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might well be the best way of controlling the drugbill. The mental health service, he also holds, mustin the future rely more upon the general practitioner.

" If mental health is ever to become a reality a veryquick calculation will show that it would be impossibleto plan such services on any other terms than their

provision through the general practitioners."With all these fresh tasks in social, clinical, and

preventive medicine awaiting him, we must not forgetthat the general practitioner has also to cope witha greatly increased volume of his own work. Muchof this may be minor illness, but a minor illness isnot the same thing as a trivial complaint, andPETERSON’S impression is that there has not reallybeen much abuse of the service by the patient. Inshort he holds that we have been unwise to treat

practitioners with such parsimony ; for moneyinvested in providing them with adequate workshopsand equipment would probably yield more returns interms of health than money spent on any other partof the service. It seems likely that the Danckwertsaward will give us a chance to right part of thisimbalance ; and though, when he wrote his report,Dr. PETERSON could not have foreseen this develop-ment, at least one of his suggestions shows a propheticawareness :

Greater financial rewards to the general practitionerwould be a true economy if this allows him to dealunhurriedly, competently, and effectively with hispatients."So far we have given the general practitioner only thejob : now it is time to give him the tools.

Annotations

THE DEHYDRATED INFANTMucH of the information concerning the regulation of

water and electrolyte balance in man has been obtainedin response to the pressing need for guidance in thetreatment of dehydration. This need is perhaps greatestin the field of paediatrics, because young children becomedehydrated more rapidly than adults and are prone togastro-enteritis, which in the past was commonly fatal.Since infants with this disease may continue to havediarrhcea for some days, relief of dehydration andprevention of its recurrence are essential. In many othermedical and surgical conditions, too, support of the

patient by measures to combat dehydration contributelargely to his chances of recovery. The value of thesemeasures has been enhanced by the wide choice ofantibiotics to control infection, so that there are nowfewer pathological states in infancy which need be

expected to cause death once the patient has survivedthe acute phase.In the treatment of dehydration the emphasis has

moved away from techniques for administering fluidsparenterally. Of first importance is an intelligent graspof principles to guide the choice and amount of fluids tobe given ; for otherwise the dangers of treatment mayexceed those of the original disorder. Recognition ofthis need has led the Medical Research Council to sponsora memorandum on the treatment of acute dehydrationin infants. The aim is to help those responsible for theday-to-day care of infants, and therefore the subjectis presented in a somewhat simplified form ; butreferences are given to fuller accounts of the dehydrationprocess and to some of the original work on which ourpresent understanding of fluid and electrolyte require-ments is based.

Severely dehydrated babies are few compared withthe large number with slight dehydration due to transientcauses, whose progress to recovery will usually be

straightforward. Early recognition will sometimesenable treatment to be undertaken at home if propersupervision is possible. It is clear, however, that infantssuffering from the more severe - and long-continueddisorders are best treated in specially equipped and well-staffed hospital units.Experience has shown that most of the severely

affected infants do well if their dehydration is relievedby parenteral infusion of solutions of sodium withoutpotassium salts, and that administration of potassiumcan safely be deferred until fluids are tolerated by mouth.In some, however, tolerance to oral feeding is longdelayed, and these may become dangerously depleted1. The Treatment of Acute Dehydration in Infants, by a working

team appointed and advised by the Committee on AcuteInfections in Infancy. Medical Research Council memorandumno. 26. H.M. Stationery Office. Pp. 49. 3s.

of potassium. At the outset those likely to make slowprogress cannot be distinguished from the rest ; and thememorandum recommends that potassium should usuallybe given to dehydrated infants who have sustained electro-lyte losses. Danger from giving potassium in this waycan be avoided by two precautions : (1) spacing evenlythroughout the twenty-four hours the administrationof dilute solutions of electrolytes ; and (2) adjusting thetotal fluid intake to ensure a free now of urine, whichshould be checked by examination of samples at 12-hourlyintervals. Here the memorandum’s advice is at variancewith the conclusion reached by Black and Milne.2 Theseworkers, however, based their opinion on a study ofexperimental potassium depletion in two normal adults ;and thus the conditions were unlike those in clinicaldehydration, where it may not be possible to detect thetransition from moderate to severe potassium depletionin very sick patients, whose signs of weakness maybe wrongly attributed to another cause. Moreover,dehydrated infants usually receive a much larger volumeof fluid per unit of body-weight than do adults. Con-sequently they pass more urine, and the danger of

including potassium in fluids for intravenous infusionis thus avoided.The clinician may perhaps best safeguard his patients

by bearing in mind the title of Professor Gamble’s 3

latest contribution to our understanding of fluid require-ments in dehydration : "The companionship of water andelectrolytes in the organisation of the body fluids."

2. Black, D. A. K., Milne, M. D. Lancet, Feb. 2, 1952, p. 244.3. Gamble, J. L. Lane Medical Lectures. London, 1951.

CORTISONE AND CAUTION

IN the excitement which customarily follows the

discovery of a new and potent therapeutic weapon, it

happens far too often that traditional and tried methodsof treatment are neglected. It may be that these oldermethods were not strikingly effective : in an age which

expects cures and to -which miracles are commonplace,the fact that most diseases are incurable is forgotten, aswell as the important rider that most diseases may beameliorated by treatment.New steroids and new moulds each have their place

in the framework of treatment, but these do not warrantthe jettisoning of established methods. The increasinguse of cortisone in rheumatoid arthritis has led to asituation where many physicians who formerly had littleinterest in the rheumatic diseases are treating cases whichwould once have been referred to the " rheumatismclinic " or to the physician in charge of the physiotherapydepartment. The neglect in some instances of funda-mental measures of therapeutic care, such as the use ofheat, assisted exercises, and splintage, has caused

experienced physicians (" B.C. rheumatologists," as Henchput it, as against " A.c. rheumatologists "-after corti-

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sone) to raise a warning voice and to emphasise that it isessential to continue, along with newer forms of treat-ment, what a group of workers at the Mayo Clinic havecalled a basic " conservative program, including physicalmedicine, adequate rest, diet, simple analgesics and othergeneral supportive measures." 1The comparison made by this group between 34

patients treated with a basic regime including physicalmedicine and 54 patients treated with cortisone inaddition is of great topical interest, particularly so sinceit emanates from the Mayo Clinic. They found that 85%of the cortisone group showed objective improvement,as against 80% of those treated similarly but withoutcortisone-a difference which on testing statistically forsignificance is found to be negligible. The groups weresimilar in most respects, but the cortisone group containeda larger proportion of chronic cases (63% with a durationof 5 years or more, compared with 47% in the controlgroup), and it is stated that this type of case shows lessimprovement with conservative treatment than cases

in which symptoms have been present for a lesser time.Even in this type of long-standing disease, however,the difference between the cortisone-treated and controlgroup does not reach significant levels : the observeddifference in the numbers improved in the two treatmentgroups (62% and 85%) gives a value for x.2 of 2-1 andmight occur by chance alone in more than 1 out of 10therapeutic trials if the treatments were absolutely thesame. The use of such statistical checks would improvea lot of the papers appearing on this subject, but manyaspects of treatment cannot be put into figures. Thosewho have had some experience in the use of cortisonein cases of rheumatoid arthritis will agree with theauthors’ modest statement that " Cortisone is an

important adjuvant to the treatment programme of

many patients with active rheumatoid arthritis."

1. Martin, G. M., Polley, H. F., Anderson, T. P. J. Amer. med.Ass. 1952, 148, 525.

2. Cooper, I. S., Kernohan, J. W., Craig, W. McK. Arch. Neurol.Psychiat. 1952, 67, 269.

TUMOURS OF THE MEDULLA OBLONGATA

- INTRINSIC tumours of the medulla are uncommon,but a report from the Mayo Clinic reviews 15 casesin which the tumour was confined to the medulla or inwhich extension into the pons or spinal cord was minimal.In 14 of these cases the extent of the tumour was verifiedat necropsy, and in the 15th the site of the tumour wasconfirmed at operation. Despite the crowding of cranialnerve nuclei and ascending and descending fibre tractsin the small space of the medulla, the clinical pictureof these tumours is far from uniform and there may be

very few neurological signs. The reason is the relativeresistance of axis-cylinders and ganglion cells to pressurefrom an infiltrating glioma. Pathologically 11 of thetumours were gliomas—7 astrocytomas, 2 glioblastomas,1 ependymoma, and 1 oligodendroglioma-while the

remaining 4 were hoemangio-endothelioinas. The com-mon early symptoms were : ataxia, partly of cerebellarorigin and partly due to disturbance of proprioceptionfrom involvement of the cuneate and gracile nuclei ;headache, chiefly in the occipital region ; and weaknessof the limbs. This weakness was due to pyramidaltract involvement, but in contrast to gliomas of the pons,where pyramidal involvement is usual, it was presentin only 9 of the medullary tumours-probably becausethe pyramidal fibres are more diffuse and widespreadin the pons than in the medulla, where they are groupedon the ventral aspect, and the majority of the tumoursoccur in the dorsal two-thirds. Cranial nerve dysfunctionwas found in 7 of the patients, and often more than onenerve was involved ; there was facial weakness in all7 cases and sixth nerve paresis in 6. In some of the

patients the sixth nerve was compressed by the enlarged

medulla as it passed between the pons and medulla, butthe Ma,yo Clinic workers do not explain the unexpectedfrequency of facial nerve involvement by tumours

apparently confined to the medulla. Of the lowercranial nerves the twelfth was involved in 3 patients,the eleventh in 2, and the ninth and tenth in 4. Therewas raised intra,cranial pressure in only 6 of the patients;and hiccup was a prominent feature in 5 cases, in 2 ofwhich this was an early symptom. A surprising featurein 2 cases was epileptic fits, and no definite explanationfor this was found.

There is considerable difficulty in the clinical diagnosisof intrinsic tumours of the medulla oblongata, owingto the great variability of the symptoms and physicalsigns. In these patents there is a real danger of suddenunexpected death from acute respiratory failure.

1. Thorn, G. W., Koepf, G. F., Clinton, M. jun. New Engl. J.Med. 1944, 231, 76.

2. Sawyer, W. H., Solez, C. Ibid, 1949, 240, 210.3. Nussbaum, H. E., Bernhard, W. G., Mattia, V. D. jun. Ibid,

1952, 246, 289. 4. Platt, R. Lancet, 1951, i, 1239. 5. Bull, G. M., Joekes, A. M., Lowe, K. G. Clin. Sci. 1950,

9, 379.

"SALT-LOSING NEPHRITIS"

IN 1944, Thorn et al.1 described two cases in whichelectrolyte disturbances due to advanced chronic renaldisease gave rise to a clinical picture akin to that ofAddison’s disease with crisis. This diagnostic difficultyhas since been reported by Sawyer and Solez 2 in a caseof nephrocalcinosis, and by Nussbaum et al.3 in a case ofchronic pyelonephritis. In these patients the absenceof hypertension or preceding acute renal disease, togetherwith the absent or very slight albuminuria, delayedrecognition of the underlying renal disease; and theraised blood-urea and sodium depletion were attributedat first to adrenocortical insufficiency. Subsequently,failure of the blood-urea to fall to normal after thesodium depletion was corrected by adequate salt intake,and such findings as normal glucose tolerance, normal17-ketosteroid excretion, and normal suppression of

eosinophils by A.C.T.H., led to recognition of the renaldisease.

In chronic nephritis minor degrees of dehydration arecommon, and care has to be taken to ensure an adequatesodium intake.

Platt 4 conceives of the failing kidney as one with areduced number of nephrons working under conditionsof osmotic diuresis due to the high blood-urea andtherefore failing to conserve sodium. Generally patientswith chronic renal disease remain in fair balance forsodium and potassium even with quite a large range ofintake of these ions. On the other hand, some of themshow a tendency to excessive sodium loss, and Plattdescribes these as potential cases of " salt.losingnephritis." The overt case of sodium depletion withvasomotor collapse is probably only the extreme exampleof this failure to conserve sodium. Just as sodium

depletion from any cause can bring about renal insuf-ficiency in the absence of organic renal disease, so it canfurther reduce function in an already diseased kidney.A vicious cycle is then set up ; and it is understandablethat azotæmia, weight-loss, vomiting, and vasomotorcollapse may stimulate an Addisonian crisis. In suchcases the tubules may perhaps be more severely damagedthan the glomeruli, and the resulting glomerulotubularimbalance may account for the failure of ion conservation.This recalls the ion-depletion states that readily arisein the early diuretic phase of acute tubular necrosis.5Gross sodium or potassium deficiency may thenarise unless enough of these elements is ingested tobalance the uncontrolled urinary losses occurringwhile the tubules are being relined with immatureepithelium.