Lluís Martínez Via
Dermatologist. Figueres. Girona (Spain).
Correspondence:Lluís Martínez Via. c/Sant Llàtzer, 12. 17600 Figueres. Girona (Spain).
Received 13 January 2008; accepted 7 March 2008
Keywords: Melanoma, Mole, Pigmented nevi, Cinematographic adaptation.
We all too often find beliefs solidly incrusted in the trunkful of prejudices of many people. For example, one of them is that the best attitude to adopt before an atypical mole would be not to touch it at all, and –how incongruous (!)- we abstain from taking any action precisely because it could be a melanoma. As dermatologists, we have all come across -and probably on more than one occasion- the need to use special efforts to explain to our patients that we must remove a nevus because it is atypical and has fair probabilities of becoming malignant and sooner or later developing into a melanoma.
Since the cinema is able to create and maintain opinions in the public at large1, my hypothesis is that the film entitled Not as a Stranger (1955), by Stanley Kramer, helped to construct a myth in Spain about not touching atypical pigmented nevi.
This assertion is founded on several aspects:
a. The film was shown for a long time, significantly more than others of those times*.
b. It is based on a famous novel that appeared in those times- that of Morton Thompson, with the same title and published in 1954.
c. It had a fantastic cast: Robert Mitchum. Olivia de Havilland, Frank Sinatra, Gloria Grahame, Broderick Crawford, Charles Bickford, and a very young Lee Marvin.
d. It has popular arguments (efforts, fame, social stratification, jealousy, adultery, retributive aspects, medical mistakes, and intrigues among professionals, among patients…)
The film has already been addressed in this journal2. Surprising medical questions were explored. Among them, the one that most aroused our attention is the attitude of Dr. Lucas Marsh (Robert Mitchum) when asked by a patient, who when admitted to hospital for other reasons, asks him to remove and ugly mole on her jaw; It makes me nervous and it doesn’t look nice. After examining the nevus, with his right thumb as though he were palpating a tumour, Dr. Marsh replies (with the verve typical of Mitchum) that it would be best not to touch it (videoclip 1).
Later, Marsh coincides by chance with the patient and asks her about the sticking plaster on her jaw. She is happy because the nevus has been removed and it is the nurse who answers: Nothing Doctor, they have taken out her nevus, which makes Marsh react angrily (videoclip 2). He rapidly looks for the patient’s medical record and has no qualms about facing up to Dr. Alfred Boone (Frank Sinatra), his best friend until that moment and the person who removed the nevus. Marsh is livid and reproaches Booone, arguing that it wasn’t a simple mole; it was a melanoma (…) and I’ll have you thrown to the dogs. As if, in fact, Dr. Boone had been grossly negligent2. Meanwhile Marsh’s wife Kristina (Olivia de Havilland), a nurse, looks on surprised and very uncomfortable about the whole scene and the aggressiveness of her husband.
The only treatment for melanoma is surgery, suitably aided by measures such as chemotherapy, etc. Some decades ago, a debate arose as to whether incisional biopsy involved greater risk than the excisional type owing to the marked ability of melanomas to metastasise. It was even questioned whether the mere palpation of a tumour might disseminate cells able to become metastatic3,4,5. Currently, it is known that biopsies should strive to be excisional, the incisional type being reserved for zones in which the former type would be very traumatic (for example, the nails).
It is also accepted that melanomas have three ways of metastasising:
a. Sequentially (first to the regional ganglia, and thence to other organs).
b. Simultaneously to organs and ganglia (ganglion affectation would be a marker of systemic affectation).
c. On the basis of the theory of the seed and the earth (as intuited by Paget in 1889), which in essence establishes that metastases will only develop if tumour cells are compatible with the receiving tissue6.
This latter theory is now the most widely accepted7.
In any case, only appropriate pathology studies (always bloody) will reveal whether one is dealing with a melanoma and also its staging (Breslow, Clark, etc). Without them, for the time being it is impossible to establish a sound therapeutic approach.
A final consideration has top do with the tile of the film, which is curious and apparently derived from chapter 9, verses 26-27 of the Book of Job:
26 And though after my skin worms destroy this body,
Yet in my flesh shall I see God: Whom I shall see for myself,
27 And mine eyes shall behold, and not another;
Though my reins be consumed within me.
Title: Not as a Stranger
Director: Stanley Kramer
Music: George Antheil
Screenwriter: Edna Anhalt and Edward Anhalt based on the novel of the same name by Morton Thompson
Cast: Olivia de Havilland, Robert Mitchum, Frank Sinatra, Gloria Grahame, Broderick Crawford, Charles Bickford, Myron McCormick, Lon Chaney Jr., Jesse White, Harry Morgan and Lee Marvin.
Runtime: 135 minutes
Production Companies: Stanley Kramer Productions
Synopsis: An ambitious but poor medical student, Lucas, marries a surgery nurse Kristina so that she can pay for his studies. Kristina loves Lucas but he only loves his work. He begins to work for a generalist physician. The death of that colleague, who becomes one of Lucas’ patients, makes him recapitulate about his life.
* In Qué grande es el cine, the program directed by José Luis Garci on Spanish TV 2 in November 2005, we had the opportunity to see Not as a Stranger and in the debate before the showing of the film, Juan Cobos, one of the usual commentators, stated that at the Cine Amaya in Madrid it beat all the records for viewers since it was shown for such a long time.