clear whether the holder got into the club by examination (B.A.), congratulation (D.sc.), exhaustion (PH.D.) or cash (M.A. Cantab.). Is it too much to hope that common sense, or compromise, will prevail ? There is a clear need to create a special degree for the occasional emergency. (We understand, for example, that the male graduate of Bedford and Somerville is to be awarded the Mm.Mm.) But otherwise the following blanket formula, or perhaps opera-cloak formula, conceals the essentials from those who have no need to know (such as patients) while revealing them to those who do (like appointments boards), or the other way round. Thus: 18 B.M., Ox., S., Ex. would mean, to those in possession of the code-book, that the bearer studied medicine and surgery at Oxford for 18 years and on examination was placed in the fourth class. Alternatively, all medical
graduates
could
simply
be *
designated *
J.
ALL
(TECH.)
M.O.
*
When he came to my outpatient clinic, he had on his best for the occasion, and his beaming face with a fringe of beard belied the tale of trouble with his water-works. He told me he did not want to spend a lot of time having treatment because he had to sell his camels as quickly as possible before getting back to his desert home. He was a bit reluctant to undress for examination, but I persuaded him that this was the only way to find out what was wrong. He got up in the knee-elbow position and kept up a running commentary on life in the big town. When I tried to do a rectal examination I found a strip of elastic adhesive bandage firmly stuck across the anus. He was very loth to part with this decoration and explained that the journey to town had been rather cold and there had been a lot of high wind on the way; he felt that the only way to avoid getting wind inside was to protect himself with this barrier. I promised faithfully that after the necessary examination I would replace it, and he was very pleased when I handed him another piece of adhesive plaster to protect himself against the elements on his return journey.
jelabiya
*
*
*
to
the Editor
OUTPATIENT WAITING TIME
SIR,-Your editorial of Nov. 30 rightly draws attention again to the importance of reducing waiting by patients in outpatient departments. Surveys which have once
been carried out in Scotland during the last three years by a working party of the Scottish Home and Health Department have revealed a great variation in efficiency between different clinics. Some showed no improvement on the very long waiting times recorded by the Nuffield Provincial Hospitals Trust as long ago as 1952, but a few could hardly have been bettered. When waiting times were long, those in charge of the clinic were sometimes aware of it (for example, because the patients could not all be accommodated in the waitingroom), but thought that the situation was inevitable because of the patients’ unreliability in attendance and unpunctuality or because of the large size and fast pace of the clinic. We should like to call attention to some recent theoretical results we have obtained 1-3 which show that these factors do not preclude the design of an efficient appointments system in which both the doctors’ and patients’ waiting is slight, while in fact waiting in large clinics ought to be less than in small clinics. The information required to design and maintain an appointments system is extremely simple. " Individual consultation-times need not be measured, only the number of patients actually seen and the total period for which the doctor was working in the clinic. This period should exclude planned breaks, time when the doctor is waiting because there are no patients, and times spent in dictating, etc., when the consultations are finished." The receptionist will be able to check patients’ arrival times against her list-noting those who come, those who do not, and any who have no appointment; while the measurement of the total period at the session during which the doctor deals with patients may easily be recorded by the doctor himself (or the nurse). A comparison of this information with the appointments list will show at once whether the appointments system needs adjustment. We suggest that it is simpler to remedy any defect by taking these direct measurements than by any overall check-whether automatic or otherwise-on the number of people waiting. We would stress, however, that the first essential for an efficient appointments system is that those in charge of it should mind whether it is successful. We agree that if a system were carefully attended to in the manner suggested by Mr. Rossiter it would be efficient.
What a treacherous trap lies in the spelling of the perspiratory adjectives-anhidrotic and hyperhidrotic. Such a watery secretion calls clearly for hydrous words; but the origin of the adjectives is p (sweat), with an I, and has no relation to (water), with a u. Modern physiologists (J. Physiol. 1948, 107, 74; and Brit. med. Bull. 1963, 19, 2, 112) can hardly be blamed for being unaware of this. On the other hand, Medical Research Council Statistical Hippocrates (Prognosis, B.C. 425, section 6) naturally gets it right. Research Unit, University College M. C. PIKE. The English cannot spell their As Bernard Shaw once said: Hospital, London W.C.1. it with but an old because have to they nothing spell language M. J. BLANCO WHITE. Edinburgh. foreign alphabet, of which only the consonants-and not all of them-have any agreed speech value." But would it have been PERSONALITY AND LUNG CANCER w°holly to the good if Shaw had succeeded in introducing a SIR,-Lung cancer has been found by different investiphonetic alphabet, thus Beeching all these old orthographic gators to be statistically associated with some 18 different Trains of Thought ? "
*
*
’*’
When rabbits pale and mice go wan It’s time to use Pregnosticon. Detoxication now is past: Prepuerin has come at last. The hour has come when there’s no need For frog or toad to lose its seed. The Ortho Test is what’s required; Now rabbits, mice, and frogs are fired!
characteristics-sex, age, marital status, country of birth population density, social class, occupation, smoking (especially of cigarettes with inhaling), consumption of alcohol, consumption of coffee, consumption of cooked shellfish and crustacea, hairiness of the 2nd phalanges of the fingers and toes, number of and residence, air pollution,
1. Blanco White, M. J., Pike, M. C. Medical Care (in the press). 2. Pike, M. C. Waiting in Hospital Outpatient and Casualty Departments Ph.D. Thesis, University of Aberdeen, 1963. 3. Blanco White, M. J. Health Bull. 1962, 20, 41.
217
teeth lost, familial factors, past history of respiratory disease, being gassed in 1914-18 war, and the number of doctors per square mile. Quite obviously these associations are widely different in nature and extent. It has, however, been stated that the association between lung cancer and cigarette smoking is much greater than any of the other associations as judged by ratio of the lungcancer mortality-rates of those possessing respectively For most and least of the characteristic concerned. Doll and Bradford were by published example, figures Hillshowing that the lung-cancer mortality-rate of male British doctors smoking a daily equivalent in terms of tobacco weight of 25 cigarettes or more was 24 times that of non-smokers. Measured in this way there is also a close association between lung cancer and a particular feature of personality which I have described as a poor outlet for emotional
discharge.23 This
personality feature was elicited clinically as a feature distinguishing lung-cancer patients from the other patients in a series of approximately 300 chest-unit inpatients almost equally divided between the two diagnostic groups. Confirmation was afforded by the use of two measures. For one measure it was predicted that a lower incidence of childhood behaviour disorders (regarded as early outlets for emotional discharge) might be expected in lung-cancer patients. For the other measure use was made of the mean neuroticism (N) score as elicited in the short form of the Maudsley personality inventory. It was argued that the N score in effect measures ability to discharge emotion and therefore a lower mean N score was predicted for lung-cancer patients. All patients were interviewed soon after their admission to hospital, the investigator being quite unaware of any of the diagnoses. Not only were both predictions fulfilled but there was a strong statistical correlation between the findings on the two measures. It may be argued that a control group of chest-unit patients is not representative of the " general public " (whatever that term may imply). It was, however, chosen to avoid bias as far as possible by ensuring like environmental conditions for the two groups at the time the psychological responses were being elicited. Healthy people in a home environment may well have different emotional motivation for cooperation in such a study. However as a further check the personality feature
was
group of same
measured in the
non-cancer
hospitals.
results for N
The
same
way in
a
summarised
as
follows:
On the
assumption that men aged 25 and over suffering respectively from lung cancer and from non-cancer non-chest diseases can be taken as representing male lung-cancer deaths and men generally in Scotland, the lung-cancer mortality-rates per 100,000 of men aged 25 and over, by levels of neuroticism scores, in Scotland in 1961
It
be
are as
follows:
that the lung-cancer
mortality-rates of those discharge as measured by low X scores is more than five times as great as those with a good outlet for emotional discharge, and nearly three times as great as those with an intermediate outlet for emotional discharge. can
with
a
seen
poor outlet for emotional
It should be noted that these 1. 2. 3.
personality
features
Doll, R., Bradford Hill, A. Brit. med. J. 1956, ii, 1071. Kissen, D. M. Brit. J. med. Psychol. 1963, 36, 27. Kissen, D. M. Acta psychother., Basel, 1963, 11, 200.
were
even
when
as
Southern General
Hospital,
DAVID M. KISSEN.
Glasgow.
second control
patients from non-chest wards in the findings were even more striking. The
scores are
cigarette smoking was held constant, just cigarette smoking was a dominant feature/ when personality was held constant. However if one takes into account degree of exposure of bronchi to cigarette smoke (which acknowledges inhaling habits), the importance of which has been emphasised by Hammond,4 the findings suggest that the poorer the outlet for emotional discharge the less the exposure to cigarette smoke required to induce lung cancer. Thus in a series of 214 lung-cancer patients graded in 5 grades of descending order of exposure to cigarette smoke (including nonsmokers) the mean N scores were 4-0, 3-8, 3-5, 2-2, 2-0. This has been described by me elsewhere in detail. On the basis of the personality findings some light is hereby thrown on some of the apparently anomalous epidemiological findings in relation to quantity smoked and in relation to inhalation of cigarette smoke. The statistical association of lung cancer with a poor outlet for emotional discharge is appreciable and is apparently greater than for any of the other associations mentioned in my first paragraph, with the exception of cigarette smoking. The suggestive interplay between this personality feature and cigarette smoking habits in lung-cancer patients is also important. Motivation for cigarette smoking is complex6 and includes, no doubt, psychological factors other than those to which I have referred here. Further study of the psychological implications of smoking motivation and of the psychological features of cancer in general and lung cancer in particular should help to bring us nearer to elucidation of the cancer problem. The findings summarised here are obviously not an argument against cigarette smoking as a cause of lung cancer. It is important, however, that one strong statistical association should not obscure other possible important associations in the elucidation of what is undoubtedly a disease of multifactorial origin. And the evidence that there is between a association suggests significant personality and lung cancer.
present
LUNG CANCER AND MONTH OF BIRTH "
SIR,-Fisher wrote: heavyweight authority ... must have temporarily discredited many a promising line of work."Honest observers differ in their conclusions either because they have done different experiments or because they interpret them differently. With these thoughts in mind it is worth having a look at how the " heavyweights " -Miss Davies of The Royal Marsden (Dec. 14), Dr. Baas and Dr. Strackee of Amsterdam University (Jan. 4), and Dr. v.d. Wal and others of Groningen University (Jan. 11) seem to have discredited Dr. Dijkstra’s work. They all did different experiments from Dijkstra’s, and in my view they all interpreted them wrongly. Apart from Dr. v.d. Wal’s series, the experiments had All differed from Dijkstra’s with different locations. regard to the period in which the cancers were diagnosed. By analogy, observations on sun spots at different times on different parts of the sun would not be the same. The observers would be doing different experiments. Miss Davies commented on her figures, " no significant variation between months being revealed ". But the mean 4. 5. 6 7.
Hammond, E. C. Bulletin de l’Institut International de Statistique, 33rd session, Paris, 1961. Kissen, D. M. in Psychosomatic Aspects of Neoplastic Disease (edited by D. M. Kissen and L. LeShan). London, 1964 (in the press). Kissen, D. M. Med. Offr, 1960, 25, 365. Fisher, R. A. The Design of Experiments. Edinburgh and London, 1949.
In A
England
Now
Letters
Running Commentary by Peripatetic Correspondents
HIGHER education is on the move. More than one senate has before it the report of its subcommittee on the taxonomy of degrees. One view is that it is the function of a degree to disguise: to provide a cloak for its holder’s class (both social and academic) and so convince him that all graduates are brothers as far as the skin; the other is that a degree should reveal, the label describing the goods, and the portion of the alphabet he uses making it clear whether the holder got into the club by examination (B.A.), congratulation (D.sc.), exhaustion (PH.D.) or cash (M.A. Cantab.). Is it too much to hope that common sense, or compromise, will prevail ? There is a clear need to create a special degree for the occasional emergency. (We understand, for example, that the male graduate of Bedford and Somerville is to be awarded the Mm.Mm.) But otherwise the following blanket formula, or perhaps opera-cloak formula, conceals the essentials from those who have no need to know (such as patients) while revealing them to those who do (like appointments boards), or the other way round. Thus: 18 B.M., Ox., S., Ex. would mean, to those in possession of the code-book, that the bearer studied medicine and surgery at Oxford for 18 years and on examination was placed in the fourth class. Alternatively, all medical
graduates
could
simply
be *
designated *
J.
ALL
(TECH.)
M.O.
*
When he came to my outpatient clinic, he had on his best for the occasion, and his beaming face with a fringe of beard belied the tale of trouble with his water-works. He told me he did not want to spend a lot of time having treatment because he had to sell his camels as quickly as possible before getting back to his desert home. He was a bit reluctant to undress for examination, but I persuaded him that this was the only way to find out what was wrong. He got up in the knee-elbow position and kept up a running commentary on life in the big town. When I tried to do a rectal examination I found a strip of elastic adhesive bandage firmly stuck across the anus. He was very loth to part with this decoration and explained that the journey to town had been rather cold and there had been a lot of high wind on the way; he felt that the only way to avoid getting wind inside was to protect himself with this barrier. I promised faithfully that after the necessary examination I would replace it, and he was very pleased when I handed him another piece of adhesive plaster to protect himself against the elements on his return journey.
jelabiya
*
*
*
to
the Editor
OUTPATIENT WAITING TIME
SIR,-Your editorial of Nov. 30 rightly draws attention again to the importance of reducing waiting by patients in outpatient departments. Surveys which have once
been carried out in Scotland during the last three years by a working party of the Scottish Home and Health Department have revealed a great variation in efficiency between different clinics. Some showed no improvement on the very long waiting times recorded by the Nuffield Provincial Hospitals Trust as long ago as 1952, but a few could hardly have been bettered. When waiting times were long, those in charge of the clinic were sometimes aware of it (for example, because the patients could not all be accommodated in the waitingroom), but thought that the situation was inevitable because of the patients’ unreliability in attendance and unpunctuality or because of the large size and fast pace of the clinic. We should like to call attention to some recent theoretical results we have obtained 1-3 which show that these factors do not preclude the design of an efficient appointments system in which both the doctors’ and patients’ waiting is slight, while in fact waiting in large clinics ought to be less than in small clinics. The information required to design and maintain an appointments system is extremely simple. " Individual consultation-times need not be measured, only the number of patients actually seen and the total period for which the doctor was working in the clinic. This period should exclude planned breaks, time when the doctor is waiting because there are no patients, and times spent in dictating, etc., when the consultations are finished." The receptionist will be able to check patients’ arrival times against her list-noting those who come, those who do not, and any who have no appointment; while the measurement of the total period at the session during which the doctor deals with patients may easily be recorded by the doctor himself (or the nurse). A comparison of this information with the appointments list will show at once whether the appointments system needs adjustment. We suggest that it is simpler to remedy any defect by taking these direct measurements than by any overall check-whether automatic or otherwise-on the number of people waiting. We would stress, however, that the first essential for an efficient appointments system is that those in charge of it should mind whether it is successful. We agree that if a system were carefully attended to in the manner suggested by Mr. Rossiter it would be efficient.
What a treacherous trap lies in the spelling of the perspiratory adjectives-anhidrotic and hyperhidrotic. Such a watery secretion calls clearly for hydrous words; but the origin of the adjectives is p (sweat), with an I, and has no relation to (water), with a u. Modern physiologists (J. Physiol. 1948, 107, 74; and Brit. med. Bull. 1963, 19, 2, 112) can hardly be blamed for being unaware of this. On the other hand, Medical Research Council Statistical Hippocrates (Prognosis, B.C. 425, section 6) naturally gets it right. Research Unit, University College M. C. PIKE. The English cannot spell their As Bernard Shaw once said: Hospital, London W.C.1. it with but an old because have to they nothing spell language M. J. BLANCO WHITE. Edinburgh. foreign alphabet, of which only the consonants-and not all of them-have any agreed speech value." But would it have been PERSONALITY AND LUNG CANCER w°holly to the good if Shaw had succeeded in introducing a SIR,-Lung cancer has been found by different investiphonetic alphabet, thus Beeching all these old orthographic gators to be statistically associated with some 18 different Trains of Thought ? "
*
*
’*’
When rabbits pale and mice go wan It’s time to use Pregnosticon. Detoxication now is past: Prepuerin has come at last. The hour has come when there’s no need For frog or toad to lose its seed. The Ortho Test is what’s required; Now rabbits, mice, and frogs are fired!
characteristics-sex, age, marital status, country of birth population density, social class, occupation, smoking (especially of cigarettes with inhaling), consumption of alcohol, consumption of coffee, consumption of cooked shellfish and crustacea, hairiness of the 2nd phalanges of the fingers and toes, number of and residence, air pollution,
1. Blanco White, M. J., Pike, M. C. Medical Care (in the press). 2. Pike, M. C. Waiting in Hospital Outpatient and Casualty Departments Ph.D. Thesis, University of Aberdeen, 1963. 3. Blanco White, M. J. Health Bull. 1962, 20, 41.
217
teeth lost, familial factors, past history of respiratory disease, being gassed in 1914-18 war, and the number of doctors per square mile. Quite obviously these associations are widely different in nature and extent. It has, however, been stated that the association between lung cancer and cigarette smoking is much greater than any of the other associations as judged by ratio of the lungcancer mortality-rates of those possessing respectively For most and least of the characteristic concerned. Doll and Bradford were by published example, figures Hillshowing that the lung-cancer mortality-rate of male British doctors smoking a daily equivalent in terms of tobacco weight of 25 cigarettes or more was 24 times that of non-smokers. Measured in this way there is also a close association between lung cancer and a particular feature of personality which I have described as a poor outlet for emotional
discharge.23 This
personality feature was elicited clinically as a feature distinguishing lung-cancer patients from the other patients in a series of approximately 300 chest-unit inpatients almost equally divided between the two diagnostic groups. Confirmation was afforded by the use of two measures. For one measure it was predicted that a lower incidence of childhood behaviour disorders (regarded as early outlets for emotional discharge) might be expected in lung-cancer patients. For the other measure use was made of the mean neuroticism (N) score as elicited in the short form of the Maudsley personality inventory. It was argued that the N score in effect measures ability to discharge emotion and therefore a lower mean N score was predicted for lung-cancer patients. All patients were interviewed soon after their admission to hospital, the investigator being quite unaware of any of the diagnoses. Not only were both predictions fulfilled but there was a strong statistical correlation between the findings on the two measures. It may be argued that a control group of chest-unit patients is not representative of the " general public " (whatever that term may imply). It was, however, chosen to avoid bias as far as possible by ensuring like environmental conditions for the two groups at the time the psychological responses were being elicited. Healthy people in a home environment may well have different emotional motivation for cooperation in such a study. However as a further check the personality feature
was
group of same
measured in the
non-cancer
hospitals.
results for N
The
same
way in
a
summarised
as
follows:
On the
assumption that men aged 25 and over suffering respectively from lung cancer and from non-cancer non-chest diseases can be taken as representing male lung-cancer deaths and men generally in Scotland, the lung-cancer mortality-rates per 100,000 of men aged 25 and over, by levels of neuroticism scores, in Scotland in 1961
It
be
are as
follows:
that the lung-cancer
mortality-rates of those discharge as measured by low X scores is more than five times as great as those with a good outlet for emotional discharge, and nearly three times as great as those with an intermediate outlet for emotional discharge. can
with
a
seen
poor outlet for emotional
It should be noted that these 1. 2. 3.
personality
features
Doll, R., Bradford Hill, A. Brit. med. J. 1956, ii, 1071. Kissen, D. M. Brit. J. med. Psychol. 1963, 36, 27. Kissen, D. M. Acta psychother., Basel, 1963, 11, 200.
were
even
when
as
Southern General
Hospital,
DAVID M. KISSEN.
Glasgow.
second control
patients from non-chest wards in the findings were even more striking. The
scores are
cigarette smoking was held constant, just cigarette smoking was a dominant feature/ when personality was held constant. However if one takes into account degree of exposure of bronchi to cigarette smoke (which acknowledges inhaling habits), the importance of which has been emphasised by Hammond,4 the findings suggest that the poorer the outlet for emotional discharge the less the exposure to cigarette smoke required to induce lung cancer. Thus in a series of 214 lung-cancer patients graded in 5 grades of descending order of exposure to cigarette smoke (including nonsmokers) the mean N scores were 4-0, 3-8, 3-5, 2-2, 2-0. This has been described by me elsewhere in detail. On the basis of the personality findings some light is hereby thrown on some of the apparently anomalous epidemiological findings in relation to quantity smoked and in relation to inhalation of cigarette smoke. The statistical association of lung cancer with a poor outlet for emotional discharge is appreciable and is apparently greater than for any of the other associations mentioned in my first paragraph, with the exception of cigarette smoking. The suggestive interplay between this personality feature and cigarette smoking habits in lung-cancer patients is also important. Motivation for cigarette smoking is complex6 and includes, no doubt, psychological factors other than those to which I have referred here. Further study of the psychological implications of smoking motivation and of the psychological features of cancer in general and lung cancer in particular should help to bring us nearer to elucidation of the cancer problem. The findings summarised here are obviously not an argument against cigarette smoking as a cause of lung cancer. It is important, however, that one strong statistical association should not obscure other possible important associations in the elucidation of what is undoubtedly a disease of multifactorial origin. And the evidence that there is between a association suggests significant personality and lung cancer.
present
LUNG CANCER AND MONTH OF BIRTH "
SIR,-Fisher wrote: heavyweight authority ... must have temporarily discredited many a promising line of work."Honest observers differ in their conclusions either because they have done different experiments or because they interpret them differently. With these thoughts in mind it is worth having a look at how the " heavyweights " -Miss Davies of The Royal Marsden (Dec. 14), Dr. Baas and Dr. Strackee of Amsterdam University (Jan. 4), and Dr. v.d. Wal and others of Groningen University (Jan. 11) seem to have discredited Dr. Dijkstra’s work. They all did different experiments from Dijkstra’s, and in my view they all interpreted them wrongly. Apart from Dr. v.d. Wal’s series, the experiments had All differed from Dijkstra’s with different locations. regard to the period in which the cancers were diagnosed. By analogy, observations on sun spots at different times on different parts of the sun would not be the same. The observers would be doing different experiments. Miss Davies commented on her figures, " no significant variation between months being revealed ". But the mean 4. 5. 6 7.
Hammond, E. C. Bulletin de l’Institut International de Statistique, 33rd session, Paris, 1961. Kissen, D. M. in Psychosomatic Aspects of Neoplastic Disease (edited by D. M. Kissen and L. LeShan). London, 1964 (in the press). Kissen, D. M. Med. Offr, 1960, 25, 365. Fisher, R. A. The Design of Experiments. Edinburgh and London, 1949.