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PARKING AND THE DISABLED DRIVER
50 scale inunction with benzyl benzoate emulsion. This substance will continue to give protection until it is washed off.
W. B. ROANTREE. PARKING AND THE DISABLED DRIVER
SIR,-Stricter traffic regulations include non-parking areas, yellow lines, pink zones, and parking meters, and are no doubt the best expedients that can be devised for the present. Unhappily, as the Disabled Drivers’ Motor Club reports in its paper The Disabled Driver, this is bearing harshly and unfairly on this small group of drivers and motorists badly crippled in their legs have unnecessarily to park a long way from their destinations. Stuart-Menteth writes of the difficulties the leg-disabled have in jostling crowds, crossing busy roads, and in walking, say, 200 yards in wind or on slippery pavements. There is a heritage of kindliness in Britain towards the disabled and this is undoubtably shared by the police. But their attitude is said to have hardened and this may be due to their having been issued with stricter instructions about parking (e.g., " no exceptions whatever ") which give them no chance to use their discretion. Undermanned, they have a hard enough task anyway. In some cities, such as Coventry, certificates to attach to the windscreen have been issued to disabled drivers by the Town Clerk on medical recommendation, and parking for the disabled is greatly facilitated. There is no national or nationally accepted scheme. What these people need is permission to park, out of rush hours, for up to half-an-hour, where not causing any obstruction or otherwise inconveniencing traffic. The number of persons concerned in the entire country cannot be great (StuartMenteth estimates not more than 2000), but only those drivers with sufficient loss of function to make walking any distance a heavy burden, should be eligible. The definition would have to be made medically and might be witnessed by a certificate added to the driver’s licence (to be produced on demand) or a badge to be put on the windscreen. It would be especially appropriate if the Ministry of Pensions and National Insurance were to be responsible both for the medical recommendations and for the provision of certificates and/or badses. Gerrards Cross, ROBERT PIPER. Bucks.
ENCEPHALOCELE SIR,-The following case is of interest, for, though the deformity described is doubtless familiar to neurologists and cerebral surgeons, it must be fairly rare, since it receives scant consideration in textbooks and none of my medical colleagues, nursing staff, nor I have ever seen a case like it before. A female African baby, aged 1 week, was admitted on Feb. 11, 1960, with a round cystic swelling of the head over - the sagittal suture (see accompanving photograph), which
had been present since birth. Though the condition was clinically and radiologically an encephalocele, and the prospects of survival were therefore negligible, it was obviously undesirable to leave the swelling intact as it was freely mobile and liable to trauma, and the mother desired its removal. The operation was carried out under local anaesthesia and sedation with chloral hydrate (gr. 71/2). After aspirating the swelling with the removal of slightly yellowish cerebrospinal fluid, an angular incision was made through healthy skin round the neck of the sac and the scalp dissected up to expose the dura mater. The superior sagittal sinus was encountered in the dura in front and behind at its entry to and exit from the encephalocele. This was tied at each point, and the narrow neck of the sac was encircled by a third ligature and cut through
distally. The scalp flaps were stitched back in the mid-line. The stitches were removed on Feb. 24, and the child was discharged on March 8. Apart from slight bulging at the site of the scar there were no complications. The pathologist’s report on a portion of the specimen removed stated that the section passed through skin, meninges, and brain. The inner layer was ventricular lining. The follow-up of African patients is difficult as they do not usually attend for periodical examinations, but the chances of survival in a case like this are extremely small. I wish to thank Dr. Winifred Lochrie for assisting me with this case.
Lilongwe African Hospital, Lilongwe, Nyasaland.
S. V. HUMPHRIES.
AGANGLIONIC MEGACOLON
SIR,-Despite the interest in aganglionic megacolon, or
Hirsch’sprung’s disease, in recent years no suggestion has been made, absence of
knowledge, as to the cause of the myenteric-plexus nerve-cells in the distal colon, beyond the opinion that maldevelopment has occurred. The following observation seems to shed light on the location of the primary defect in this disease. to our
The hypertrophy of nerve-trunks in the aganglionic segment " appears analogous to amputation " neuroma, suggesting that the preganglionic parasympathetic cells fibres seek " but do not " find " the absent myenteric nerve-cells. If correct, this view implies a certain functional integrity of the proximal nervous system. Further evidence for the action of local factors in this disease are Toolan’s experiments1 on embryonic gut growth in cortisone and X-ray conditioned adult rat hosts. Mince or strip grafts were used and transplanted to the chest wall of young adult animals. All transplants matured, and were adult in histological pattern; most contained normal ganglion cells in normal myenteric and submucosal plexuses. We have reviewed sections of colon taken at necropsy from 19 patients with the Arnold-Chiari neuraxial dysplasia complex. An additional 10 cases were not used, as no sections of colon were available. In all sections, ganglion cells were present and appeared more or less normal. The Arnold-Chiari defect, in our experience, is usually associated with spina bifida or myelomeningocele (21 of 25 described) and additional abnormalities of the spinal cord were observed (hydromyelia, 10 of 24; syringomyelia and diastematomyelia, at least 1 each). Despite these abnormalities of the cord (largely lower thoracic and lumbosacral) ganglion cells in the large intestine were intact. Sections of small intestine from 21 of these cases also contained normal submucosal and myenteric ganglion cells and nerves. If the myelomeningoceles of these patients are always epidermidised neural plates, as proposed by Cameron,2 it would not seem possible that the neural lesion could develop later than the myenteric plexus.
These findings suggest that the defect in the localised form of Hirschsprung’s disease arises as a result of local
factors,
not
dependent
on
the
integrity of the spinal cord,
1. Toolan, H. W. Cancer Res. 1957, 17, 707. 2. Cameron, A. H. J. Path. Bact. 1957, 73, 195.
W. B. ROANTREE. PARKING AND THE DISABLED DRIVER
SIR,-Stricter traffic regulations include non-parking areas, yellow lines, pink zones, and parking meters, and are no doubt the best expedients that can be devised for the present. Unhappily, as the Disabled Drivers’ Motor Club reports in its paper The Disabled Driver, this is bearing harshly and unfairly on this small group of drivers and motorists badly crippled in their legs have unnecessarily to park a long way from their destinations. Stuart-Menteth writes of the difficulties the leg-disabled have in jostling crowds, crossing busy roads, and in walking, say, 200 yards in wind or on slippery pavements. There is a heritage of kindliness in Britain towards the disabled and this is undoubtably shared by the police. But their attitude is said to have hardened and this may be due to their having been issued with stricter instructions about parking (e.g., " no exceptions whatever ") which give them no chance to use their discretion. Undermanned, they have a hard enough task anyway. In some cities, such as Coventry, certificates to attach to the windscreen have been issued to disabled drivers by the Town Clerk on medical recommendation, and parking for the disabled is greatly facilitated. There is no national or nationally accepted scheme. What these people need is permission to park, out of rush hours, for up to half-an-hour, where not causing any obstruction or otherwise inconveniencing traffic. The number of persons concerned in the entire country cannot be great (StuartMenteth estimates not more than 2000), but only those drivers with sufficient loss of function to make walking any distance a heavy burden, should be eligible. The definition would have to be made medically and might be witnessed by a certificate added to the driver’s licence (to be produced on demand) or a badge to be put on the windscreen. It would be especially appropriate if the Ministry of Pensions and National Insurance were to be responsible both for the medical recommendations and for the provision of certificates and/or badses. Gerrards Cross, ROBERT PIPER. Bucks.
ENCEPHALOCELE SIR,-The following case is of interest, for, though the deformity described is doubtless familiar to neurologists and cerebral surgeons, it must be fairly rare, since it receives scant consideration in textbooks and none of my medical colleagues, nursing staff, nor I have ever seen a case like it before. A female African baby, aged 1 week, was admitted on Feb. 11, 1960, with a round cystic swelling of the head over - the sagittal suture (see accompanving photograph), which
had been present since birth. Though the condition was clinically and radiologically an encephalocele, and the prospects of survival were therefore negligible, it was obviously undesirable to leave the swelling intact as it was freely mobile and liable to trauma, and the mother desired its removal. The operation was carried out under local anaesthesia and sedation with chloral hydrate (gr. 71/2). After aspirating the swelling with the removal of slightly yellowish cerebrospinal fluid, an angular incision was made through healthy skin round the neck of the sac and the scalp dissected up to expose the dura mater. The superior sagittal sinus was encountered in the dura in front and behind at its entry to and exit from the encephalocele. This was tied at each point, and the narrow neck of the sac was encircled by a third ligature and cut through
distally. The scalp flaps were stitched back in the mid-line. The stitches were removed on Feb. 24, and the child was discharged on March 8. Apart from slight bulging at the site of the scar there were no complications. The pathologist’s report on a portion of the specimen removed stated that the section passed through skin, meninges, and brain. The inner layer was ventricular lining. The follow-up of African patients is difficult as they do not usually attend for periodical examinations, but the chances of survival in a case like this are extremely small. I wish to thank Dr. Winifred Lochrie for assisting me with this case.
Lilongwe African Hospital, Lilongwe, Nyasaland.
S. V. HUMPHRIES.
AGANGLIONIC MEGACOLON
SIR,-Despite the interest in aganglionic megacolon, or
Hirsch’sprung’s disease, in recent years no suggestion has been made, absence of
knowledge, as to the cause of the myenteric-plexus nerve-cells in the distal colon, beyond the opinion that maldevelopment has occurred. The following observation seems to shed light on the location of the primary defect in this disease. to our
The hypertrophy of nerve-trunks in the aganglionic segment " appears analogous to amputation " neuroma, suggesting that the preganglionic parasympathetic cells fibres seek " but do not " find " the absent myenteric nerve-cells. If correct, this view implies a certain functional integrity of the proximal nervous system. Further evidence for the action of local factors in this disease are Toolan’s experiments1 on embryonic gut growth in cortisone and X-ray conditioned adult rat hosts. Mince or strip grafts were used and transplanted to the chest wall of young adult animals. All transplants matured, and were adult in histological pattern; most contained normal ganglion cells in normal myenteric and submucosal plexuses. We have reviewed sections of colon taken at necropsy from 19 patients with the Arnold-Chiari neuraxial dysplasia complex. An additional 10 cases were not used, as no sections of colon were available. In all sections, ganglion cells were present and appeared more or less normal. The Arnold-Chiari defect, in our experience, is usually associated with spina bifida or myelomeningocele (21 of 25 described) and additional abnormalities of the spinal cord were observed (hydromyelia, 10 of 24; syringomyelia and diastematomyelia, at least 1 each). Despite these abnormalities of the cord (largely lower thoracic and lumbosacral) ganglion cells in the large intestine were intact. Sections of small intestine from 21 of these cases also contained normal submucosal and myenteric ganglion cells and nerves. If the myelomeningoceles of these patients are always epidermidised neural plates, as proposed by Cameron,2 it would not seem possible that the neural lesion could develop later than the myenteric plexus.
These findings suggest that the defect in the localised form of Hirschsprung’s disease arises as a result of local
factors,
not
dependent
on
the
integrity of the spinal cord,
1. Toolan, H. W. Cancer Res. 1957, 17, 707. 2. Cameron, A. H. J. Path. Bact. 1957, 73, 195.