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RESPONSIBILITIES OF GOVERNMENT IN RELATION TO DRUGS
855 SUNLIGHT AND MELANOMAS SiR,ňYour editorial (Jan. 23, p. 172) contains a few assertions which are debatable. The late A. G. Oettle’s finding of " the rarity of this tumour in Negroes " requires Nowhere in the world are considerable qualification. melanomas very common tumours. The incidence in the south-western region of England is 1-7 per 100,000.1 The incidence in Uganda Negroes varies from 1-4 per 100,000 to 3-8 per 100,000.2 Bearing in mind that the incidence in south-west England probably represents the highest regional incidence for Great Britain, it is truer to say that melanoma is at least as common in some African states as it is in England. What is different is the distribution of melanoma on the body skin, for in the African Negro the foot is a site of election 2.3; Lewis,2 who had no difficulty in collecting 152 cases for study between 1963 and 1966, found that 64% occurred in this site. Secondly, the belief of Lee and Merrill4 that the Negro conjunctiva is non-pigmented and therefore equivalent as a test tissue to Caucasian conjunctiva is fallacious. Heavily pigmented races, such as are found in Africa and India, quite frequently show a minor degree of pigmentation of the mucosm, being associated perhaps with the somewhat higher incidence of melanoma of nasal and oral cavities in these races. Thirdly, the general reader of your editorial was likely to gain the impression that " melanoma " is a single disease, when in fact it is a group of tumours which have one feature in common-the neoplastic cells are melanogenic. For example, conjunctival melanoma, with its waxing and waning in-situ phase, perhaps to be measured in decades, is a totally different disease from a melanoma arising in association with a mole, and both are unrelated in behaviour to melanoma of the choroid. Clinical practice reflects this. Lentigo maligna and the melanoma arising in it are quite radiosensitive; the melanomas of the skin arising by other histogenetic paths are in general insensitive. Finally, some perspective on the relevance of sunlight and melanomas may be gained from a consideration of melanomas comparable with human ones, in lower animals. In the domestic dog and cat malignant melanomas, with a
histogenesis comparable with some common human melanomas, arise in skin protected from sunlight. The feline ear, though, is a site of election for the development of benign melanoma; this is a site relatively glabrous on its external surface. In man melanoma rarely arises on the auricle. But this is merely to say that all the skin of the head, equally exposed to sunlight, is not equally susceptible to the development of melanoma.
from it; particularly revealing, I thought, were the points of view expressed by some of the students interviewedthey undoubtedly felt inadequately prepared for some aspects of their future jobs as G.P.s. Certainly I believed the facts I was offered in the programme, it is therefore reasonable to assume that other viewers did. However, my own responses to the programme, and my assumptions about others’ responses, are of marginal importance. What does matter is the fact that Professor Rhodes was prepared to maintain a dignified silence about what he apparently regarded as a dishonest presentation of the situation vis-a-vis medical education. Surely, if the programme did select, edit, and present material dishonestly, it was incumbent upon Professor Rhodes to have said so, loud and clear, and to have made vigorous attempts to present what he regards as a true picture ? To have waited for me to display my " naivety " in the correspondence columns of The Lancet is to give me too great a load of responsibility altogether! North Wembley, Middlesex.
RESPONSIBILITIES OF GOVERNMENT IN RELATION TO DRUGS SIR,-Dr. Andrew Herxheimer (Feb. 27, p. 446) suggests that the obligation on drug companies to provide comparative information on their products would tend to cause them to " reject promotional techniques that rely upon and encourage uncritical and self-satisfied attitudes among prescribers ". This seems entirely reasonable. Looking at the situation the other way round, is it not also likely that the banning of these promotional techniques-in particular, advertising techniques exerting influences of which one is not aware-would encourage the drug companies to provide this comparative information ? Of course, for such advertising to be banned it would have to be proved harmful. Without suggesting that studies ought to be undertaken to determine the effects of such advertising on the prescriber’s choice of therapy, the question could be " put to him or her: How do you decide between different therapies ? " Naturally, if the advertising is truly aimed at the subconscious, it must be difficult for even the most introspective prescriber to answer this question honestly. If prescribers were to take a closer look at advertisements, and perhaps reread Vance Packard’s The Hidden Persuaders, their comments might be very interesting indeed. Dublin 4, Ireland.
Your editorial illustrates once more the chiaroscuro nature of melanomas, most paradoxical of tumours, and I am sure has helped to lighten the darkness. Department of Histopathology, Royal Marsden Hospital, London S.W.3.
ARNOLD LEVENE.
HORIZON ON MEDICAL EDUCATION SiR,ňIam a little startled to find that Professor Rhodes (April 10, p. 750) considers I was naive because I accepted the facts presented about medical education in the B.B.C.’s television programme Horizon. Why should he have expected me to immediately dismiss it as " bad journalism " ? There was no reason why I should. There was no obvious evidence that the programme producers had chosen to select and present material in a tendentious manner. Far 1. 2. 3. 4.
Peterson, N. C., Bodenham, D. C., Lloyd, O. C. Br. J. plast. Surg. 1962, 15, 49. Lewis, M. G. Br. J. Cancer, 1967, 21, 483. Hewer, T. F. J. Path. Bact. 1935, 4, 473. Lee, J. A. H., Merrill, J. M. Med. J. Aust. 1970, ii, 846.
CLAIRE RAYNER. IZAYNER.
PHILIP R. KENNEDY.
PREGNANCY AND SERUM-C.P.K. LEVELS IN POTENTIAL CARRIERS OF " SEVERE " X-LINKED MUSCULAR DYSTROPHY
SiR,ňThose engaged in counselling female relatives of boys with the " severe " X-linked form of the childhood (Duchenne) type of muscular dystrophy-as defined by Stevensonand Blyth and Pugh 2-may first see these potential carriers when they are already pregnant, and the decision whether or not to terminate the pregnancy may largely depend upon the advice then given. We think it useful, therefore, to report some results of enzyme estimations made on seven potential carriers and one certain carrier, each of whom was tested both during and out of pregnancy.
The two laboratories concerned were the department of chemical pathology, The Hospital for Sick Children, Great Ormond Street (Lab. I), and the muscular dystrophy research laboratory, National Hospital, Queen Square, 1. 2.
Stevenson, A. C. Ann. hum. Genet. 1953, 18, 50. Blyth, H., Pugh, R. J. ibid. 1958, 23, 127.
histogenesis comparable with some common human melanomas, arise in skin protected from sunlight. The feline ear, though, is a site of election for the development of benign melanoma; this is a site relatively glabrous on its external surface. In man melanoma rarely arises on the auricle. But this is merely to say that all the skin of the head, equally exposed to sunlight, is not equally susceptible to the development of melanoma.
from it; particularly revealing, I thought, were the points of view expressed by some of the students interviewedthey undoubtedly felt inadequately prepared for some aspects of their future jobs as G.P.s. Certainly I believed the facts I was offered in the programme, it is therefore reasonable to assume that other viewers did. However, my own responses to the programme, and my assumptions about others’ responses, are of marginal importance. What does matter is the fact that Professor Rhodes was prepared to maintain a dignified silence about what he apparently regarded as a dishonest presentation of the situation vis-a-vis medical education. Surely, if the programme did select, edit, and present material dishonestly, it was incumbent upon Professor Rhodes to have said so, loud and clear, and to have made vigorous attempts to present what he regards as a true picture ? To have waited for me to display my " naivety " in the correspondence columns of The Lancet is to give me too great a load of responsibility altogether! North Wembley, Middlesex.
RESPONSIBILITIES OF GOVERNMENT IN RELATION TO DRUGS SIR,-Dr. Andrew Herxheimer (Feb. 27, p. 446) suggests that the obligation on drug companies to provide comparative information on their products would tend to cause them to " reject promotional techniques that rely upon and encourage uncritical and self-satisfied attitudes among prescribers ". This seems entirely reasonable. Looking at the situation the other way round, is it not also likely that the banning of these promotional techniques-in particular, advertising techniques exerting influences of which one is not aware-would encourage the drug companies to provide this comparative information ? Of course, for such advertising to be banned it would have to be proved harmful. Without suggesting that studies ought to be undertaken to determine the effects of such advertising on the prescriber’s choice of therapy, the question could be " put to him or her: How do you decide between different therapies ? " Naturally, if the advertising is truly aimed at the subconscious, it must be difficult for even the most introspective prescriber to answer this question honestly. If prescribers were to take a closer look at advertisements, and perhaps reread Vance Packard’s The Hidden Persuaders, their comments might be very interesting indeed. Dublin 4, Ireland.
Your editorial illustrates once more the chiaroscuro nature of melanomas, most paradoxical of tumours, and I am sure has helped to lighten the darkness. Department of Histopathology, Royal Marsden Hospital, London S.W.3.
ARNOLD LEVENE.
HORIZON ON MEDICAL EDUCATION SiR,ňIam a little startled to find that Professor Rhodes (April 10, p. 750) considers I was naive because I accepted the facts presented about medical education in the B.B.C.’s television programme Horizon. Why should he have expected me to immediately dismiss it as " bad journalism " ? There was no reason why I should. There was no obvious evidence that the programme producers had chosen to select and present material in a tendentious manner. Far 1. 2. 3. 4.
Peterson, N. C., Bodenham, D. C., Lloyd, O. C. Br. J. plast. Surg. 1962, 15, 49. Lewis, M. G. Br. J. Cancer, 1967, 21, 483. Hewer, T. F. J. Path. Bact. 1935, 4, 473. Lee, J. A. H., Merrill, J. M. Med. J. Aust. 1970, ii, 846.
CLAIRE RAYNER. IZAYNER.
PHILIP R. KENNEDY.
PREGNANCY AND SERUM-C.P.K. LEVELS IN POTENTIAL CARRIERS OF " SEVERE " X-LINKED MUSCULAR DYSTROPHY
SiR,ňThose engaged in counselling female relatives of boys with the " severe " X-linked form of the childhood (Duchenne) type of muscular dystrophy-as defined by Stevensonand Blyth and Pugh 2-may first see these potential carriers when they are already pregnant, and the decision whether or not to terminate the pregnancy may largely depend upon the advice then given. We think it useful, therefore, to report some results of enzyme estimations made on seven potential carriers and one certain carrier, each of whom was tested both during and out of pregnancy.
The two laboratories concerned were the department of chemical pathology, The Hospital for Sick Children, Great Ormond Street (Lab. I), and the muscular dystrophy research laboratory, National Hospital, Queen Square, 1. 2.
Stevenson, A. C. Ann. hum. Genet. 1953, 18, 50. Blyth, H., Pugh, R. J. ibid. 1958, 23, 127.