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MALIGNANT MELANOMA OF THE SKIN
1039
individual practitioner in building up the picture of the pattern ’
of disease and of medical care in society. Although Professor Pemberton has defined these two components of social medicine, he has not indicated the difficulties of measuring them. They should be measured simultaneously.u Epidemiological measurements are easier and less
complicated to obtain than those of the effects of medical care, which is made up of a greater number of variable factors. Treatment when applied to society involves not only measurement of the provision of information about treatment to doctors, but also measurement of how they assimilate this information, and of how they use it for treatment of their patients. Analysis of how the information affects prescribing, bed usage, and time lost from employment due to sickness, all give measures of how effectively doctors use their therapeutic resources. These measurements are complicated to carry out and difficult to interpret, but they can be made by operational-research techniques.12 Whether or not departments of social medicine split into departments of epidemiology and medical care, there is urgent need for extensive and planned research in the field of medical care in society. Department of Pharmacology, Trinity College, University of Dublin, Dublin 2.
C. W. M. WILSON.
VISITING CHILDREN IN HOSPITAL SIR,-Although I appreciate the altruism of their campaign, the carefully worded letter from Dr. MacCarthy and Dr. Mac Keith (April 23) should be put into perspective, for the medical press has a wide public these days. Your correspondents should know that surgeons and anaesthetists are as sympathetic as are paediatricians for child patients, and have no desire to heal their bodies and hurt their minds Dr. MacCarthy and Dr. Mac Keith may be admitting this in that " what is commonly found to be workable as a routine in private
saying
practice should not be wholly inapplicable to hospital wards ". It is a pity they do not go on to mention the restrictions both temporal and spatial in hospital facilities, which make their routine desirable and difficult at the same time. Hospital facilities are determined from a distance by the administrator and Civil Servant, who are concerned with quantity production and not quality. Dr. MacCarthy and Dr. Mac Keith are advocating an increase in quality, and it should be pointed out for the bureaucrats and not in the first most of whom are ready to alter and improve their management of patients. that their strictures
are
place for the clinicians,
E. H. SEWARD.
ANTENATAL EDUCATION SiR,-Mrs. Kitzinger is certainly right when she states in her letter last week that the time is ripe for a new approach to the education of expectant parents, but she underestimates the training that is available to midwives, health visitors, and physiotherapists. University College Hospital has for several years been running a fortnight’s course for physiotherapiststhis includes physiological and psychological aspects of childbirth, observation of labours, and the theory and practice of teaching. Shorter courses are held in other London centres and in Leeds. The Obstetric Association of Chartered Physiotherapists is a specialist group within the Chartered Society of Physiotherapy, open only to those physiotherapists who have attended such a course and have worked for 6 months in a maternity unit; it also holds a study weekend once a year. The Royal College of Midwives, some county health authorities, and the National Childbirth Trust run short courses for midwives and health visitors. 11. Wilson, C. W. M., Banks, J. A., Mapes, R. E. A., Korte, S. M. T. Br. med. J. 1963, ii, 604. 12. Wilson, C. W. M., Banks, J. A., Mapes, R. E. A., Korte, S. M. T. Problems and Progress in Medical Care; p. 173. Nuffield Provincial Hospitals Trust, London, 1964.
Unfortunately employing authorities do not always insist that their antenatal teachers have attended any course or have a special understanding of the problems of childbearing; health visitors and physiotherapists are much more often selected for this work simply because it happens to be their turn on the rota. It is certainly true, as Mrs. Kitzinger says, that preparation for childbirth cannot be taught simply as a series of exercises, though these have their place in the avoidance of stress during pregnancy and in the postnatal recovery of muscle tone. In that part of a course devoted to specific preparation for labour they are but one small facet of the attempt to encourage a woman’s self confidence. Any experienced physiotherapist uses her relaxation classes to create an atmosphere in which her mothers will talk freely, and she must be alert to spot problems whether directly or indirectly expressed. The Royal College of Midwives’ recent survey showed that still not enough teachers have sufficient understanding of a pregnant woman’s emotional needs, nor are they sufficiently good at the art of listening. If the Health Education Council recommends a standard course it seems that the major requirements for all students are help in wise counselling, in the leadership of group discussions, and in the choice of both verbal and visual images to appeal to mothers from different cultural backgrounds. Each group of students would then need to gain experience in whichever side of the work had not previously been included in her professional training-for example, physiotherapists would be given instruction in obstetrics, and midwives would learn to perform and to teach exercises. Not every teacher in a group needs to be a specialist in all branches, provided each knows sufficient of the others’ work-a mother often benefits from her contacts with several teachers. Practical experience of parenthood is certainly a great advantage providing it is supplemented by sufficient objective observation of others. We can hardly send all staff off to have a couple of babies before allowing them to teach. M. WILLIAMS Chairman, 26
Obstetric Association of Chartered
Brampton Grove,
London N.W.4.
Physiotherapists.
MALIGNANT MELANOMA OF THE SKIN SIR,-Iread with interest your leading article.1 While it is informative, there appears to be some slanting of the viewpoint. Benign naevi are all junctional at inception. Most have a slight junctional element at all times. The greatest number and growth of nsevi occur below the age of thirty with spontaneous disappearance beyond this age. The world’s published reports contain less than twenty carefully documented malignant melanomas arising before the age of puberty. (Giant hairy nsevi have an impressive malignant potential and should not be included with other nasvi.) Most melanomas come after the age of forty, with the peak incidence at seventy. The implication that the benign junctional nasvus is the usual source of the malignant melanoma is probably false. To the best of my knowledge removal of a portion of a cutaneous malignancy has not been proved to spread the malignancy. I favour removing an entire pigmented lesion to give the pathologist the best possible specimen, but feel no qualms about removing only the most suspicious areas when necessary. Again, I plead ignorance of any evidence that a few days’ delay for diagnosis is detrimental to therapy of malignant melanoma. Many melanomas are treated by physicians who are not surgeons. The malignant melanoma in situ on the face is a slow-growing but fatal lesion. A small specimen can be removed for microscopic diagnosis and the entire lesion curetted superficially, or a wide radical excision can be done. Either treatment results in complete cure. Each physician will laud the type of treatment which he can skilfully employ. The benefit to the patient, however, does not correlate directlv with the size of the snrsical snecimen.
S. W. BECKER, 1.
Lancet, 1965, ii, 1173.
Jr.
individual practitioner in building up the picture of the pattern ’
of disease and of medical care in society. Although Professor Pemberton has defined these two components of social medicine, he has not indicated the difficulties of measuring them. They should be measured simultaneously.u Epidemiological measurements are easier and less
complicated to obtain than those of the effects of medical care, which is made up of a greater number of variable factors. Treatment when applied to society involves not only measurement of the provision of information about treatment to doctors, but also measurement of how they assimilate this information, and of how they use it for treatment of their patients. Analysis of how the information affects prescribing, bed usage, and time lost from employment due to sickness, all give measures of how effectively doctors use their therapeutic resources. These measurements are complicated to carry out and difficult to interpret, but they can be made by operational-research techniques.12 Whether or not departments of social medicine split into departments of epidemiology and medical care, there is urgent need for extensive and planned research in the field of medical care in society. Department of Pharmacology, Trinity College, University of Dublin, Dublin 2.
C. W. M. WILSON.
VISITING CHILDREN IN HOSPITAL SIR,-Although I appreciate the altruism of their campaign, the carefully worded letter from Dr. MacCarthy and Dr. Mac Keith (April 23) should be put into perspective, for the medical press has a wide public these days. Your correspondents should know that surgeons and anaesthetists are as sympathetic as are paediatricians for child patients, and have no desire to heal their bodies and hurt their minds Dr. MacCarthy and Dr. Mac Keith may be admitting this in that " what is commonly found to be workable as a routine in private
saying
practice should not be wholly inapplicable to hospital wards ". It is a pity they do not go on to mention the restrictions both temporal and spatial in hospital facilities, which make their routine desirable and difficult at the same time. Hospital facilities are determined from a distance by the administrator and Civil Servant, who are concerned with quantity production and not quality. Dr. MacCarthy and Dr. Mac Keith are advocating an increase in quality, and it should be pointed out for the bureaucrats and not in the first most of whom are ready to alter and improve their management of patients. that their strictures
are
place for the clinicians,
E. H. SEWARD.
ANTENATAL EDUCATION SiR,-Mrs. Kitzinger is certainly right when she states in her letter last week that the time is ripe for a new approach to the education of expectant parents, but she underestimates the training that is available to midwives, health visitors, and physiotherapists. University College Hospital has for several years been running a fortnight’s course for physiotherapiststhis includes physiological and psychological aspects of childbirth, observation of labours, and the theory and practice of teaching. Shorter courses are held in other London centres and in Leeds. The Obstetric Association of Chartered Physiotherapists is a specialist group within the Chartered Society of Physiotherapy, open only to those physiotherapists who have attended such a course and have worked for 6 months in a maternity unit; it also holds a study weekend once a year. The Royal College of Midwives, some county health authorities, and the National Childbirth Trust run short courses for midwives and health visitors. 11. Wilson, C. W. M., Banks, J. A., Mapes, R. E. A., Korte, S. M. T. Br. med. J. 1963, ii, 604. 12. Wilson, C. W. M., Banks, J. A., Mapes, R. E. A., Korte, S. M. T. Problems and Progress in Medical Care; p. 173. Nuffield Provincial Hospitals Trust, London, 1964.
Unfortunately employing authorities do not always insist that their antenatal teachers have attended any course or have a special understanding of the problems of childbearing; health visitors and physiotherapists are much more often selected for this work simply because it happens to be their turn on the rota. It is certainly true, as Mrs. Kitzinger says, that preparation for childbirth cannot be taught simply as a series of exercises, though these have their place in the avoidance of stress during pregnancy and in the postnatal recovery of muscle tone. In that part of a course devoted to specific preparation for labour they are but one small facet of the attempt to encourage a woman’s self confidence. Any experienced physiotherapist uses her relaxation classes to create an atmosphere in which her mothers will talk freely, and she must be alert to spot problems whether directly or indirectly expressed. The Royal College of Midwives’ recent survey showed that still not enough teachers have sufficient understanding of a pregnant woman’s emotional needs, nor are they sufficiently good at the art of listening. If the Health Education Council recommends a standard course it seems that the major requirements for all students are help in wise counselling, in the leadership of group discussions, and in the choice of both verbal and visual images to appeal to mothers from different cultural backgrounds. Each group of students would then need to gain experience in whichever side of the work had not previously been included in her professional training-for example, physiotherapists would be given instruction in obstetrics, and midwives would learn to perform and to teach exercises. Not every teacher in a group needs to be a specialist in all branches, provided each knows sufficient of the others’ work-a mother often benefits from her contacts with several teachers. Practical experience of parenthood is certainly a great advantage providing it is supplemented by sufficient objective observation of others. We can hardly send all staff off to have a couple of babies before allowing them to teach. M. WILLIAMS Chairman, 26
Obstetric Association of Chartered
Brampton Grove,
London N.W.4.
Physiotherapists.
MALIGNANT MELANOMA OF THE SKIN SIR,-Iread with interest your leading article.1 While it is informative, there appears to be some slanting of the viewpoint. Benign naevi are all junctional at inception. Most have a slight junctional element at all times. The greatest number and growth of nsevi occur below the age of thirty with spontaneous disappearance beyond this age. The world’s published reports contain less than twenty carefully documented malignant melanomas arising before the age of puberty. (Giant hairy nsevi have an impressive malignant potential and should not be included with other nasvi.) Most melanomas come after the age of forty, with the peak incidence at seventy. The implication that the benign junctional nasvus is the usual source of the malignant melanoma is probably false. To the best of my knowledge removal of a portion of a cutaneous malignancy has not been proved to spread the malignancy. I favour removing an entire pigmented lesion to give the pathologist the best possible specimen, but feel no qualms about removing only the most suspicious areas when necessary. Again, I plead ignorance of any evidence that a few days’ delay for diagnosis is detrimental to therapy of malignant melanoma. Many melanomas are treated by physicians who are not surgeons. The malignant melanoma in situ on the face is a slow-growing but fatal lesion. A small specimen can be removed for microscopic diagnosis and the entire lesion curetted superficially, or a wide radical excision can be done. Either treatment results in complete cure. Each physician will laud the type of treatment which he can skilfully employ. The benefit to the patient, however, does not correlate directlv with the size of the snrsical snecimen.
S. W. BECKER, 1.
Lancet, 1965, ii, 1173.
Jr.