2 701

and above the 1000 c.cm. needed to balance thenormal daily output, and the amount needed tomake up for vomiting or diarrhoea. The adequacyof treatment must be controlled by daily weighings,for it is not possible always to measure the urinaryoutput. Dehydration must be relieved within a

few hours, and in the infant with " d and v " thevomiting often ceases as soon as this has been done.YOUNG suggested that the fluid used to make up

fluid loss should be " half-normal " saline (0-45%NaCI) containing 2% glucose, and that subsequentfluid should be " one-fifth normal " saline (0-18%Nad) containing 4% glucose ; 300 c.cm. of the strongersolution should be given intravenously, accompaniedby as much as is necessary of the weaker solution bythe same route or by mouth. Failing the skilled

personnel to carry out the intravenous technique thesolutions could be given by mouth. YOUNG did notfavour subcutaneous administration of fluid becauseit is only rarely that sufficient fluid can be got in bythis route, and there is no control over the rate ofabsorption. There seems to be no advantage ingiving bicarbonate or lactate (Hartmann’s solution)with the sodium chloride. The infant body can selectthe proportions of sodium and chlorine it requires,provided that sufficient water is available for adequaterenal excretion ; this is borne out by adult experience,for neutral sodium chloride intravenously is equallyeffective in the alkalosis of pyloric stenosis and theacidosis of diabetic coma. Among other speakersat the RSM meeting there was considerable supportfor subcutaneous saline, and it was suggested thatsaline by mouth was unpalatable to the infant andmight lead to insufficient intake and in many casesvomiting. But there was agreement that the reliefof dehydration is an urgent matter, that " physio-logical " saline is not an appropriate fluid to use,and that it is necessary to work out precisely theminimum fluid requirements of the sick child, andto ensure that the proper amount is given, whatever route is selected. It is not enough just to" set up a drip."

SCIATICA IN THE FORCESIN the Services, where there is a special need for

rapidity and accuracy in diagnosis and disposal,sciatica does not seem to be following clinical tradition.Constant contact with the same patients-no longerfree as civilians to seek another doctor-has disprovedthe legend that the disease is self-limiting and onlyoccasionally recurrent ; it shows a well-marked tend-

ency to chronicity, giving rise to considerable wastagein hospitalisation and invaliding and offering an

avenue for neurotic escapism. Always demoralisingin peace-time, it becomes doubly so under Serviceconditions ; good men struggle to continue at theirjobs but those of weaker fibre may end with an

hysterical perpetuation of organic symptoms. An

Army bulletin 1 points out that sciatica no longermeans a specific disease due to a true neuritis, but hascome to indicate a syndrome of postcrural pain ofmany possible origins. Early diagnosis and treat-ment are of cardinal importance ; patients should beadmitted to hospital for anything more than a minorattack, and thorough examination carried out. Thisshould include a careful record of the nature of the

1. Army med. Depart. Bull. no. 16, November, 1942.

pain, its mode of production and relation to injuryor occupation, of any changes in sensation, muscle-power or reflexes in the legs, and of the function of thelumbosacral spine. Accessory investigations includeradiograms of lumbar spine and pelvis, lumbarpuncture, and (for soldiers are not immune from malig-nant pelvic disease) rectal examination: Myelo-graphy with iodised oil or air should not be doneexcept under a neurologist’s advice. Not least in-

importance is an assessment of emotional state andresistance to pain. Among the common causes,fibrositis of the fasciae, muscles, ligaments or joint-capsules in the lumbosacral, gluteal and hip regionsis often associated with trauma, postural strain andcongenital bony anomalies rather than focal sepsis.The pain is referred from the more deeply situatedlesions which may require location with an exploringneedle, and KELLGREN 2 has found 70% of cases tooriginate in this way. These respond to the familiartechnique of local injection with procaine,3 in whichthe criteria of an immediate aggravation of the painfollowed by permanent or semi-permanent relief mustbe satisfied if the diagnosis is to be confirmed. Wherethe lesion is inaccessible to the needle manipulationmay succeed. With sciatica of fibrositic origin thereshould be no disturbances of sensation or tendon-reflexes in the legs ; these, if present, are symptomaticof a neuritis or radiculitis, or of a prolapsed inter-vertebral disc. In the former, recently under fire asan entity but championed by this bulletin, an acuteonset of often severe pain is associated with tendernessof the nerve and hamstrings, slight sensory impair-ment, occasional weakness in dorsiflexion of the footand a diminished or absent ankle-jerk. The cerebro-

spinal fluid, normal in a neuritis, may in radiculitiscontain an excess of protein and lymphocytes. Achronic neuritis may respond to the perineural injec-tion of procaine, but the use of oxygen here or sub-cutaneously is not devoid of risk ; radiculitis may berelieved by epidural injections of procaine followed bynormal saline.With prolapsed intervertebral disc, which SYMONDS 4

regards as by far the commonest cause of sciatica inService cases, trauma is of aetiological significance,but may be entirely absent and should not be regardedas essential in the history. The common story is ofback strain while stooping, followed fairly soon bylow back pain, and, perhaps weeks later, by sciaticpain worse on exertion or coughing. Scoliosis, tender-ness of the nerve and of the hamstrings and calf-muscles, weakness of the plantar and dorsiflexors ofthe foot, and a diminished or absent ankle-jerk arecommon physical signs. Sensory changes are usualin the form of hypaesthesia on the outer side of theleg below the knee and on one or other border of thefoot, with loss of postural sensation in the correspond-ing toes. Occasionally there is bilateral pain andsphincter disorder, but this cauda equina syndromemore usually follows the unwise manipulation of acase of disc prolapse, or, as a florid progress ofsymptoms and signs, is due to the rarer causes of grossspinal disease, pelvic tumours and tumours of thecauda itself. Once the diagnosis of prolapsed discis made—and this is largely on clinical grounds alone,for plain radiograms are unhelpful, air-myelography

2. Kellgren, J. H. Lancet, 1941, i, 561.3. Good, M. G. Ibid, 1942, ii, 597.4. Symonds, C. P. Proc. R. Soc. Med. 1942, 35, 511.

702

unreliable and the iodised oil now available too irritant- the Army patient should as a rule be invalided evenif he recovers ; recurrence is frequent, and operationshould be reserved for key-men who can be kept on insedentary employment. From experience in theRAF, SYMONDS agrees that diagnosis should be madewithout the use of contrast media, and, though headvises a trial of long immobilisation, he has foundoperation so unsuccessful in getting men back goduty that he would invalid the patient if immobilisa-tion fails.Whatever the cause of the pain, symptomatic

treatment in the first attack will consist of rest in bedand analgesics, with local heat. Complete rest fromthe outset until the pain has gone should replaceperseverance with ambulatory treatment, which mayencourage chronicity. In all cases, attention tomorale is of the greatest importance ; diversional

therapy during the early confinement to bed and moreconstructive work later will help to prevent thepsychoneurotic accentuation and perpetuation ofsymptoms. Ways of achieving this end have beensuggested by JEFFERSON,5 and success in avoidingthese complications may seem some compensationfor the not infrequent failure of physical therapeutics.

Annotations

CLINICS FOR WOMEN’S AILMENTS

TREATMENT of venereal diseases in the Forces isintensive and efficient, but the British Social HygieneCouncil believe that facilities are not adequate fortreatment of civilians, especially women, seafarers andindustrial workers in rural areas. Their plea to localauthorities, first published in 1940, asked for an educa-tional campaign among women on the lines that neglectof any female ailment-any discharge or pain, for

example-might have serious consequences, and perhapsinterfere with a healthy family life. As a complementto such teaching, they consider that clinics for treatmentof ailments of women should be set up, offering freediagnosis and, when necessary, treatment. Such clinicswould be staffed by doctors experienced in both gynae-cology and venereal disease, and since they would treatboth types of case no stigma would attach to patientsattending. The gynaecological work of the clinic couldbe financed under the maternity and child welfare pro-visions made by the Ministry of Health. The Govern-ment has undertaken to contribute 75% of the cost of anyextra treatment facilities made necessary by war

conditions ; unfortunately there is at present a rulingthat ailments of women clinics and VD almoners cannotrank for the 75% grant. The council contend that thisruling should be reversed, and indeed suggest that thecost of new facilities made necessary by an influx of newpopulation into an area should be borne entirely by theGovernment, local authorities not being asked to meetnew charges in what is really a national emergency.The present position, as set out by the council in a note’

to Members of Parliament entitled 33B and the V.D.Situation (from Tavistock House, W.C.1) is that 70,000new cases of venereal disease were reported from civilianclinics last year, and that the figures of incidence haverisen to the level reported in 1932. Men at the peak ageof infection (19-23) in the Forces are effectively treated ;but there are no special provisions for treating men ofthe Merchant Navy as there are for the fighting services,and in many of the small ports now being more usedfacilities for treatment are inadequate. Wives and

partners of men in the Services or Merchant Navy are5. Jefferson, G. Ibid, p. 295.

scattered in war industries throughout the country, andwould probably seek confidential treatment voluntarilyif it were available conveniently and without social stigma.Were civil clinics meeting the needs of women they wouldnow be treating more women than men, but the reverseis the case. Transport difficulties and industrial dispersaldeter infected people from attending ; moreover theclinic hours often coincide with working time, and womenespecially will not ask for time off to attend because ofthe necessity of explaining to employers. Most clinicshave no follow-up service, and in many places localadministration nullifies the regulations for repayment offares to patients. Almoners have been extremelysuccessful in persuading contacts’to accept voluntarytreatment, and if ailments of women clinics are set up thecouncil consider that men and women should be

appointed to the medical officer’s staff to advise and helppatients and seek out contacts.

Defence Regulation 33B, which makes it possible tocompel people to come for treatment if they are namedas the source of infection by two patients,l is now underdiscussion in the House on a prayer to the Governmentfor its revocation. The council would like to see it

replaced by a new regulation giving similar powers ofcompulsion, but ensuring also that proper facilities forvoluntary treatment would be provided. These wouldinclude not only clinics organised and staffed as sug-gested, but opportunities for short intensive courses

of treatment in hospital, and arrangement of clinic hoursto suit the convenience of patients in jobs. Theysuggest, too, that as a war measure the Wassermannreaction of all pregnant women should be done.

ATROPHIC RHINITIS AND THE ŒSTROGENICHORMONE

WITHIN the memory of older practitioners certaindiseases have almost disappeared and others have becomerarer. The anaemia of female adolescence-chlorosis-is a striking example of the former, and atrophic rhinitisof the latter. These two diseases have several othercommon features : both mainly affect females, patientsfirst come under observation in adolescence, and the bulkof them are from the poorer classes ; improved hygieneand sanitation, changes in diet and more outdoor exerciseare all believed to play some part in their gradual dis-appearance. There is no precise knowledge of the aetio-logy of atrophic rhinitis, but even strong advocatesof other theories, Cullom,2 for instance, admit thatnutrition is an important factor, and a study of thepathology lends additional support to this view. Themorbid anatomy of atrophic rhinitis has been classicallydescribed by Wyatt Wingrave.3 As its name indicates,the changes are those of atrophy or degeneration. Thesubepithelial tissues become broken up by increase infibrosis. The mucous glands atrophy, possibly because ofa resulting impairment of their nutrition, and hyalinisa-tion and pigmentation follow. The epithelial basementmembrane breaks up and disappears, and the epitheliumitself changes from a ciliated pseudostratified columnarto a stratified squamous type. In other words, the

pattern of the whole mucous membrane alters from oneof activity to that of inactivity. The function of therespiratory mucous membrane is to secrete mucus, whichit then moves into the nasopharynx as an unbroken sheetby means of its cilia. The mucus warms inspired air andalso traps and acts upon foreign matter. The changesdescribed are followed by a scantier secretion of morewatery mucus and a discontinuity of the mucus sheet inareas where the cilia have disappeared. These stationarymasses of mucus dry and form the crusts character-istic of the disease. It is remarkable that such drasticlocal changes are not accompanied by any apparent

1. See Lancet, Nov. 14, p. 589.2. Cullom, M. M. J. Amer. med. Ass. 1941, 117, 987.3. J. Laryngol. 1894, 8, 96.