The purpose of this study was to evaluate subungual melanoma as a site-specific entity, to determine the influence of regional nodal involvement, and to ascertain where possible the role of histologic grading of the primary site. Thirty-three patients with subungual melanoma whose median age was 56 yr underwent treatment between 1950 and 1975. There were 11 male and 22 female patients. Forty-eight per cent of lesions were 11 male and 22 female patients. Forty-eight per cent of lesions occurred on the hand. Of 23 clinical stage I patients, seven patients underwent amputation only, while 16 patients underwent amputation and regional nodal dissection. Histologic examination of the primary tumor suggested a trend towards thicker/ulcerated lesions to be associated with metastatic melanoma in regional lymph nodes and/or death due to disease. Early survival patterns favored female patients but there was no significant difference in 10-year survival when analysed by patient sex. Clinical/pathologic stages were the most significant factors affecting long-term survival with 5- and 10-year survivals of 66% and 55% in stage I patients and 22% and 0% in stage II patients.

In hospitalized patients, the commonest causes of acute insomnia are the effects of illness, environmental sleep disruption, medication, anxiety, and depression. Treatment should correct underlying medical disorders; reduce environmental sleep disruptions; and lower anxiety with psychological interventions, sedative or hypnotic medication, and relaxation training. Special clinical problems include chronic pain, delirium, and insomnia in the elderly.

The authors describe the role of metaphor in the theory and practice of psychotherapy. Metaphors are considered fundamental elements of our worlds of language and concepts and not just figures of speech, poetic devices, parables, or creative ways to make interpretations. Metaphors shape the process of therapy by structuring the therapist's perceptions, stance, and attitude. They also organize the way problems are discussed as well as the solution that are seen as effective. The authors review the literature on metaphor in psychotherapy and explore common psychotherapeutic metaphors such as "psychotherapy is war," "the mind is a brittle object," "the conduit metaphor," and a variety of somatic metaphors. They conclude with a discussion of how metaphors function in the process of psychotherapy.

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