345

Annotations.

EPIDEMIC DIARRHŒA.

"Ne quid nimis."

DURING the last July week 11 children under2 years of age in Greater London, and 38 in the 105great towns of England and Wales, died from diarrhoeaand enteritis. During the same week 6 deaths inGlasgow were attributed to the same causes and oneeach in Dundee and Aberdeen. The total fatalities werefewer than in the hotter week immediately precedingand much fewer than in the corresponding week oflast year. In an original article which appears thisweek in our columns, Dr. Donald Paterson tells usthat 147 cases, diagnosed as summer diarrhoea, were.admitted during the hot months of 1921 to theHospital for Sick Children in Great Ormond-street.Of these less than one-half were discharged cured.Whatever may be the tendency to a reduction in thenumber of cases of this disease, it is evident from thecase mortality that summer diarrhoea when it occursremains extremely grave. Dr. Paterson writes of theaetiology of the disease as still in doubt, especially inregard to the part which bacteria play on the foodbefore or after ingestion. He quotes with approvalC. E. Bloch’s observation in 1920 that, whetherpathogenic bacteria are or are not found in the stools,the clinical picture, pathological findings, and epi-demiological course of the disease are much the same.Dr. David Nabarro contributes a report on 41 fatalolses which were examined bacteriologically duringlife, or after death, or both. After the common B. colithe organism most frequently isolated was B. coli ianaerogenes in addition to the 12 fatal cases it wasfound also in several cases which recovered.B. dysenieriae was isolated from four cases, B. para-typhosus B from two, and in no case was Morgan’sNo. 1 bacillus discovered. Study of aetiology has notyet thrown light on treatment which remains muchas it was. Removal of the child from the environ-ment in which it contracted the disease into a bedsurrounded by fresh moving air ; administration ofsaline to make up loss of fluid, apparently best givenintraperitoneally when symptoms are urgent; strongglucose solution by the mouth, as being eagerly takenand containing a larger number of calories than otherfood equally bland-these are the measures approvedby experience. No medicinal remedies appeared toinfluence appreciably the course of the disease.We may still hope that some more effective way

may be found of treating this summer scourge of ourlarge towns. The helplessness of medicine in face ofthe severely toxic and dehydrated child makesprevention of the disease worthy of every kind of effort.In his annual report for 1921 on the great urbanarea for whose public health he is responsible, Dr.W. H. Hamer has a paragraph of great interest on theepidemiology of diarrhoea and enteritis, and it isfortunate to have his experience now that we areapproaching the usual time of maximum incidence.During the whole of last year 2152 children under2 years of age died in London from diarrhoea andenteritis, giving a mortality rate per thousand birthsof 21-55, slightly below the average for the ten years1911 to 1920. It is well known that Ballard found in1885 that when the 4 ft.-underground temperaturereaches 56° F. diarrhoea commences. In view of thehigh average temperature of last summer, Dr. Hamerfinds the mortality from diarrhoea remarkably low.In a diagram in his report the relation between summerdiarrhoea and temperature is shown graphically, andfor the 38 years up to 1914 the agreement betweenthe two curves is very remarkable. From 1914 on,however, there is a remarkable difference betweenthe actual mortality and that estimated as probablefrom the summer temperature. Dr. Hamer gives hisreasons for thinking that this is not, as might appear,entirely an effect of the war, but rather the accentua-tion of a tendency already noticeable in pre-war years.

Separation allowances combined with food rationingcertainly did improve the quality and even thequantity of food supplied to the very poor, the classin which mortality from infant diarrhoea is greatest,and the special administrative measures directedtowards the care of expectant and nursing mothersas well as of their infants, inaugurated before the war,continued to develop in spite of war conditions. Overand above these direct influences Dr. Hamer seesanother modifying factor-in the effect of nationalhealth insurance in bringing the medical practitionerinto closer relation with the homes of the poor. How-ever the beneficent result is to be explained it is afact that the peak of the mortality curve, usually afortnight or so behind that of the temperature, hasrecently lagged as much as seven or eight weeks.Diarrhoea occurring so long after the crest of theheat-wave is less deadly. Increase in the lag com-menced about the time of the commencement of thedecline of infant mortality generally, and cannot, inDr. Hamer’s view, be explained by differences inclassification. Infants born since 1900 really seem tohave been rendered more resistant and to possessincreased power to withstand the strain of abnormalconditions. Decrease in the amount of horse manureon the streets may well have been a contributingfactor. The gradual decline of diarrhoea is oneof the best examples of the effect of providing asanitary environment. ____

THE NEW YORK LIFE EXTENSION INSTITUTE.

THE Life Extension Institute, Inc., was founded in1914 ; its aims were described as the lengthening ofhuman life and the increase of individual humanefficiency--aims which it was proposed to attain by theappointment of expert medical examiners, with fullyequipped laboratories in all the larger centres ofpopulation, who would periodically examine thephysical condition of its own policy-holders, ofpolicy-holders of other life insurance companiescontracting with it for the purpose, and, on paymentof a small fee, of any other person who might desireit. Schools, industrial establishments, and healthauthorities were also to be contracted with, and theHygiene Reference Board of the Institute containedmany names well known in medicine. A report on thepast year’s working has recently been issued in theform of a letter to the members of this Board, in whichthe Institute claims to have made substantial progressin its work, although the business depression in 1921was felt to some extent. The insurance work of theInstitute is double its volume a year ago ; seven

insurance companies are served by it, and others arecontemplating contracts. This is stated to be largelythe result of the statistical study made by theMetropolitan Life Insurance Company, showing a

reduction in mortality of 28 per cent. among thepolicy-holders tabulated (those examined by theInstitute in 1914 and 1915), and a reduction of67 per cent. in the mortality among those foundimpaired. The company states that this has been a200 per cent. investment (returns$2 net profit forevery dollar expended), "thus demonstrating thefundamental sanitv of the Institute’s insuranceprogram and evidencing the tremendous futurepossibilities of the work." Many inquiries have beenreceived from scientific men and health authoritiesabroad asking for details as to the work of theInstitute.A notable piece of work conducted by the Institute

in 1921 was the investigation of ill-health as a causeof waste in industry, on behalf of the FederatedAmerican Engineering Societies, under Mr. Hoover.The full report of this investigation has been amplifiedinto a book entitled " Health Building and LifeExtension : A Discussion of the Means by whichThe Health Span, The Work Span and The Life Spanof Man can be Extended," written by Dr. E. L. Fisk,medical director of the Institute, to be publishedshortly. Much information on health conditions

1 THE LANCET, 1914, i., 1199.

346 THE WELFARE OF THE DEAF.

drawn from scattered sources has been assembled,systematised, and discussed in this book. Anothereducational effort of the Institute, a volume preparedby Dr. Fisk in the " American Viewpoint " series.will contain a simple story of health and hygiene, andinformation as to governmental health organisations,for the education of immigrants, school children,industrial workers, and that portion of the publicwhich welcomes information presented in a simple andpictorial form. A moving-picture series has beenplanned to present the material in this work and tomake available a film library of simple, fundamentalhealth instruction. An unpaid examination of 100Post Office employees revealed that 12 per cent. ofthese men were in need of some form of medicalattention. On the basis of this study the cooperationof the United States Public Health Service wassecured, and 1000 Post Office employees were

examined ; the report on this inquiry is not yet Ipublished. Plans are nearing completion for turning Iover as a free gift the common stock of the Institute to ’iseveral leading Universities, and the ultimate retire- ’

ment of the preferred stock, thus placing the finalcontrol of the Institute in the hands of the trustees ofthese Universities, who will be able to safeguard it inthe distant future for such work as it can best perform.At its New York office the Institute employs a staffof about 30 physicians, whole-time and part-time,and 120 technicians and lay employees. Consultingspecialists work with the regular staff. The Institutehas referred its examinees to their family physiciansfor medical treatment which, at an average rate ofmedical charge, would represent fees amounting tobetween five and ten millions of dollars. TheInstitute does not practise medicine. No dividendshave yet been paid : the President of the Institute,Mr. H. A. Ley, gives his time without salary. A noteis added to the report, to the effect that neither themedical director nor any member of the staff hold anystock of the Institute or derive any emoluments fromit other than moderate salaries.

THE ROLE OF THE PROSTATE IN URINO-

GENITAL TUBERCULOSIS.

NOT long ago tuberculosis of the prostate wascommonly regarded as a rare and comparativelyunimportant condition, of far less importance thantuberculosis of the epididymis. Thanks to the investi-gations of Simmonds of Hamburg and other patholo-gists, this mistake has been corrected, and it is nowgenerally admitted that the prostate plays a mostsinister part in conveying tuberculosis from the urinaryto the genital system. This teaching is confirmedin a recent paper by Dr. P. J. Schultz’ of the Patho-logical Institute of the Berlin-Moabit Hospital.Among 14,086 necropsies performed between April 1st,1908, and April 1st, 1920, he found 125 cases ofgenital and urino-genital tuberculosis in the male.In as many as 104 cases the prostate was involved,the vesiculae seminales taking second place with 78cases, and the epididymis third place with 66 cases.In 35 cases the prostate was the only gland in thegenital system to be involved, and in 23 of these casesboth the urinary system and the genital system werein other respects intact. The prostate, in other words,would seem to have been infected by the blood-streamin these 23 cases. All the 125 cases were associatedwith tuberculosis elsewhere, and with few exceptions,the lungs and pleurae were also the seat of tuberculouschanges. Isolated " genito-primary " tuberculosis ofthe epididymis proved to be exceedingly rare and onlyfour such cases were observed ; in a fifth case theepididymis was the only structure in the genitalsystem affected by tuberculosis, but in this case renaltuberculosis was also found. The question withwhich Dr. Schultz was largely concerned was thecomparative importance of

" testipetal " and" testi-

fugal " infection. He has come to the conclusionthat, in the overwhelming majority of cases, the

1 Zeitschr. f. Tuberkulose, 1922, Bd. xxxvi., Hft. 2.

genital system becomes infected by the prostate; that"testipetal" spread of infection is, in other words,the rule and not the exception. Without this gland,which forms a connecting link between the urinaryand the genital systems, men would suffer as seldomfrom tuberculosis of the epididymis in conjunctionwith renal tuberculosis as women suffer from tuber-culosis of the Fallopian tubes in conjunction withrenal tuberculosis. An important conclusion to bedrawn from this paper is that, in one respect at anyrate, tuberculosis of the kidneys is fraught withgreater danger to men than to women.

THE WELFARE OF THE DEAF.

A SPECIAL appeal has recently been issued by theNational Bureau for Promoting the General Welfareof the Deaf. Since its foundation in 1911, theBureau has helped to coordinate the numerous

organisations for the deaf. It has brought together forpurposes of discussion many persons interested in allaspects of their welfare, and has collected and classifiedinformation, maintained a valuable library, andanswered many inquiries relating to such variedmatters as lip-reading, employment, electrical aids,private and public schools for deaf children, highereducation for the deaf, and how to deal with quacks.It has provided information for Government Depart-ments and public authorities. The Bureau drewpublic attention to the causation and prevention ofdeafness by means of a series of lectures--delivered in1912 by Dr. J. Kerr Love, and later issued in bookform-which constitute an indispensable basis forfurther research, and has also published a useful andmuch-needed handbook of information relating to thedeaf, the only work of its kind available. Imme-diately before the war the Bureau brought together arepresentative gathering in order that a practicalscheme might be formulated for the foundation of aNational Training College of Teachers of the Deaf.The war prevented further work on this scheme, but itmay be said that the foundation of the present Chairof Deaf Education, at Manchester, by the late SirJames E. Jones, was largely due to this movement.The war left the Bureau in a condition described in theappeal as one of " partial functional paralysis."There is ample provision for the education of deafchildren in the 51 day and residential schools estab-lished throughout the country by private philanthropy,or by municipal and county education committees,but much remains to be done with regard to schoolattendance and to the evolution of the best teachingmethods. There is no general provision for suitableeducation or technical training of the adolescent deaf,whilst the work for the adult deaf everywherelanguishes for want of public support. An organi-sation such as the National Bureau is, therefore,required to coordinate isolated effort, to bring Z5

together agents and interested people for concertedaction, and to carry through a national policy.The appeal is signed by Mr. Macleod Yearsley (ActingChairman of the Bureau) and Messrs. G. SibleyHaycock, Arthur J. Story, and Albert Smith, whoexpress the opinion that the future functions of theBureau should be briefly as follows : (1) assistanceand education of the adolescent deaf by getting intotouch with the various schools and societies, and byconference and otherwise seeking to unify theirexperiences and results ; (2) continuance of the workof coordination and of general assistance to the deafin which it has been so successful in the past, with thecreation of an efficient publicity department; (3)institution of a medical department which should(a) stimulate prompt and efficient treatment ofchildren deaf or threatened with deafness, in thepre-school period as well as during the scholastic age,and (b) promote and assist by all means in its powerthe studies of causation and prevention ; (4) institu-tion of a political department to urge the earliereducation of deaf children and their higher educationafter the age of 16, and establishment of a college orcolleges for higher education or technical training