74 IRISH JOURNAL OF MEDICAL SCIENCE

treatment must (so far as the goitre is concerned) be regarded as purely coincidental. Eisen has stressed that very limited opera- tions (such as was performed in this case) have resulted in marked improvement, and even in some cases in complete cure. The pro- gress of this case confirms his observations.

The condition appears to have been a very extensive thyroiditis of unknown origin producing mainly a mechanical disability. The operation presumably benefited the patient partly by relieving the pressure effects and probably by drainage of irritant material and the re-establishment of a more active tissue fluid circulation.

I f the small nodule removed from the left upper pole was a lymph gland it is of no particular interest, but if it was an isolated piece of thyroid tissue presenting lymphocytic changes of the Hashimoto type it would appear that the two conditions may co- exist in the same gland, and that probably the fibrosis is a result of the lymphocytic infiltration, although the clinical features do not correspond with those of a typical Hashimoto struma.

References.

Eisen : (1936) Am. Jo. Med. Sei. , 192, 673. Chute & Lahey (1932) : Ann. Sur. , 95, 4, 493. Je l l : (1929) Brit. Jo. ~urg., xxvii, 351.

THE PROBLEM OF STUDENT HEALTH.*

By JOHN DUFFY.

Twice and t w ~ over it is good to go over that which is good, successively presenting the ,ravers o] the orw truth.--PLATO.

T H E subject of student health is one in which I have been very interested for many years. For it has often, unfortu- nately, fallen to my lot to witness the tragic end of many

a young Lycidas, "dead ere his prime," in almost every case of easily preventible disease, if only the proper procedure had been in operation to diagnose and treat it in time. And so I propose to discuss the problem as it exists, to point out what has been done about it in other countries, and finally to tell something of the enlightened and progressive step which University College, Dublin, is proposing to take, with the co-operation of the students them. selves, to safeguard and maintain a high standard of student health.

That a very distinct disease problem exists among the students o~ any college or university is often not definitely reeognised by

$ Paper read to the Medic~| Society, University College, Dublin, October 27fh, 1941.

THE PROBLEM OF STUDENT HEALTH '/5

the university authorities. This may be accounted for by the fact that students who fall ill consult their family physicians, in many cases not until after leaving the college. No one practitioner would see more than a ~ew such cases, and therefore to him there would be no special problem amongst students. Only when these cases begin to pass through one special channel, such as a tuberculosis department, or through special student health services, such as those attached to universities on the Continent or in America, does the magnitude of the problem begin to assert itself and elamour for recognition. The former, I regret to say, has been my sad experi- ence during 16 years' association with the Public Health Depart- ment of this city. I do not exaggerate when I say that I could easily count upwards of 20 students of my own years in this College who have fallen victims--many of them fatal victims--of tuber- culosis, the disease p a r excel lence of young adult life. Hundreds of thousands constitute the annual tribute that mankind pays to this disease, aptly called by John Bunyan " The Captain of the Men of Death." There is no infection so universal among men, and but few, if any, others in which the case mortality is so low. Need I recount its sinister features? Of indefinite and insidious onset, it is, without prompt treatment, often a disease of long duration, with phases of quiescence and exacerbation, becoming in many cases a lifetime threat, with the possibility that an accident or some other disease may at any time claim precedence and rob the tubercle bacillus of its prey. The high incidence of tuberculosis amongst university students is not due primarily to their mode of life as students, but is largely accounted for by the fact that the college age-period, namely, late adolescence and early maturity, is one from which a high toll is exacted by tuberculosis all over the world. The sharp upward trend of the tuberculosis mortality curve from the low level of pre-puberty years to the high level of early adult life coincides with the age-period of the college student. Moreover, it is now generally recognised that although the peak of tuberculosis mortality occurs after the college age, the beginnings of the disease are commonly traceable in individual cases to the period of the late teens or early twenties.

Thus the colleges are faced at once with a problem and a great opportunity. The problem lies in the susceptibility of the age- period and the corresponding relative concentration of the disease, and the opportunity in the now well-developed large-scale methods for early recognition of tuberculosis, permitting prompt arrest of many cases, and prevention of serious illness and death. For in the case of this disease early diagnosis is tantamount to prevention and cure. The colleges constitute one of the great filters through which a section--and a valuable section--of the youth of the country passes. Seldom after the college age is it so easy in this group to institute mass measures for the prevention of the disease. The importance of mass measures for early diagnosis is evident in the nature of tuberculosis. I t is still, unfortunately, true that the majority of eases of pulmonary tuberculosis come to light when

76 IRISH JOURNAL OF MEDICAL SCIENCE

already in an advanced state. Of 66,861 patients admitted to tuberculosis hospitals and sanatoria in the United States in 1935, and reported by the American Medical Association, only 13.1 per cent. were in the minima! stage, whilst 29.7 and 57.2 per cent. were classified as moderately and far advanced respectively. The reason for this lies in the fact that its symptoms are trivial in the early stages and commonly not serious enough to urge the patient to seek medical advice. Herein lies the opportunity for the colleges, which control a large body of susceptible youth, and can at no great inconvenience to the students subject the whole group to measures for locating the incipient cases. This" method of group investigation represents the latest contribution of preventive medicine to the attack on tuberculosis.

Briefly the method of case-finding which has been found best and most economical and has been sponsored by the American Student Health Association is based on a progTamme of mass tuberculin testing with the two-strength purified protein derivative (P.P.D.) of Long and Seibert, followed by x-ray examination of all positive reactors. The cost 'can be still further reduced by the adoption of the latest technical advance in the field of radiology, namely, the introduction of miniature screen radiography. The work of de Abreu in South America, of Holfelder in Germany, of Galbraith in Australia, and that of Sparks, of Bentley and Leitner, and others in England all testify that the method is thoroughly sound and efficient, and is in fact the solution of the problem where large numbers have to be dealt with. I might add for the information of those who are still deterred and alarmed by the question of expense that careful figures of cost, as worked out by Galbraith in the Australian Army survey in 1940 to include materials, wages of staff, salaries of specialists, together with a liberal allowance for maintenance and depreciation of plant, indicate that the total cost by this method works out at 10d. per x-ray examination. It must be remembered, however, that this low cost applies only where very large numbers are being dealt with ; nevertheless, it gives some idea of the relative inexpensiveness of the method.

The success of an active programme for finding the disease as compared with a passive one in which the student is left to seek medical advice when he feels the need of it, has been described by numerous physicians from college health services in recent years. Pioneer work in this field has been done in U.S.A., notably by Myers in Minnesota, Soper in Yale, Lee H. Ferguson in Western Reserve, Opie and Landis in Philadelphia, as well as by Heimbeck in Norway, Malmros and Hedvall in Sweden, and the authorities of Strasburg, Miinster, Munich, Paris, and many other European universities. Surveys from all this work are now to hand, and are increasing year by year, so that the literature is now considerable. From it some idea may be gained of the incidence of tuberculosis amongst university students in various countries. In Miinster 1.14 per cent. of students examined were found to have active tubercu- losis~ in Munich Kattentidt found 2 per cent. Stiehm found that

THE PROBLE~I OF STUDENT HEALTH 77

in the University of Wisconsin 1.5 per cent. of all tuberculin-tested students had adult-type infiltration, and of these one-fifth needed sanatorium treatment. At Yale Soper and Wilson found 1.8 per cent. ; whilst 4 to 5 per cent. is the figure given by Saye in Barcelona students; and the very high figure of 17.9 per cent. among young members of professional classes in China by Hall and Chang. In a recent three-year survey carried out at University College Hospital, London, D'Arey Hart, Hilton, and Morland found 13 eases of early disease in 417 students examined, and of these eight cases (1.9 per cent.) had active tuberculosis, and were advised to have sanatorium treatment. The incidence of clinical tuberculosis has been found to be relatively high in the medical-student group, and it is signifi- cant to note that the risk is greater during the third and fourth years of study when opportunities for massive infection during clinical work arise. The statistics given by Lees show that in the University of Pennsylvannia radiological examination revealed the following incidence of tuberculosis in various groups of students :. freshmen, 0.3 per cent. ; undergraduates, 0.6 per cent. ; law students, nil in 165; and medical students, 5.8 per cent. From these figures one could safely assume that the incidence of the disease in university students in this country is at least such as would warrant the establishment of health services in our universities and colleges.

Why the problem has been so long ignored by university adminis- trators has always to me appeared inexplicable. For the past 100 years and more it has been recognised, as the great German hygienist Johann Peter Frank had originally maintained, that the real wealth of a nation is in its population. A college education re- presents a considerable investment of money and educational re- sources which certainly will not be realised in terms of disabling illness or premature death. So that the ultimate results of condi- tions arising out of a breakdown with tuberculosis in the boy or girl in a university must represent a serious economic loss to the indivi- dual, the college, and the community. Even in a country like America, wi~h unlimited funds for medical research and progress, and where moreover philanthropy is a national trait, the establish- ment of student health services in the universities was an uphill task for the pioneers. After years of intense propagandist activity in public health work it was not until 1920, when the American Student Health Association was organised, that the first chest clinic connected with a university was established in the United S~ates by Dr. J. A. Myers of Minnesota, who was a pioneer in this field and probably has made the greatest single contribution to it. The lack of interest is very clearly shown by the fact that between 1920 and 1929, although yearly meetings were held, only one paper on tuber- culosis was read before the American Student Health Association-- again by Dr. Myers, on his experience at the University of Minnesota. In 1930 Dr. W. B. Soper started work at Yale, and since then great progress has been made, so that by now practically every university and college has its own student health service-- either through well-organised full-time departments in charge of a

78 IRISH JOURNAL OF MEDICAL SCIENCE

medical director, or through part-time arrangements with local hospitals or physicians. In most instances the detection and con- trol of tuberculosis has been made a major part of the health pro- gramme. Such has been the advance in public opinion that the students themselves are demanding from college authorities the establishment of such services. Thoughtless youth is concerning itself with its own health in a sphere hitherto indifferently served by thoughtful maturity.

Progress in these countries is apparently being made along some- what similar, though of course slower and more conservative lines. Except for the work at University College Hospital, London, and at the Welsh National School of Medicine, Cardiff, little or nothing has so far been done. To the physicians and authorities of the Adelaide Hospital, Dublin, who last year started tuberculin-testing and x-ray examination of all their students and nurses, must be given the credit for the establishment of the first student health service in Ireland. This year, also, I read that the British Medical Students' Association is concerning itself with the question of student health with special reference to periodic x-ray examination of the chest. In ~he same connection the National Union of Students has advocated compulsory examination of students at the end of a university course, or after three years of study; and this body is prepared to press for the appointment of a medical officer in every university school to look after the health of the student body as a whole.

In order to stress the essentials I have purposely omitted to men- tion the many other activities of a well-developed college health pro- gramme. I will mention only one which has a bearing on my main thesis, namely, the classification of the students into groups accord- ing to their physical fitness for games and athletics. It is well- known that unrestricted activity and participation in strenuous ou~- door sports without medical supervision is in many cases harmful and often totally subversive of their ultimate object, namely, the maintenance of physical fitness. The establishment of a health department would thus remove the anomaly that exists at present of rather too much provision being made for games, and too little supervision and regulation of the s~udent's fitness to indulge in them to his best advantage.

Consequently, to those of us who are interested in this question of student health it is a great pleasure to learn that, due mainly to the efforts of the recent Dean of the Medical Faculty, Professor McLoughlin, and to the sympathetic encouragement of the Presi- dent, Dr. Conway, the authorities of University College, Dublin, have initiated a two-year experimental scheme for the examination of students. It is to be hoped that the students themselves will not only co-operate but will show by their enthusiasm that they appre- ciate the opportunity which their predecessors missed, and for lack of which some of them paid dearly in ill-health and even loss of life. It lies with you yourselves to make of this scheme a success, and thereby ensure that the ten to twenty of your number who., as

TH E PROBLEM OF STUDENT H E A L T H 79

matters stand, are destined to come down sooner or later with clinical tuberculosis will be diagnosed and advised in time to pre- yen what must be, for some of them at least, an appall ing catas- trophe in their lives. The time is long overdue for the eradication of undergraduate tuberculosis. We have the necessary weapons, we have the goodwill to bring success. It only remains to enlist the enthusiasm and fighting spirit of the whole student body. With this reinforcement we can forecast an early banishment of the greatest menace of student life. And I am sure you will agree with me that it is hardly necessary to ask the question : Is it worth while? Should you need an answer, it is to be found in the ancient dictum of Hippocrates : "Wherever the art of medicine is loved, there also is love of humanity."

BOOK REVIEWS. Common Skin Diseases. By A. B. ROXBURGH. Lewis. 6th Ed. 16/-.

The demand for a" further edition of this useful work within two years is proof of its popularity. The author notes carefully an.y advances in theory and treat- men t and discusses them from practical expermnce. Impor t an t examples are the radiat ion therapy of thor ium X. This form of radiat ion is found useful in r ingworm of the nails and capillary naevi in children. Dermato-myositis, con- sidered by Dowling and Frendentha l to be the same disease as generalised seleroderma bu t almost unknown unt i l a few years ago, is well discussed in all i ts aspects. The author accepts the theory t ha t impetigo is of two types, streptococcal and staphylococcal, and the differences are set for th clearly in tabular form. The paragraphs on bullous impetigo of the newborn have been amplified. Very useful will be found the section on industrial dermati t is wi th a list of the ten commonest chemical causes and chief points in prophylaxis. Scabies is thoroughly dealt with, including the modern t r ea tment wi th henzyl benzoate. Finally, the chapter on avitaminosis has been re-wri t ten and expanded, adding much valuable information on this impor tan t subject in relation to dermatology. The number of excellent illustrations in the text have been increased. This book remains of high value to the specialist as well as the general practitioner. M . D .

Sick Children. By D. PATTE1~SO~. CasseU. 4th Ed. This compact volume, now in i ts four th edition, is clear, well wri t ten and

surprisingly complete for such a small book. Diagnosis and t r ea tmen t are dealt wi th most fully, whilst etiology and pathology are sufficiently stressed to make the work quite readable. To the s tudent , preparing for his final examination, this book will be particularly welcome, as i t should add much to his knowledge yet li t t le to his reading. As a book of reference for the pract i t ioner i t also has a definite place. The tabular presenta t ion of the blood chemistry, cerebro- spinal fluid analysis in heal th and disease and other like mat te rs is part icularly useful in this respect.

The chapters on blood diseases, nephrit is , tuberculosis, nervous diseases and disorders of the endocrine glands have been re -wr i t t en a n d a new chapter dealing with the sulphonamide group of drugs i n s been added. Thus the book has been brought up to date. I t is wor thy of a place in the l ibrary of every s tudent and practi t ioner of medicine. T . M . K .

D i ~ , e e o] the 2~o8e, Throa~ and Ear. By Sz~so~ HALL. Livingstone. 2nd Ed. 15[-.

This book has been wri t ten to meet the needs of the general practi t ioner and s tudent . I t is a synopsis of the more general diseases wi th thei r t r ea tment in this special branch.

For a book of its size too much detail is devoted to operat ive measures. Otologists will scarcely approve of the au thor ' s giving a " s a f e " method to the inexperienced in the performance of an emergency radical mastoid. The radical operat ion can be carried out a t a later date when simpler t r ea tmen t has t ided the pa t ient through the or/sis. Although a book of 445 pages, i t is publiehecl in a convenient size. The illustration5 are clear and inst~c~rve. I t m a ~ k which ehould be epprecieted b y yrac~ittoners end s~ud~nts,

A . P . 1 r.