70 13 January 1968 Leading Articles MWDIC 1OURNAIlogical response does not necessarily follow. In a straight-forward study of basic hygiene in two Indian villages hefound that a knowledge of the danger of flyborne infectionhad virtually no influence on the decision whether or not toconstruct an effective compost pit. The decision was moreclosely related to motives remote from considerations ofhealth and was mainly in response to social pressures fromkey individuals. Similarly P. Hobbs'0 has suggested thatyoung smokers are influenced not by information but by theirpeer group and perhaps by the example if not the utterancesof respected elders.

In advertising" it was long since realized that simpleproclamation of the undoubted merits of a product is notenough. Advertising campaigns aim at the development of abrand image with techniques which tap basic impulsesapparently only remotely connected with the product.Industry, too, has recognized that exchange of informationwill not alone improve communication.' 13 The managementof change, whether of personal habits or of public attitudes,

requires an understanding of the forces motivating individualsand groups in the community. Medicine may thus havesomething to learn from industry and advertising on thetechniques of effective communication.

1 Wid Hlth Org. tech. Rep. Ser., 1959, No. 177.2 Brit. med. 7., 1966, 2, 655.Jones, K., in Trends in the National Health Services, ed. Farndale,W. A. J. 1964. London.

Gatherer, A., and Reid, J. J. A., Public Attitudes and Mental HealthEducation: Northampton Mental Health Project 1963. 1967.Northamptonshire County Council.

Willcocks, A., Ment. Hlth (Lond.), 1967, 26, 14.6Cartwright, A., Martin, F. M., and Thomson, J. G., Lancet, 1960, 1,

327.Medical Students' Attitudes towards Smoking, Ministry of Health.

1967. H.M.S.O.Brit. med. 7., 1967, 4, 120.Sehgal, B. S., Int. 7. Hlth Educ., 1967, 10, 60.Hobbs, P., Hlth Educ. 7., 1965, 23, 41.Packard, V., The Hidden Persuaders. 1960. Harmondsworth, Middle-

sex.Jacques, E., The Changing Culture of a Factory. 1951. London.

" Brown, J. A. C., The Social Psychology of Industry. 1958Harmondsworth, Middlesex.

Acute GastroenteritisA variety of organisms can cause acute gastroenteritis.Among them are various strains of Escherichia coli, salmon-ellae, shigellae, and protozoa such as Giardia lamblia.Though enteroviruses and adenoviruses have been associatedwith outbreaks of gastroenteritis, E. J. Bell and N. Grist'consider " it is unlikely that these are significant causes ofuncomplicated diarrhoeal disease." Indeed, a recognizablepathogen can be found in only 20 to 30% of cases.

In young children a combination of acute respiratory andgastrointestinal upset frequently occurs in short epidemics.Infections of the urinary tract, pneumonia, meningitis, andsepticaemia may also present with diarrhoea and vomiting.When of purely dietetic origin diarrhoea and vomiting mayusually be differentiated by its transient nature and theabsence of pyrexia and constitutional disturbance. In resi-dential nurseries and hospitals it is imperative to segregatethe patient until the diagnosis has been established. Insporadic cases particular inquiry should be made aboutprevious bowel habits, the mode of onset, association withsimilar illness in other children, and the presence of bloodin the stools. Chronic diarrhoea is seldom due to infection,but giardiasis should be considered as a possible cause. Onceit has been excluded the patient should be investigated forfibrocystic disease, coeliac disease, and genetic disorders ofcarbohydrate metabolism due to deficiencies of specificenzymes.

Gastroenteritis caused by pathogenic strains of E. coli isgenerally limited to children under the age of 2 years ; inolder children and adults a very heavy dose of the organismis required to produce diarrhoea. It is not uncommon tofind specific serotypes in healthy young children. D. R.Gamble and K. E. K. Rowson' estimated that 2% of youngchildren are infected with specific serotypes at any one time,and S. Thomson and colleagues3 found that about one-quarter of all babies were infected with types 0-111, 0-55,and 0-26 during the first year of life. It is evident, therefore,that there is marked variation in virulence among differentstrains of one serotype. The appearance of a virulent strain

in a maternity unit, children's nursery, or paediatric ward mayprove disastrous; in the present outbreak on Tees-side appar-ently E. coli 0-128 is responsible.

Prevention of spread can be assured only by prompt isola-tion of cases at onset and thorough screening of contacts.Investigation of an individual should continue until a mini-mum of three negative stool cultures have been obtainedUntil these investigations have been completed no furtherbabies should be admitted. For patients with severe andpersistent vomiting, immediate restoration of the fluid andelectrolyte balance is an essential life-saving measure. It canbe done only by intravenous infusion. In less severe casestreatment may be carried out at home. The prescribing ofglucose water is to be strongly condemned, since it conducesto serious depletion of electrolytes and may therefore lead toa fatal issue. There is indeed a strong case for includingin the National Formulary a tablet which can be dissolved inwater to give a solution suitable for treating early dehydra-tion. The indications for admission to hospital are persistentvomiting or diarrhoea, or signs of dehydration. It is impor-tant to stress that young children with gastroenteritis requirevery close observation, since their condition can deterioratewith alarming rapidity. The fundamental treatment is thecorrection of fluid and electrolyte imbalance. Antibiotics areof secondary importance. In outbreaks of gastroenteritiscaused by pathogenic E. coli the choice of drug will dependon the sensitivity of the organism. Once dehydration hasbeen corrected and the bowel disturbance settles, milk feedsof increasing strength may be introduced gradually. Anyexacerbation of symptoms is an indication for giving a weakermixture. After an attack of gastroenteritis many babieshave a reduced tolerance for sugar and fats. Before a con-valescent child is allowed to mix with other young childrenin a nursery or hospital ward at least six consecutivelynegative specimens of stool should have been obtained.

Bell, E. J., and Grist, N., Brit. med. Y., 1967, 4, 741.' Gamble, D. R., and Rowson, K. E. K., Lancet, 1957, 2, 619.Thomson, S., Watkins, A. G., and Gray, 0. P., Arch. Dis. Childh.,

1956, 31, 340.