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BRONCHIAL CARCINOMA
425
Letters
to
tance, especially if the person is very concerned about it. Patients often have grave doubts about the hypnotics prescribed : they fear that drugs will damage their brain. It is well to spend some time explaining to the patient that the medicine prescribed can be successfully dealt with by the body, and cannot possibly cause harm. Dr. Parnell and Dr. Skottowe did not mention the Rorschach test, which is said to be a useful addition to psychiatric examination in predicting suicidal tendencies. Many papers on Rorschach findings in cases of attempted suicide have appeared within recent years. It has been pointed out that preoccupation with heavy grey colouring of the blots, usually on more than one figure and almost always on fig. 4, suggests suicidal trends. Marguerite Hertz, of Cleveland, Ohio, believes that Rorschach testing detects more suicidal risks than are recognised by behaviour signs or other symptoms. In regard to the case quoted by Dr. Wilkinson (Feb. 9) it is interesting to note that in Rorschach studies there is a suggestion that outwardly directed aggressiveness and hostility are less characteristic of suicidal patients. While I agree with Dr. Sawle Thomas (Feb. 9) that many depressed patients are successfully treated by outpatient electroconvulsion therapy, the thorough-going psychotic depressive with suicidal ideas is a serious risk, and should be treated in a mental hospital. In my experience it is during the period of recovery, when the emotional field is still variable, that suicide occurs ; extra caution should be exercised and it is better for the patient to be away from home.
the Editor
BRONCHIAL CARCINOMA
SiR,-Mr. Nicholson and his associates (Feb. 9) deplore the average delay of six months between the onset of symptoms and the attendance of patients at their clinic. They misguide us when they state that " we must strive to persuade the public to recognise and take heed of these symptoms early, and not to neglect them for six months." The delay in diagnosis of carcinoma of the lung is not due to the failure of patients to report their symptoms to their doctors. It is largely due to the failure of the medical profession as a whole to diagnose carcinoma of the lung at an early stage. This long delay is experienced in almost all surgical centres. It is due to the essential difficulties in diagnosis, which requires special techniques available only in thoracic surgical units. The present tendency for general practitioners to refer chest cases to chest clinics, which have evolved from the old tuberculosis dispensary, in order to get an X ray, has contributed largely to the delay. An analysis of the causes of delay in referring the 135 cases submitted to operation for carcinoma of the lung at the London Hospital in 1954 showed an average delay from first symptom to attendance at the department of thoracic surgery of 6-4 months. This delay was made up as follows : From first 1.5 months.
From
symptom
to
consulting general practitioner :
seeing general practitioner
to
1-1 months.
From
seeing
3’8 months.
chest
physician
to
seeing seeing
chest
physician :
chest surgeon :
-
A further analysis of these figures revealed that the average delay between physician and surgeon was 2 months for those cases which proved to be inoperable at thoracotomy, 4 months for those who had a pneumonectomy, and 5.5 months for those who had lobectomy. The delay was greatest in those most likely to benefit from surgery. The difficulties in diagnosis are the real problem. Diagnosis requires special techniques available to surgeons but not to most physicians. If general practitioners could have chest X rays for their patients independently of consultant physicians, the delay between first symptom and operation might be appreciably shortened. General practitioners who suspect that their patients have carcinoma of the lung should be encouraged to send them direct to surgical centres. There are enough fully trained There thoracic surgeons to deal with the problem. could be a great economy, a benefit to patients, and less frustration if there existed an independent radiological service so that general practitioners could have a direct report on which they could exercise their own responsibility. Radiology is now an essential part of clinical examination. VERNON C. THOMPSON. TOWARDS PREVENTING SUICIDE
SIR,-Dr. Parnell and Dr. Skottowe (Jan. 26) have raised
important issue and have re-emphasised the warning signs of possible suicide. I am always put on the alert when ideas of guilt, self-depreciation, and selfaccusation, associated with tension and agitation, are in evidence and if the patient does not get any relief from unburdening. Again, if a patient is preoccupied with one organ or one system, and is convinced that the disorder is serious, then one should realise that he is a potential an
suicide.
It is a fallacy to think that the patient who talks about killing himself will not do so. Insomnia is also of great impor-
Lawrence (Feb. 9) mentions the important between alcoholism and suicide. I regard alcoholism as a form of physiological suicide. Certain patients have unconscious drives which allow them to kill themselves by alcohol. It is not surprising that on occasions the process is speeded up by overt attempts which are often successful. Of course, the causes given for self-destruction are much too contradictory to be of any use in understanding the suicidal drive. Sometimes it how to understand from be persons suffering may easy psychotic and nervous illnesses can commit suicide, but it is very difficult to understand the unexpected suicide. The great majority of suicides are " normal " people and the reasons given for their attempts, such as problems of Dr.
relationship
love, finance,
or
bereavement,
which have fired the loaded Severalls Hospital, Colchester.
are
merely " triggers
gun." -r, T"r i-) ROBERT H. F. F. c
SIR,-The article by Dr. Parnell and Dr. Skottowe, the correspondence which followed it, seem to
and
that the prevention of suicide isalways desirable. Is that assumption justified ? Dr. PullarStrecker reminds us (Feb. 9) that 130 years ago it was legal to bury suicides at a cross-roads with a stake through their bodies. Presumably that reflected the attitude of very many people at the time. But public opinion has moved far since then, and I suggest that it is still moving. Many have come to realise that it is utterly hypocritical to condemn the individual suicide on the ground of the " sanctity of human life " while all the nations are pure= pared to send their young men to die in war. And many are frankly questioning the too-facile assumption that suicide always betokens an unsound mind. Are we not moving towards a time when many of those who, by reason of the infirmities of old age, are no longer able to make a worth-while contribution to the community in which they live and to enjoy life, will fearlessly ask themselves whether it is not better to " cut the painter " rather than join the ever-increasing host of those waiting to die in old people’s homes, mental institutions, or the homes of kindly (or not-so-kindly) friends and relations ?’! It seems to me that the social and economic stresses and strains of our rapidly ageing population must inevitably lead to such questionings, and, as a probable result, to a rising suicide-rate, at least among the old. It would be of interest to know if the high suicide-rates of Switzerland and Denmark show any evidence of such assume
a
trend.
Letters
to
tance, especially if the person is very concerned about it. Patients often have grave doubts about the hypnotics prescribed : they fear that drugs will damage their brain. It is well to spend some time explaining to the patient that the medicine prescribed can be successfully dealt with by the body, and cannot possibly cause harm. Dr. Parnell and Dr. Skottowe did not mention the Rorschach test, which is said to be a useful addition to psychiatric examination in predicting suicidal tendencies. Many papers on Rorschach findings in cases of attempted suicide have appeared within recent years. It has been pointed out that preoccupation with heavy grey colouring of the blots, usually on more than one figure and almost always on fig. 4, suggests suicidal trends. Marguerite Hertz, of Cleveland, Ohio, believes that Rorschach testing detects more suicidal risks than are recognised by behaviour signs or other symptoms. In regard to the case quoted by Dr. Wilkinson (Feb. 9) it is interesting to note that in Rorschach studies there is a suggestion that outwardly directed aggressiveness and hostility are less characteristic of suicidal patients. While I agree with Dr. Sawle Thomas (Feb. 9) that many depressed patients are successfully treated by outpatient electroconvulsion therapy, the thorough-going psychotic depressive with suicidal ideas is a serious risk, and should be treated in a mental hospital. In my experience it is during the period of recovery, when the emotional field is still variable, that suicide occurs ; extra caution should be exercised and it is better for the patient to be away from home.
the Editor
BRONCHIAL CARCINOMA
SiR,-Mr. Nicholson and his associates (Feb. 9) deplore the average delay of six months between the onset of symptoms and the attendance of patients at their clinic. They misguide us when they state that " we must strive to persuade the public to recognise and take heed of these symptoms early, and not to neglect them for six months." The delay in diagnosis of carcinoma of the lung is not due to the failure of patients to report their symptoms to their doctors. It is largely due to the failure of the medical profession as a whole to diagnose carcinoma of the lung at an early stage. This long delay is experienced in almost all surgical centres. It is due to the essential difficulties in diagnosis, which requires special techniques available only in thoracic surgical units. The present tendency for general practitioners to refer chest cases to chest clinics, which have evolved from the old tuberculosis dispensary, in order to get an X ray, has contributed largely to the delay. An analysis of the causes of delay in referring the 135 cases submitted to operation for carcinoma of the lung at the London Hospital in 1954 showed an average delay from first symptom to attendance at the department of thoracic surgery of 6-4 months. This delay was made up as follows : From first 1.5 months.
From
symptom
to
consulting general practitioner :
seeing general practitioner
to
1-1 months.
From
seeing
3’8 months.
chest
physician
to
seeing seeing
chest
physician :
chest surgeon :
-
A further analysis of these figures revealed that the average delay between physician and surgeon was 2 months for those cases which proved to be inoperable at thoracotomy, 4 months for those who had a pneumonectomy, and 5.5 months for those who had lobectomy. The delay was greatest in those most likely to benefit from surgery. The difficulties in diagnosis are the real problem. Diagnosis requires special techniques available to surgeons but not to most physicians. If general practitioners could have chest X rays for their patients independently of consultant physicians, the delay between first symptom and operation might be appreciably shortened. General practitioners who suspect that their patients have carcinoma of the lung should be encouraged to send them direct to surgical centres. There are enough fully trained There thoracic surgeons to deal with the problem. could be a great economy, a benefit to patients, and less frustration if there existed an independent radiological service so that general practitioners could have a direct report on which they could exercise their own responsibility. Radiology is now an essential part of clinical examination. VERNON C. THOMPSON. TOWARDS PREVENTING SUICIDE
SIR,-Dr. Parnell and Dr. Skottowe (Jan. 26) have raised
important issue and have re-emphasised the warning signs of possible suicide. I am always put on the alert when ideas of guilt, self-depreciation, and selfaccusation, associated with tension and agitation, are in evidence and if the patient does not get any relief from unburdening. Again, if a patient is preoccupied with one organ or one system, and is convinced that the disorder is serious, then one should realise that he is a potential an
suicide.
It is a fallacy to think that the patient who talks about killing himself will not do so. Insomnia is also of great impor-
Lawrence (Feb. 9) mentions the important between alcoholism and suicide. I regard alcoholism as a form of physiological suicide. Certain patients have unconscious drives which allow them to kill themselves by alcohol. It is not surprising that on occasions the process is speeded up by overt attempts which are often successful. Of course, the causes given for self-destruction are much too contradictory to be of any use in understanding the suicidal drive. Sometimes it how to understand from be persons suffering may easy psychotic and nervous illnesses can commit suicide, but it is very difficult to understand the unexpected suicide. The great majority of suicides are " normal " people and the reasons given for their attempts, such as problems of Dr.
relationship
love, finance,
or
bereavement,
which have fired the loaded Severalls Hospital, Colchester.
are
merely " triggers
gun." -r, T"r i-) ROBERT H. F. F. c
SIR,-The article by Dr. Parnell and Dr. Skottowe, the correspondence which followed it, seem to
and
that the prevention of suicide isalways desirable. Is that assumption justified ? Dr. PullarStrecker reminds us (Feb. 9) that 130 years ago it was legal to bury suicides at a cross-roads with a stake through their bodies. Presumably that reflected the attitude of very many people at the time. But public opinion has moved far since then, and I suggest that it is still moving. Many have come to realise that it is utterly hypocritical to condemn the individual suicide on the ground of the " sanctity of human life " while all the nations are pure= pared to send their young men to die in war. And many are frankly questioning the too-facile assumption that suicide always betokens an unsound mind. Are we not moving towards a time when many of those who, by reason of the infirmities of old age, are no longer able to make a worth-while contribution to the community in which they live and to enjoy life, will fearlessly ask themselves whether it is not better to " cut the painter " rather than join the ever-increasing host of those waiting to die in old people’s homes, mental institutions, or the homes of kindly (or not-so-kindly) friends and relations ?’! It seems to me that the social and economic stresses and strains of our rapidly ageing population must inevitably lead to such questionings, and, as a probable result, to a rising suicide-rate, at least among the old. It would be of interest to know if the high suicide-rates of Switzerland and Denmark show any evidence of such assume
a
trend.