DECUBITUS ULCERS AND AMYOTROPHIC LATERAL SCLEROSIS

658

adenoidectomy of value for the two main indications for adenoidectomy-nasal blockage and serous otitis media? In both of these conditions there are measurements and such studies would prove of inestimable value. Department of Otolaryngology, Royal Infirmary, Glasgow G4 0SF

CHECK-LIST OF DIURNAL SYMPTOMS

monitor,

to

G. G. BROWNING

IS BED WETTING PSYCHOLOGICAL?

SiR,—Your editorial response’ to Berg’s paperand others perpetuates many of the incomplete observations, unwarranted assumptions, and oversights which cloud the issue of enuresis. You uncritically accept or make the following assumptions: that the spontaneous-cure rate is 20% per annum; that most bedwetting children have normal radiographs and smallerthan-normal bladder capacities; and that physical factors, easily detected, seldom cause enuresis. And you ask "is the incontinence one symptom of a wider emotional disorder?" and is urgency, which night wetters are likely to have "a conditioned response which can be modified by behaviour therapy for the child--or its parents?" Since many enuretics achieve a dry bed by becoming nocturic and carry symptoms of frequency, urgency, and stress incontinence and prostatic problems3 and impotence4into adult life, a dry bed is an incomplete criterion of cure. Most wetters, particularly those with diurnal symptoms, have abnormal cystourethrograms, including reflux in about 10%.5-9 The enuretic’s bladder size is normal. 10 Premature detrusor contractions, irritation, produces a funcgenerally secondary to peripheral tional reduction in capacity. 11I The misconception that physical disease seldom causes enuresis-a misconception which underlies and largely explains untenable sociological and psychiatric hypotheses---derives from the belief, entirely erroneous,’ that negative physical and urinary examination ensures the absence of disease and from neglect of the weighty case for organic enuresis. 5-8, 11-14, 16 Physicians fail to appreciate the more subtle aspects of the spectrum of urethral disorders.’,12,14 and flow dynamics. 15 Exclusion of cases with gross disease, about which there is no controversy, leaves some 90% of wetters with associated diurnal symptoms (see table) while 10% have none that we can detect. Persistent daytime voiding invariably reflects organic disease-usually lower urinary tract, sometimes anorectal.11 Urological treatment relieves diurnal problems within weeks in about 85%,7 and, after a longer period, night wetting is improved in 50-75%7,8,12,14,16 of the patients. Sleep depth and factors we cannot detect or do not understand probably account for most of the 10% minority who have no symptoms during the day. Deep sleep, ignored in your editorial, is a central factor in both groups. 7,17 1. Lancet, 1977, ii, 1214. 2. Berg, I., Fielding, D., Meadow, R. Archs Dis. Childh. 1977, 52, 651. 3. Medical News J. Am. med.Ass. 1969, 209, 354. 4. Huhner, M., Disorders of the Sexual Function in Male and Female;

p. 210.

Philadelphia, 1928. 5. Brodny, M. L., Robins, S. A.J.Am. med.Ass. 1944, 126, 1000. 5. Fisher, O. D., Forsythe, W. I. Archs Dis. Childh. 1954, 29, 460. 7. Arnold, S. J. Postgrad med. 1968, 43, 191. 8. Arnold, S. J., Ginsburg, A. Urology, 1974, 4, 145. 9. Arnold, S. J., Ginsburg, A., Berg, R. ibid. 1973, 1, 397. 10. Troup, C. W., Hodgson, N. B.J. Urol. 1971, 105, 129. 11. Winsbury-White, H. P. in Textbook of Genito-urinary Surgery 12. 13. 14. 15. 16. 17.

H. P. Winsbury-White); p. 275. Edinburgh, 1948. Mahoney, D.T.J. Urol. 1971, 106, 1971. Arnold, S. J., Ginsburg, A. Postgrad med. 1975, 58, 73. Hendren, W. H.J. Urol. 1971, 106, 298. Ritter, R. C., Zinner, N. R., Paquin, A. J.J. Urol. 1964, Arnold, S. J., Ginsburg, A. Urology, 1973, 2, 1973. Pierce, C. M. Can. spychiat. Ass-J. 1963, 8, 415.

(edited by

That bute to

widely

a

factors

must

somehow

cause or

contri-

held but

unsupported belief. IS Urgency,

an

irritative

phenomenon not a conditioned reflex (to what?), does not warrant suggesting that child or parent requires behaviour modification therapy. Correction of voiding difficulties produces psychological benefits.’ One would expect parental and peer response to daytime wetting to create more behaviour disturbances than night wetting alone which is easier to hide. We agree that most children’s doctors can be confident diagnosis and management of enuresis-provided are aware of the limitations of your editorial. they S. J. ARNOLD 11 Pine Street, A. GINSBURG Morristown, New Jersey 079 60, U.S.A.

about the

DECUBITUS ULCERS AND AMYOTROPHIC LATERAL SCLEROSIS were intrigued by the Lancet correspondence on suggestion that pressure sores spare patients with amyotrophic lateral sclerosis (A.L.s.). At the Inglis House of Philadelphia, a chronic disease institution with nearly three hundred long-term residents having debilitating diseases such as paraplegia, quadriplegia, multiple sclerosis, Parkinson’s disease, and cerebral palsy, the prevalence of decubitus ulcers is 10% and this seldom varies, despite the annual turnover of fifty patients. A review of our records for the past decade, encompassing nearly eight hundred patients, revealed five residents with

SIR,-We

the

of whom had decubitus ulcers. The three who remained free of ulcers were a 44-year-old White woman whose disease ran a rapid downhill course and who died 3 years later; a 47-year-old woman who died 8 years after diagnosis of A.L.S.; and a 58-year-old man with A.L.S. for 10 years. A 41-year-old woman who had had A.L.s. for 17 years had decubitus ulcers over the sacrum 7 months before her death. A 41-year-old woman with A.L.S. for 21 years acquired a large decubitus ulcer over the sacrum 9 months ago. Examination confirms the neurological diagnosis, and histopathological examination of the ulcer and adjoining skin fits the appearances of specimens taken from other patients with decubitus ulcers. A.L.S. two

18.

91, 161.

psychological

persistent bedwetting and voiding difficulties remains

Shaffer, D.

in Bladder Control and Enuresis

(edited by I. Kolvin, R. C. Mac-

Keith, and S. R. Meadow); p. 133. London, 1973. 1. Forrester, J. M. Lancet, 1976, i, 970. 2. Furukawa, T. ibid. p. 862. 3. Furukawa, T., Toyokura, Y. ibid. Jan. 21, 1978, p. 159.

659 A Medline search failed to yield any additional references. We do not think that our findings are unique and can only conclude that others have not reported their observations. No disease is more immune to this devastating condition of the bedridden than another. All patients are candidates for ulcers once blood-flow is compromised, and do not agree that A.L.s. spares tissue breakdown and thus prevents the ulcers. Department of Dermatology, University of Pennsylvania School of Medicine, LAWRENCE C. PARISH* and Medical and Nursing Service, GLEN SMITH House, Inglis ELIZABETH COLLINS Philadelphia, Pennsylvania, U.S.A.

PRIORITIES IN THE N.H.S.

SIR,-Your Parliamentary correspondent (March 4, p. 511) reports that the B.M.A. is highly critical of the Secretary of State’s strategy for shifting the balance of priorities in favour of services for the elderly, for the mentally ill and handicapped, SOUTH WESTERN REGION: GROWTH IN REVENUE EXPENDITURE

1975-76

TO

1976-77

(EXCLUDING PERSONAL

SOCIAL

SERVICES)

MANUAL DILATATION OF ANUS—HOW OLD?

SiR,-In 1968 Mr P. H. Lord reported success with massive anal sphincters in patients with hmmorrhoids.1 Since then others have tried this method with satisfactory results, and it is now often referred to as the Lord procedure. In 1886, Allingham,2 writing on haemorrhoids, described divulsion of the anus (as manual dilatation was then known) in these words:

stretching of

"I will pass on to dilatation of anal sphincters so strongly advocated by Messrs. Verneuil, Fontan, Panas, Gosselin and Monad. The method is as follows:- The patient being full under the influence of an anwsthetic, the surgeon inserts both thumbs into the rectum and dilates gradually first in the antero-posterior and then in the opposite direction using an amount of force sufficient to overcome spasm. He continues to manipulate the sphincter until it is reduced to a pulpy mass, so that he can easily insert his whole hand and even draw it out as

a fist."

Lockhart-Mummery in 1923 devoted a chapter to the subject in his book

on

the diseases of colon and rectum.2 He stated:

of strangulated and sloughing internal piles, stretching the sphincter is often the best means of giving immediate relief and it will sometimes afford permanent relief in slight cases of internal piles where there is occasional prolapse accompanied by haemorrhage". Lockhart-Mummery gave credit to Mr Teale of Paris for "In

cases

this form of treatment in 1865. There are minor variations in the techniques described by him and Lord. Dilatation was done by first introducing two fingers of both the hands well lubricated. The procedure took 5-10 min. The anus was not packed afterwards nor were anal dilators used. Why was such a useful method of treatment forgotten? The most probable reason must have been the lack of a suitable anxsthetic agent. The need for deep anaesthesia was recognised by Lockhart-Mummery ("it is important not to commence the divulsion until deep anaasthesia has been obtained"), and Faber stressed this point in 1972.’’ An intravenous short-acting anaesthetic agent suits this requirement admirably, but the first of the group, thiopentone, was not available until 1935. Ether must have led to many failures because of inadequate sphincter relaxation. Dilatation done without sufficient muscular relaxation must have required greater force and led to a higher incidence of complications. Chloroform was too toxic. I have tried intravenous anaesthesia on a few patients with success. It is particularly suitable in countries where the patients are generally very anaemic and can ill afford to lose more blood during the conventional haemorrhoidectomy, and a shorter postoperative stay (it was tried on an inpatient basis) helps to relieve pressure on overcrowded hospitals. Intravenous anaesthesia is also more economical.

first

advocating

some

of Surgery, Darbhan Medical College Hospital, Laheriasarai, Bihar, India

Department

HARI NARAYAN BHARDWAJ

1. 2.

Lord, P. H. Proc. R. Soc. Med. 1968, 61, 935.

3.

Lockhart-Mummery,

Allingham, W. in International Encyclopaedia of Surgery: a systemic treatise on the theory and practice of surgery, (edited by John Ashurst); vol. VI, p. 126.

P. Diseases of the Rectum and Colon and their Surgical Treatment; p. 224. London, 1923. 4. Faber, R. G. (1972) in "Hæmorrhoidectomy versus manual dilatation of the Anus". Lancet, 2,718-19.

*

Illustrative national average growth-rate per annum for Health and Personal Social Services in England. t Calculated.

from Priorities

and for children, and that it questions the Government’s policy of slowing down the expansion of acute services. The table gives figures for 1975/6 and 1976/7 for client groups in this region. It would be interesting to have figures for other re-

gions. Avon Area Health Lewin’s Mead, Bristol BS1 2EE

Authority (Teaching),

D. J. HUCKLESBY A. H. SNAITH

CHOLINESTERASE INHIBITION IN TREATMENT OF ALZHEIMER’S DEMENTIA

SIR,-Several workersl-3 have pointed to the loss of cortical choline acetyltransferase in Alzheimer type dementia. It is possible that acetylcholine deficiency, rather than loss of cholinergic neurones may be a primary process in this condition, and dietary choline4.s and lecithin6have both been tried, on the analogy of levodopa in parkinsonism. The other obvious line of attack, on this hypothesis, would be the use of an anticholinesterase. Unfortunately none of the anticholinesterase drugs available for other therapeutic purposes look safe enough for trial, and all of them act systemi-

cally. What is needed is a cholinesterase inhibitor with predominantly central effects. Such a substance would be of research value in identifying cholinergic systems in laboratory animals even if the acetylcholine hypothesis of senile dementia proves incorrect. In such a context the "irreversible" inhibitors of cholinesterase deserve another look. They have been extensively researched as insecticides and war gases; not all this research is available, and large numbers of compounds must have been screened. It is possible that among these insufficiently toxic compounds we might find either a family of substances with near-selective action on brain acetylcholinesterase or pointers to a tailor-made inhibitor with controllable effects, the cholinergic equivalent of carbidopa or of the less-toxic monoamine-oxidase inhibitors. It would be of value if chemists with experience in this area would review their records: the possibility of producing as good remission in Alzheimer-type 1. Davies, P., Maloney, A. J. F. Lancet, 1976, ii, 1403. 2. Perry, E. K., Perry, R. H., Blessed, G., Tomlinson, B. E. ibid. 1977, i, 189. 3. White, P., Goodhart, M. J., Keet, J. P., Hiley, C. R., Carrasco, L. H., Williams, I. E. I., Bowen, D. M. ibid. 1977, i, 668. 4. Cohen, E. L., Wurtman, R. J. Science, 1976, 191, 56. 5. Boyd, W. D., Graham-White, J., Blackwood, G. Glen, I., McQueen, J.

Lancet, 1977, ii, 711. 6.

Perry, E. K., Perry, R. H., Tomlinson, B. E. ibid. i.p. 243