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Civil Defence : A Basic Training Manual
P U B L I C H E A L T H , January, 1944
44 only be used as a supplement. Glucose solutions must not be given subcutaneously, owing to the risk of abscess formation. Also, subcutaneous injection is painful and distressing to the infant. Peritoneal Route.--This is ideal for the rapid partial relief of dehydration. One can give up to 200 c.c. of an isotonic glucosesaline solution rapidly with a two-way syringe and, provided the solution is of body heat, with very little distress to the patient. Should the solution be too hot or too cold, colic supervenes. The fluid is rapidly absorbed from the peritoneal cavity and the gut is apparently never punctured with a needle. In extremely debilitated children a sterile fibrinous peritonitis occasionally occurs. This is of no significance and does not give rise to clinical signs. Intravenous Route.--This is theoretically the ideal, and frequently the only one by which fluid can be given sufficiently quickly in desiderate cases. However, the technical difficulties are not easy to overcome, and in infants it invariably means cutting down on the vein and tying in a cannula, which is quite a tricky operation in a vessel only 2 mm. in diameter and means that the vein is lost for further infusions. By this route, particularly, it is easy to overdo the saline, and, unless the fluid requirement is accurately calculated, produce water retention with oedema and anuria. Intramuscular Route is almost as satisfactory as the intravenous route, without its technical difficulties. It is carried out by the same method as an intravenous infusion, except that the needle is plunged into a muscle mass such as the thigh or deltoid. The apparatus can have two needles attached to a Y-tube, when the resultant intake will be more rapid. Glucose-saline solutions can be used by this method, but absorption is slow, usually at the rate of 20 drops a minute. Should the limb begin to swell from too rapid an input it is easy to stop the flow for ten minutes and then start again at a slower rate. Practically, it is the best route to use for maintenance after the immediate correction of dehydration. Medullary Route.--This is gaining favour for introducing fluids. It is given, like an intravenous infusion, but instead of introducing the needle into a vein a stout needle is used and driven through bone into the medulla. The most satisfactory site is the upper end of the t~ia. When once in position, however restless the child, there is no possibility of the needle slipping out, and fluid can be run in at any desired speed. Isotonic saline, blood, or plasma can be given by this route.
Some Last Points In tile t r e a t m e n t of dehydration accurate charting of tile total fluid intake, its composition, and the routes used is necessary, as well as a record of vomits, stools, and the frequency of passing urine. I t is not, as a rule, possible to measure the quantities passed, although that is the ideal. Daily weighing of the infant should also be carried out and its fluid r e q u i r e ments calculated afresh each day. T h e s e r u m chemistry and the blood count are not necessary, b u t are helpful as an additional check. T h e r e is a v e r y real danger of giving too m u c h or too little salt. T o o m u c h salt will lead to water retention, w i t h oedema and anuria ; while dehydration w h i c h is due to loss of water and salt cannot be relieved if too little salt is given. If a large v o l u m e of glucose solution is administered intravenously diuresis will occur, leading to further dehydration. I f an infant can be kept correctly balanced for a few days the m o s t seriously ill will recover ; while if he is allowed to become d e h y d r a t e d a second time tile prognosis is invariably worse. An acute infection is m o r e dangerous to a baby than to an adult, but if he recovers no p e r m a n e n t d a m a g e is done. Detailed medical and n u r s i n g care are necessary w h e n he is sick in o r d e r to regulate his water metabolism, but he m a y pass f r o m extreme dehydration to perfect health in the course of a few days. I beg to state that the London County Council are not responsible for the views here expressed. R.EFERENCES
ALDRIDGE, A. G . V . (1941). Arch. Dis. Child., 16, 81, 182. JONES and MORGAN. (1939). Lancet, 9. 611. MCCANCE, R. A., and YOUNO, W. F. (1942). Arch. Dis. Child., 17, 65. YOUNC, W. F. (1943). Proc. roy. Soc. Med., May.
The Harben Lectures will be delivered on January 24th, 25th and 26th, at 8 p.m., in the Lecture Hall of the Royal Institute of Public Health and Hygiene by Dr. Melville D. Mackenzie. The subject will be " A study of the potentialities of international collaboration in medicine in the post-war world."
BOOK
REVIEWS
Civil Defenee: A Basic Training Manual. By Lieut.-Commander F. A. M. EDEN, R.N. L o n d o n . 1942. J o r d a n and Sons, L t d . Pp. 88 ; illustrated. Price 2s. T h i s booklet is d e v o t e d for the most part to p r o v i d i n g u n d e r one cover information on defence against war gases which all m e m b e r s of the Civil Defence Services should have. It presents in succinct f o r m their characteristics and the factors governing their use and effects, and the first-aid treatment of them. T h e author describes the types of respirators, their fitting, cleaning, and disinfection. H e deals adequately w i t h the wearing 6f protective clothing, w i t h the routine in a cleansing station, and w i t h the decontamination of materials. As might be expected f r o m such an experienced instructor, the information is set d o w n in logical order and w i t h a nice e c o n o m y in the use of words. T h e style m a y be illustrated by the author's statement that preventive treatment in cases of m u s t a r d gas contamination " consists essentially in the speedy and complete removal of all contaminated clothing and in freeing the skin f r o m the contaminant w h e t h e r liquid or v a p o u r . " Methods for freeing the skin f r o m liquid or v a p o u r are t h e n clearly described. T w o chapters on elementary protection against high-explosive b o m b s and on incendiary b o m b control conclude a practical and useful book. Fractures and Dislocations. " Practitioner " h a n d b o o k . E d i t e d by Sir HUMPItREY ROLLESTON and ALAN MONCRIEFF. 1943. 104 pp. Price 7s. 6d. net. T h i s is the eighth of the Practitioner booklets, and it deals, in v e r y brief form, w i t h the c o m m o n fractures and dislocations and w i t h head injuries. It is a s y m p o s i u m by eight wellknown authorities, each of w h o m has revised his original article and brought it up to date. It is s o m e w h a t surprising, therefore, to find that in the chapter dealing w i t h fractures of the pelvis no reference is m a d e to the t r e a t m e n t of the fracture, the author concerning himself entirely with. the treatment of the comparatively r,,re visceral complications. Incidentally, his advocacy of perineal drainage of a r u p t u r e d urethra w o u l d not find favour nowadays. I n the chapter on leg injuries there are repeated references to passive m o v e m e n t as a f o r m of treatment. Fhis again is almost aniversally c o n d e m n e d in m o d e m writings. T h e section on head injuries suffers f r o m lack of lucidity, while in the chapter on spinal injuries the quite erroneous statement is m a d e that cord damage is "inevitable in fracture dislocations. It is also stated in this article that approximately 50% of all spinal fractures suffer cord damage, a figure quite out of h a r m q n y w i t h m o d e r n experience. The Natural Development of the Child. By AGATHA BOVeLEY, PH.D. Second edition. E d i n b u r g h : E. & S. Livingstone. 1943. Pp. 184, w i t h 84 photographic illustrations. Price 8s. 6d. net. Postage 5d. In this little book the author follows the child f r o m birth to adolescence, describing the special difficulties likely to be encountered at each s t a g e of d e v e l o p m e n t and how these difficulties can best be handled. It is written primarily for the teacher, b u t is also i n t e n d e d for parents, and contains m u c h that will be interesting and useful to all concerned w i t h children. T h e reaction of children to the war is discussed, and case histories and illustrations add to the attraction of the book. T h e author takes the wise standpoint that the child's happiness is of m o r e importance to his ultimate d e v e l o p m e n t than the level of his scholastic achievements. Dr. Bowley stresses the need for a close co-operation between doctor, educationist, and psychologist. Perhaps one m i g h t even go further, and, w i t h o u t any disparagement to this excellent treatise, claim that a medical t r a i n i n g gives the perfect foundation for the child psychologist. T h e paediatrician of the future should possess an expert knowledge of the normal mental development of the child as well as of the physical g r o w t h ; b o t h are so interlinked that to omit normal psychology f r o m the medical c u r r i c u l u m w o u l d h a m p e r the advance of medicine.
44 only be used as a supplement. Glucose solutions must not be given subcutaneously, owing to the risk of abscess formation. Also, subcutaneous injection is painful and distressing to the infant. Peritoneal Route.--This is ideal for the rapid partial relief of dehydration. One can give up to 200 c.c. of an isotonic glucosesaline solution rapidly with a two-way syringe and, provided the solution is of body heat, with very little distress to the patient. Should the solution be too hot or too cold, colic supervenes. The fluid is rapidly absorbed from the peritoneal cavity and the gut is apparently never punctured with a needle. In extremely debilitated children a sterile fibrinous peritonitis occasionally occurs. This is of no significance and does not give rise to clinical signs. Intravenous Route.--This is theoretically the ideal, and frequently the only one by which fluid can be given sufficiently quickly in desiderate cases. However, the technical difficulties are not easy to overcome, and in infants it invariably means cutting down on the vein and tying in a cannula, which is quite a tricky operation in a vessel only 2 mm. in diameter and means that the vein is lost for further infusions. By this route, particularly, it is easy to overdo the saline, and, unless the fluid requirement is accurately calculated, produce water retention with oedema and anuria. Intramuscular Route is almost as satisfactory as the intravenous route, without its technical difficulties. It is carried out by the same method as an intravenous infusion, except that the needle is plunged into a muscle mass such as the thigh or deltoid. The apparatus can have two needles attached to a Y-tube, when the resultant intake will be more rapid. Glucose-saline solutions can be used by this method, but absorption is slow, usually at the rate of 20 drops a minute. Should the limb begin to swell from too rapid an input it is easy to stop the flow for ten minutes and then start again at a slower rate. Practically, it is the best route to use for maintenance after the immediate correction of dehydration. Medullary Route.--This is gaining favour for introducing fluids. It is given, like an intravenous infusion, but instead of introducing the needle into a vein a stout needle is used and driven through bone into the medulla. The most satisfactory site is the upper end of the t~ia. When once in position, however restless the child, there is no possibility of the needle slipping out, and fluid can be run in at any desired speed. Isotonic saline, blood, or plasma can be given by this route.
Some Last Points In tile t r e a t m e n t of dehydration accurate charting of tile total fluid intake, its composition, and the routes used is necessary, as well as a record of vomits, stools, and the frequency of passing urine. I t is not, as a rule, possible to measure the quantities passed, although that is the ideal. Daily weighing of the infant should also be carried out and its fluid r e q u i r e ments calculated afresh each day. T h e s e r u m chemistry and the blood count are not necessary, b u t are helpful as an additional check. T h e r e is a v e r y real danger of giving too m u c h or too little salt. T o o m u c h salt will lead to water retention, w i t h oedema and anuria ; while dehydration w h i c h is due to loss of water and salt cannot be relieved if too little salt is given. If a large v o l u m e of glucose solution is administered intravenously diuresis will occur, leading to further dehydration. I f an infant can be kept correctly balanced for a few days the m o s t seriously ill will recover ; while if he is allowed to become d e h y d r a t e d a second time tile prognosis is invariably worse. An acute infection is m o r e dangerous to a baby than to an adult, but if he recovers no p e r m a n e n t d a m a g e is done. Detailed medical and n u r s i n g care are necessary w h e n he is sick in o r d e r to regulate his water metabolism, but he m a y pass f r o m extreme dehydration to perfect health in the course of a few days. I beg to state that the London County Council are not responsible for the views here expressed. R.EFERENCES
ALDRIDGE, A. G . V . (1941). Arch. Dis. Child., 16, 81, 182. JONES and MORGAN. (1939). Lancet, 9. 611. MCCANCE, R. A., and YOUNO, W. F. (1942). Arch. Dis. Child., 17, 65. YOUNC, W. F. (1943). Proc. roy. Soc. Med., May.
The Harben Lectures will be delivered on January 24th, 25th and 26th, at 8 p.m., in the Lecture Hall of the Royal Institute of Public Health and Hygiene by Dr. Melville D. Mackenzie. The subject will be " A study of the potentialities of international collaboration in medicine in the post-war world."
BOOK
REVIEWS
Civil Defenee: A Basic Training Manual. By Lieut.-Commander F. A. M. EDEN, R.N. L o n d o n . 1942. J o r d a n and Sons, L t d . Pp. 88 ; illustrated. Price 2s. T h i s booklet is d e v o t e d for the most part to p r o v i d i n g u n d e r one cover information on defence against war gases which all m e m b e r s of the Civil Defence Services should have. It presents in succinct f o r m their characteristics and the factors governing their use and effects, and the first-aid treatment of them. T h e author describes the types of respirators, their fitting, cleaning, and disinfection. H e deals adequately w i t h the wearing 6f protective clothing, w i t h the routine in a cleansing station, and w i t h the decontamination of materials. As might be expected f r o m such an experienced instructor, the information is set d o w n in logical order and w i t h a nice e c o n o m y in the use of words. T h e style m a y be illustrated by the author's statement that preventive treatment in cases of m u s t a r d gas contamination " consists essentially in the speedy and complete removal of all contaminated clothing and in freeing the skin f r o m the contaminant w h e t h e r liquid or v a p o u r . " Methods for freeing the skin f r o m liquid or v a p o u r are t h e n clearly described. T w o chapters on elementary protection against high-explosive b o m b s and on incendiary b o m b control conclude a practical and useful book. Fractures and Dislocations. " Practitioner " h a n d b o o k . E d i t e d by Sir HUMPItREY ROLLESTON and ALAN MONCRIEFF. 1943. 104 pp. Price 7s. 6d. net. T h i s is the eighth of the Practitioner booklets, and it deals, in v e r y brief form, w i t h the c o m m o n fractures and dislocations and w i t h head injuries. It is a s y m p o s i u m by eight wellknown authorities, each of w h o m has revised his original article and brought it up to date. It is s o m e w h a t surprising, therefore, to find that in the chapter dealing w i t h fractures of the pelvis no reference is m a d e to the t r e a t m e n t of the fracture, the author concerning himself entirely with. the treatment of the comparatively r,,re visceral complications. Incidentally, his advocacy of perineal drainage of a r u p t u r e d urethra w o u l d not find favour nowadays. I n the chapter on leg injuries there are repeated references to passive m o v e m e n t as a f o r m of treatment. Fhis again is almost aniversally c o n d e m n e d in m o d e m writings. T h e section on head injuries suffers f r o m lack of lucidity, while in the chapter on spinal injuries the quite erroneous statement is m a d e that cord damage is "inevitable in fracture dislocations. It is also stated in this article that approximately 50% of all spinal fractures suffer cord damage, a figure quite out of h a r m q n y w i t h m o d e r n experience. The Natural Development of the Child. By AGATHA BOVeLEY, PH.D. Second edition. E d i n b u r g h : E. & S. Livingstone. 1943. Pp. 184, w i t h 84 photographic illustrations. Price 8s. 6d. net. Postage 5d. In this little book the author follows the child f r o m birth to adolescence, describing the special difficulties likely to be encountered at each s t a g e of d e v e l o p m e n t and how these difficulties can best be handled. It is written primarily for the teacher, b u t is also i n t e n d e d for parents, and contains m u c h that will be interesting and useful to all concerned w i t h children. T h e reaction of children to the war is discussed, and case histories and illustrations add to the attraction of the book. T h e author takes the wise standpoint that the child's happiness is of m o r e importance to his ultimate d e v e l o p m e n t than the level of his scholastic achievements. Dr. Bowley stresses the need for a close co-operation between doctor, educationist, and psychologist. Perhaps one m i g h t even go further, and, w i t h o u t any disparagement to this excellent treatise, claim that a medical t r a i n i n g gives the perfect foundation for the child psychologist. T h e paediatrician of the future should possess an expert knowledge of the normal mental development of the child as well as of the physical g r o w t h ; b o t h are so interlinked that to omit normal psychology f r o m the medical c u r r i c u l u m w o u l d h a m p e r the advance of medicine.