11 FEBRUARY 1978
BRITISH MEDICAL JOURNAL
Dr Spencer. They are centred in organisations whose intentions are good but whose efforts diminish the morale of those who work in mental handicap hospitals. Clinicians in general medicine and surgery do not have their efforts criticised by lay organisations to the extent that psychiatrists do. In the field of mental handicap hospitals the Department of Health and Social Security reiterates that public spending cuts will not apply. In spite of this, lay organisations, often critical of the work of psychiatrists and nurses, forecast the transfer of the care of mentally handicapped patients to psychologists and social workers working in centres in the community. Nothing is done by the DHSS to counter such criticism and its consequent depressing effect on those doctors and nurses who spend their lives looking after severely handicapped patients and who know that many of their charges could never survive outside hospital. Mental handicap is one of the grey areas of medicine and workers in its hospitals need unqualified support. In the past this was provided by loyal management committees and regional hospital boards. Since. reorganisation single mental handicap hospitals find themselves isolated in the management sphere of area health authorities which are not always sympathetic and which have to be reminded frequently of the exemption from spending cuts. Perhaps the DHSS could think more positively of its responsibility for the mental handicap hospitals and provide them with the leadership they need. JOHN T HUTCHINSON
see and hold their baby it would appear that the leaflet is to be given to parents as soon as the baby is born. I feel that in the period immediately following the birth the parents are bound to feel shocked and certainly unable to take in such a mass of literature. Surely the suggestion that the baby be held by them would be better put gently to them by the medical or nursing staff present. Subsequently discussion about stillbirth could be encouraged at a personal level between the ward staff and parents before the mother is discharged from hospital. It would seem important that all these parents should be visited by the health visitor at a point when the midwife has finished visiting; so often this is the time when their grief is most acute. I suggest that this leaflet should be given to the parents by the health visitor when she feels it to be appropriate and when the parents know that she will be visiting again, should they wish to discuss any matters arising from its contents. As a health visitor working in a department of medical genetics I frequently have contact with parents who have had one or more stillborn babies. Many of them express feelings of isolation and an inability to discuss their situation with relatives and friends. I am therefore pleased that those concerned professionally with these patients are becoming more involved with this aspect of patient care. I am sure that the proposed leaflet would be very helpful to doctors, nurses, health visitors, social workers, and clergymen and would help to increase their insight into the many conChairman, flicting feelings that parents experience at this Mental Health Group Committee, BMA point of crisis in their lives. St Giles's Hospital, London SE5 MARY WEETMAN University Department of Medical Genetics, St Mary's Hospital, Manchester
Help for parents after stillbirth
SIR,-Further suggestions are requested by Professor R W Beard and his colleagues (21 January, p 172). It has been my experience that parents blame not only themselves but, more destructively, each other. This should be made more explicit. Often this anger presents in loss of libido in either partner, a symptom also of loss of sexual self-esteem. Some mention of this could prevent secondary misinterpretation by the partners. A more definite warning that a further pregnancy should not be seen as a replacement baby (often an ill-advised suggestion by doctors or friends) should be given priority in counselling. As a corollary to the increasing awareness of the psychological disturbance related to stillbirth could some thought also be given to the similar problems often experienced with a late miscarriage ? These women are even less likely to receive professional help, as they are rarely followed up by gynaecologists and do not qualify for statutory visits from midwives, while society views the event as of minor significance. DOROTHY BLACK University Department of Psychiatry,
Whiteley Wood Clinic, Sheffied
SIR,-I read with interest the letter from Professor R W Beard and his colleagues (21 January, p 172) and their proposals to distribute a leaflet to parents who have experienced the birth of a stillborn child. The comprehensive nature of this leaflet is very impressive. My only re-servation about it concems the time at which it is to be -given to parents. Since it suggests that the parents
363
gloves is a commnon occurrence, with sometimes as much as 6 x 107 particles/cm2 surface area. Furthermore,. some samples were heavily contaminated with a diatomaceous material, shown in the accompanying figure together with the typical spectral analysis indicating the siliceous nature of the powder.
8
A
B soo0 r
v
t
_
250
Si (Ka)
Co(a)
Cu(Ka. KO)
(A) Typical diatomaceous. particles recovered from the surface of surgical gloves (X5780) (B) spectral analysis from EMMA-4 showing the high silicon content of the particles. The copper peaks (Koa and KP3) relate to the em grid.
Contamination of surgical gloves SIR,-It has long been accepted that the use of talc as a surgical-glove powder can result in postoperative peritoneal adhesions as well as granulomata at the site of operation. Consequently starch powder has been used for the past 20 years in place of talc, although concern has been expressed in the medical literature that a similar granulomatous reaction is produced by this material. We have shown recently, however,' 2 that samples of surgeon's gloves manufactured during the 1972-5 period have been contaminated with talc. Furthermore, tissue histologically classified as starch granulomata and showing the classical rounded starch particles with Maltese-cross birefringence was shown to contain talc. The analyses were undertaken using the highly sophisticated electron microscope microanalyser (EMMA-4, AEI) and it was obvious that only such procedures would localise and identify these extremely small particles which contaminated the gloves. At that time glove-manufacturing processes were probably ineffective in preventing access of talc, but continued quality control by these laboratories of subsequent batches of gloves has indicated that the major Briti-sh manufacturer has been able to eliminate the problem and such gloves produced in the UK are uncontaminated. It was stated then' that certain samples of American-produced gloves which were investigated were heavily contaminated with talc. More extensive investigations have confirmed these earlier observations, clearly indicating that talc contamination of the American
It is obvious that more careful control is necessary of the available procedures for the quality control of the materials used in the manufacturing processes concerned in surgical glove production. Since some of these American gloves are now available on the British market, care should be taken by the medical profession in their particular choice. W J HENDERSON A V MASKELL K GRIFFITHS Tenovus Institute for Cancer Research, Welsh National School of Medicine
W T BARR Department of Pathology, University Hospital of Wales, Cardiff Henderson, W J, et al, Lancet, 1975, 1, 1419. 2Henderson, W J, et al, British J3ournal of Surgery, 1975, 62, 941.
Doxorubicin cardiotoxicity: role of digoxin in prevention SIR,-We would like to reply to the various criticisms made by Dr C J Williams (21 January, p 176) in relation to our recent article (3 December, p 1447). In his letter Dr Williams states that "evidence on the protective effects of digoxin given before doxorubicin in animal models is conflicting.5''-3 It is unfortunate that none of the three references cited makes any mention of the use of digoxin given before doxorubicin in order to prevent cardiomyopathy in animals.
364
BRITISH MEDICAL JOURNAL
Two of the references' 2 do, however, present data concerning the use of short-acting cardiac glycosides given before doxorubicin and it is true to say that the evidence of the protective effects of these in animal models is conflicting. However, as we stated in our paper, it seems illogical to us to use short-acting cardiac glycosides such as ouabain in this situation when they have a much shorter half life than either doxorubicin or its metabolites. We are not aware of any work in either animals or man in which digoxin has been used in the manner we described in the paper, but would welcome any information on this point from your readers. The next point on which we are taken to task is our alleged failure fully to report known risk factors. We did, in fact, precis this information in the paper in that all three groups of patients were comparable as regards these risk factors. We did not mention previous radiation to the heart or concomitant cyclophosphamide, as none of the patients had either of these. As regards the patient who developed electrocardiographic changes of doxorubicin toxicity after stopping her digoxin, a more accurate impression of the length of time she had been off the digoxin could perhaps have been conveyed by the use of the term "some months" rather than "some weeks," and hence we feel it unlikely that she was developing doxorubicin cardiotoxicity before stopping the
myopathy by the concomitant administration of digoxin in patients treated for gynaecological cancers. Supposedly digoxin acts as a competitive inhibitor for doxorubicin and its metabolites on receptor sites. If so, the action may hold good for the tumour tissue as well as cardiac and skeletal muscle. How far the efficacy of the drug is reduced by the digoxin blockade has to be studied. The findings are of clinical value only when it is proved that digitalisation does not reduce the chemotherapeutic efficacy of doxorubicin. T M MATHEW St Mary's Hospital, Rochester, New York
Labetalol and urinary catecholamines SIR,-In a recent letter (24 December, p 1673) Drs P M Harris and D A Richards describe interference by labetalol in the estimation of free catecholamines. They suggest that this might be by a metabolic mechanism, thus making it difficult to screen for phaeochromocytoma in patients being treated with labetalol. Several tests are available for this purpose. In our laboratory, on a 24-h urine collection, we normally estimate the normetadrenaline and metadrenaline by the method of Pisanol adapted by Crout et a12 and, in suspected abnormal patients, we estimate 4-hydroxy-3methoxy mandelic acid (HMMA) by the method of Pisano et al.3 We do not estimate free catecholamines. We found that labetalol affects the normetadrenaline and metadrenaline test such that quite high results are obtained when large doses of labetalol are taken. HMMA was estimated in these specimens and normal results were obtained. Cessation of labetalol treatment produced a large decrease in the normetadrenaline and metadrenaline levels after about a week while the HMMA values remained unaltered. We suggest that if a patient being treated with labetalol is to be screened for phaeochromocytoma this may be done by estimating the HMMA output in urine. Further work is being undertaken to clarify the interference by labetalol in the normetadrenaline and metadrenaline test, but our tests so far suggest that this is chemical rather than metabolic.
digoxin. The criticism of lack of data concerning the rate of administration of doxorubicin is quite justifiable and a lamentable omission on our part. In practice all patients had 50 mg/m2 doxorubicin given as a bolus injection lasting approximately one minute into the tubing of a fast-flowing saline drip. Such treatment was repeated every three or four weeks depending upon the patient's white cell count. It is unfortunate that Dr Williams should infer that we believe that oxytetracycline can improve necrosis of myofibrils in doxorubicin cardiotoxicity. We do not believe this, and, furthermore, only recorded the use of oxytetracycline so that all details concerning the management of these patients should be available. As we stated in the paper, "whether in fact it [oxytetracycline] played any part in the recovery of the patients remains a matter for conjecture." B P CHAPMAN We do not claim that digoxin will prevent ANGELA G VEITCH doxorubicin cardiotoxicity, a point which we BRIAN SHEPHERD felt was reflected in the title of the paper, but Hospital, it appears that it may allow clinicians to treat Raigmore Inverness patients with total doses higher than the present recommended upper limit. Our aim Pisano, J J, Clinica Chimica Acta, 1960, 5, 406. J R, Pisano, J J, and Sjoerdsma, A, Aierican in publishing these findings was to stimulate 2 Crout, Heart JIournal, 1961, 61, 375. interest and to hope that others may be able to Pisano, J J, Crout, J R, and Abraham, D, Clitica Chimica Acta, 1962, 7, 285. investigate further and hopefully redefine the safe upper limit of this most useful cytotoxic agent. D GUTHRIE Incontinence A L GIBSON Newcastle General Hospital, Newcastle upon Tyne Arena, G, et al, in International Symposium on Adriamycin, ed S Carter et al, pp 96-116. New York, Springer, 1972. 2 Philips, F, et al, Cancer Chemotherapy Reports, 1975, 6, 177. 3 Lefrak, E A, et al, Cancer, 1973, 32, 302.
SIR,-May I comment briefly on the article by Drs D Guthrie and A L Gibson (3 December, p 1447) ? It was interesting to see the significant reduction of doxorubicin-induced cardio-
SIR,-Your leading article on this subject (14 January, p 61) is timely and its orientation towards the elderly (omitted in the title) is welcomed. Amplification of the title is needed as, for example, the commonest cause of urinary retention with overflow in the general population is likely to be neuropathic, followed by prostatic hypertrophy. Incontinence in the elderly differs from that in other age groups in aetiology, investigation, and treatment. Detrusor instability is more common here and is believed to be due to cerebrovascular atherosclerosis leading to
11 FEBRUARY 1978
diminished cortical control of micturition. Its features are nocturia, urgency, urge incontinence, intermittent dribbling, and stress incontinence. The effect of these symptoms may be aggravated by the patient's relative immobility and by being unable to get out of bed at night (due to a high bed, presence of cot side, and excess night sedation). If hospital nursing and medical staff fail to appreciate the difficulties confronting the newly admitted older patient and do not recognise confusional states (which can easily occur) the problem will be further compounded. Investigations in the elderly should be minimal and selective. Conservative measures to control incontinence should be tried first. These include collection of a midstream specimen of urine for culture and sensitivity testing and a urinary diary to note the times when incontinence occurs: the latter will enable a simple regimen of 2-3-hourly toileting to be tried. If this fails two-channel cystometry (using bladder and rectal pressurerecording catheters to measure the detrusor pressure) can be used to detect detrusor instability. If present the treatment is medical, using flavoxate hydrochloride 200-300 mg four times a day, emepronium bromide, or imipramine hydrochloride 25-50 mg twice daily. When there is an uncomplicated history of stress incontinence in a patient who is mentally alert and physically fit and has a normal cystometrogram incontinence surgery should be offered. With modern anaesthesia and intensive postoperative care surgery in the elderly need not be restricted to life-saving measures and patients should not be excluded for reasons of age alone. Surgical management must include control of respiratory disease, avoidance of scopolamine as a premedication, early mobilisation following surgery, awareness on the part of the patient, relatives, and nurses of the expected rate of postoperative progress, and avoidance of night sedation (especially barbiturates and nitrazepam). The nursing staff should anticipate the needs and problems of the elderly and be aware of the ease with which confusional states may develop. If medical treatment fails and surgery is contraindicated or refused a vast array of incontinence garments, pads, and appliances is now available. The variety of measures and the large numbers of patients who can benefit necessitate the training of a nurse who is familiar with the problems of incontinence and of their methods of treatment and who can equip individual patients with the correct garment and appliances-something which the average surgical supplies officer has neither the training nor the time to do. The precedent for this type of nurse has already been set in the form of the "stoma care nurse," and her equivalent in the area of urinary incontinence is badly needed. STUART L STANTON LINDA CARDOZO PETER MILLARD HOPE TRENCHARD St George's Hospital Medical School, SW17
London
SIR,-Your leading article on incontinence (14 January, p 61) reveals only too well what a difficult subject this is to comprehend. It is obviously impossible in such a short space to cover such a vast subject comprehensively. There is, however, one error of fact which requires correction. The trigone of the bladder is not related developmentally to the vagina.
BRITISH MEDICAL JOURNAL
Dr Spencer. They are centred in organisations whose intentions are good but whose efforts diminish the morale of those who work in mental handicap hospitals. Clinicians in general medicine and surgery do not have their efforts criticised by lay organisations to the extent that psychiatrists do. In the field of mental handicap hospitals the Department of Health and Social Security reiterates that public spending cuts will not apply. In spite of this, lay organisations, often critical of the work of psychiatrists and nurses, forecast the transfer of the care of mentally handicapped patients to psychologists and social workers working in centres in the community. Nothing is done by the DHSS to counter such criticism and its consequent depressing effect on those doctors and nurses who spend their lives looking after severely handicapped patients and who know that many of their charges could never survive outside hospital. Mental handicap is one of the grey areas of medicine and workers in its hospitals need unqualified support. In the past this was provided by loyal management committees and regional hospital boards. Since. reorganisation single mental handicap hospitals find themselves isolated in the management sphere of area health authorities which are not always sympathetic and which have to be reminded frequently of the exemption from spending cuts. Perhaps the DHSS could think more positively of its responsibility for the mental handicap hospitals and provide them with the leadership they need. JOHN T HUTCHINSON
see and hold their baby it would appear that the leaflet is to be given to parents as soon as the baby is born. I feel that in the period immediately following the birth the parents are bound to feel shocked and certainly unable to take in such a mass of literature. Surely the suggestion that the baby be held by them would be better put gently to them by the medical or nursing staff present. Subsequently discussion about stillbirth could be encouraged at a personal level between the ward staff and parents before the mother is discharged from hospital. It would seem important that all these parents should be visited by the health visitor at a point when the midwife has finished visiting; so often this is the time when their grief is most acute. I suggest that this leaflet should be given to the parents by the health visitor when she feels it to be appropriate and when the parents know that she will be visiting again, should they wish to discuss any matters arising from its contents. As a health visitor working in a department of medical genetics I frequently have contact with parents who have had one or more stillborn babies. Many of them express feelings of isolation and an inability to discuss their situation with relatives and friends. I am therefore pleased that those concerned professionally with these patients are becoming more involved with this aspect of patient care. I am sure that the proposed leaflet would be very helpful to doctors, nurses, health visitors, social workers, and clergymen and would help to increase their insight into the many conChairman, flicting feelings that parents experience at this Mental Health Group Committee, BMA point of crisis in their lives. St Giles's Hospital, London SE5 MARY WEETMAN University Department of Medical Genetics, St Mary's Hospital, Manchester
Help for parents after stillbirth
SIR,-Further suggestions are requested by Professor R W Beard and his colleagues (21 January, p 172). It has been my experience that parents blame not only themselves but, more destructively, each other. This should be made more explicit. Often this anger presents in loss of libido in either partner, a symptom also of loss of sexual self-esteem. Some mention of this could prevent secondary misinterpretation by the partners. A more definite warning that a further pregnancy should not be seen as a replacement baby (often an ill-advised suggestion by doctors or friends) should be given priority in counselling. As a corollary to the increasing awareness of the psychological disturbance related to stillbirth could some thought also be given to the similar problems often experienced with a late miscarriage ? These women are even less likely to receive professional help, as they are rarely followed up by gynaecologists and do not qualify for statutory visits from midwives, while society views the event as of minor significance. DOROTHY BLACK University Department of Psychiatry,
Whiteley Wood Clinic, Sheffied
SIR,-I read with interest the letter from Professor R W Beard and his colleagues (21 January, p 172) and their proposals to distribute a leaflet to parents who have experienced the birth of a stillborn child. The comprehensive nature of this leaflet is very impressive. My only re-servation about it concems the time at which it is to be -given to parents. Since it suggests that the parents
363
gloves is a commnon occurrence, with sometimes as much as 6 x 107 particles/cm2 surface area. Furthermore,. some samples were heavily contaminated with a diatomaceous material, shown in the accompanying figure together with the typical spectral analysis indicating the siliceous nature of the powder.
8
A
B soo0 r
v
t
_
250
Si (Ka)
Co(a)
Cu(Ka. KO)
(A) Typical diatomaceous. particles recovered from the surface of surgical gloves (X5780) (B) spectral analysis from EMMA-4 showing the high silicon content of the particles. The copper peaks (Koa and KP3) relate to the em grid.
Contamination of surgical gloves SIR,-It has long been accepted that the use of talc as a surgical-glove powder can result in postoperative peritoneal adhesions as well as granulomata at the site of operation. Consequently starch powder has been used for the past 20 years in place of talc, although concern has been expressed in the medical literature that a similar granulomatous reaction is produced by this material. We have shown recently, however,' 2 that samples of surgeon's gloves manufactured during the 1972-5 period have been contaminated with talc. Furthermore, tissue histologically classified as starch granulomata and showing the classical rounded starch particles with Maltese-cross birefringence was shown to contain talc. The analyses were undertaken using the highly sophisticated electron microscope microanalyser (EMMA-4, AEI) and it was obvious that only such procedures would localise and identify these extremely small particles which contaminated the gloves. At that time glove-manufacturing processes were probably ineffective in preventing access of talc, but continued quality control by these laboratories of subsequent batches of gloves has indicated that the major Briti-sh manufacturer has been able to eliminate the problem and such gloves produced in the UK are uncontaminated. It was stated then' that certain samples of American-produced gloves which were investigated were heavily contaminated with talc. More extensive investigations have confirmed these earlier observations, clearly indicating that talc contamination of the American
It is obvious that more careful control is necessary of the available procedures for the quality control of the materials used in the manufacturing processes concerned in surgical glove production. Since some of these American gloves are now available on the British market, care should be taken by the medical profession in their particular choice. W J HENDERSON A V MASKELL K GRIFFITHS Tenovus Institute for Cancer Research, Welsh National School of Medicine
W T BARR Department of Pathology, University Hospital of Wales, Cardiff Henderson, W J, et al, Lancet, 1975, 1, 1419. 2Henderson, W J, et al, British J3ournal of Surgery, 1975, 62, 941.
Doxorubicin cardiotoxicity: role of digoxin in prevention SIR,-We would like to reply to the various criticisms made by Dr C J Williams (21 January, p 176) in relation to our recent article (3 December, p 1447). In his letter Dr Williams states that "evidence on the protective effects of digoxin given before doxorubicin in animal models is conflicting.5''-3 It is unfortunate that none of the three references cited makes any mention of the use of digoxin given before doxorubicin in order to prevent cardiomyopathy in animals.
364
BRITISH MEDICAL JOURNAL
Two of the references' 2 do, however, present data concerning the use of short-acting cardiac glycosides given before doxorubicin and it is true to say that the evidence of the protective effects of these in animal models is conflicting. However, as we stated in our paper, it seems illogical to us to use short-acting cardiac glycosides such as ouabain in this situation when they have a much shorter half life than either doxorubicin or its metabolites. We are not aware of any work in either animals or man in which digoxin has been used in the manner we described in the paper, but would welcome any information on this point from your readers. The next point on which we are taken to task is our alleged failure fully to report known risk factors. We did, in fact, precis this information in the paper in that all three groups of patients were comparable as regards these risk factors. We did not mention previous radiation to the heart or concomitant cyclophosphamide, as none of the patients had either of these. As regards the patient who developed electrocardiographic changes of doxorubicin toxicity after stopping her digoxin, a more accurate impression of the length of time she had been off the digoxin could perhaps have been conveyed by the use of the term "some months" rather than "some weeks," and hence we feel it unlikely that she was developing doxorubicin cardiotoxicity before stopping the
myopathy by the concomitant administration of digoxin in patients treated for gynaecological cancers. Supposedly digoxin acts as a competitive inhibitor for doxorubicin and its metabolites on receptor sites. If so, the action may hold good for the tumour tissue as well as cardiac and skeletal muscle. How far the efficacy of the drug is reduced by the digoxin blockade has to be studied. The findings are of clinical value only when it is proved that digitalisation does not reduce the chemotherapeutic efficacy of doxorubicin. T M MATHEW St Mary's Hospital, Rochester, New York
Labetalol and urinary catecholamines SIR,-In a recent letter (24 December, p 1673) Drs P M Harris and D A Richards describe interference by labetalol in the estimation of free catecholamines. They suggest that this might be by a metabolic mechanism, thus making it difficult to screen for phaeochromocytoma in patients being treated with labetalol. Several tests are available for this purpose. In our laboratory, on a 24-h urine collection, we normally estimate the normetadrenaline and metadrenaline by the method of Pisanol adapted by Crout et a12 and, in suspected abnormal patients, we estimate 4-hydroxy-3methoxy mandelic acid (HMMA) by the method of Pisano et al.3 We do not estimate free catecholamines. We found that labetalol affects the normetadrenaline and metadrenaline test such that quite high results are obtained when large doses of labetalol are taken. HMMA was estimated in these specimens and normal results were obtained. Cessation of labetalol treatment produced a large decrease in the normetadrenaline and metadrenaline levels after about a week while the HMMA values remained unaltered. We suggest that if a patient being treated with labetalol is to be screened for phaeochromocytoma this may be done by estimating the HMMA output in urine. Further work is being undertaken to clarify the interference by labetalol in the normetadrenaline and metadrenaline test, but our tests so far suggest that this is chemical rather than metabolic.
digoxin. The criticism of lack of data concerning the rate of administration of doxorubicin is quite justifiable and a lamentable omission on our part. In practice all patients had 50 mg/m2 doxorubicin given as a bolus injection lasting approximately one minute into the tubing of a fast-flowing saline drip. Such treatment was repeated every three or four weeks depending upon the patient's white cell count. It is unfortunate that Dr Williams should infer that we believe that oxytetracycline can improve necrosis of myofibrils in doxorubicin cardiotoxicity. We do not believe this, and, furthermore, only recorded the use of oxytetracycline so that all details concerning the management of these patients should be available. As we stated in the paper, "whether in fact it [oxytetracycline] played any part in the recovery of the patients remains a matter for conjecture." B P CHAPMAN We do not claim that digoxin will prevent ANGELA G VEITCH doxorubicin cardiotoxicity, a point which we BRIAN SHEPHERD felt was reflected in the title of the paper, but Hospital, it appears that it may allow clinicians to treat Raigmore Inverness patients with total doses higher than the present recommended upper limit. Our aim Pisano, J J, Clinica Chimica Acta, 1960, 5, 406. J R, Pisano, J J, and Sjoerdsma, A, Aierican in publishing these findings was to stimulate 2 Crout, Heart JIournal, 1961, 61, 375. interest and to hope that others may be able to Pisano, J J, Crout, J R, and Abraham, D, Clitica Chimica Acta, 1962, 7, 285. investigate further and hopefully redefine the safe upper limit of this most useful cytotoxic agent. D GUTHRIE Incontinence A L GIBSON Newcastle General Hospital, Newcastle upon Tyne Arena, G, et al, in International Symposium on Adriamycin, ed S Carter et al, pp 96-116. New York, Springer, 1972. 2 Philips, F, et al, Cancer Chemotherapy Reports, 1975, 6, 177. 3 Lefrak, E A, et al, Cancer, 1973, 32, 302.
SIR,-May I comment briefly on the article by Drs D Guthrie and A L Gibson (3 December, p 1447) ? It was interesting to see the significant reduction of doxorubicin-induced cardio-
SIR,-Your leading article on this subject (14 January, p 61) is timely and its orientation towards the elderly (omitted in the title) is welcomed. Amplification of the title is needed as, for example, the commonest cause of urinary retention with overflow in the general population is likely to be neuropathic, followed by prostatic hypertrophy. Incontinence in the elderly differs from that in other age groups in aetiology, investigation, and treatment. Detrusor instability is more common here and is believed to be due to cerebrovascular atherosclerosis leading to
11 FEBRUARY 1978
diminished cortical control of micturition. Its features are nocturia, urgency, urge incontinence, intermittent dribbling, and stress incontinence. The effect of these symptoms may be aggravated by the patient's relative immobility and by being unable to get out of bed at night (due to a high bed, presence of cot side, and excess night sedation). If hospital nursing and medical staff fail to appreciate the difficulties confronting the newly admitted older patient and do not recognise confusional states (which can easily occur) the problem will be further compounded. Investigations in the elderly should be minimal and selective. Conservative measures to control incontinence should be tried first. These include collection of a midstream specimen of urine for culture and sensitivity testing and a urinary diary to note the times when incontinence occurs: the latter will enable a simple regimen of 2-3-hourly toileting to be tried. If this fails two-channel cystometry (using bladder and rectal pressurerecording catheters to measure the detrusor pressure) can be used to detect detrusor instability. If present the treatment is medical, using flavoxate hydrochloride 200-300 mg four times a day, emepronium bromide, or imipramine hydrochloride 25-50 mg twice daily. When there is an uncomplicated history of stress incontinence in a patient who is mentally alert and physically fit and has a normal cystometrogram incontinence surgery should be offered. With modern anaesthesia and intensive postoperative care surgery in the elderly need not be restricted to life-saving measures and patients should not be excluded for reasons of age alone. Surgical management must include control of respiratory disease, avoidance of scopolamine as a premedication, early mobilisation following surgery, awareness on the part of the patient, relatives, and nurses of the expected rate of postoperative progress, and avoidance of night sedation (especially barbiturates and nitrazepam). The nursing staff should anticipate the needs and problems of the elderly and be aware of the ease with which confusional states may develop. If medical treatment fails and surgery is contraindicated or refused a vast array of incontinence garments, pads, and appliances is now available. The variety of measures and the large numbers of patients who can benefit necessitate the training of a nurse who is familiar with the problems of incontinence and of their methods of treatment and who can equip individual patients with the correct garment and appliances-something which the average surgical supplies officer has neither the training nor the time to do. The precedent for this type of nurse has already been set in the form of the "stoma care nurse," and her equivalent in the area of urinary incontinence is badly needed. STUART L STANTON LINDA CARDOZO PETER MILLARD HOPE TRENCHARD St George's Hospital Medical School, SW17
London
SIR,-Your leading article on incontinence (14 January, p 61) reveals only too well what a difficult subject this is to comprehend. It is obviously impossible in such a short space to cover such a vast subject comprehensively. There is, however, one error of fact which requires correction. The trigone of the bladder is not related developmentally to the vagina.
