field, were lined up with certain irregular schools of medicine and were really a hindrance to health workers instead of an assistance. Such societies of laymen as the Friends of Medical Progress will do much in the future to prevent the increase of smallpox by urging vaccination and keeping the general public informed on the importance of the same. CHILD HEALTH THE HEALTH OF THE SCHOOL CHILD Mrs. Louis I. Dublin and John C. Gebhart, Director, Department of Educators, public health officials, social workers, and parents are today devoting much thought and time to child health. The ideal we have set before us is that every child shall be perfectly healthy and free from physical defects; that he shall be spared the illnesses now due to infectious diseases, and so grow up to manhood and womanhood unhampered, so far as humanly possible, by many of the physical handicaps which are now found among them. In spite of the progress that has been made in the past quarter of a century in the conservation of child life, the actual health conditions prevailing among the large mass of our child population are still quite deplorable. While we have succeeded in cutting our infant death-rate in half in the last twenty-five years and have taught the average mother a higher standard of infant welfare, the same methods are still to be applied to children over two years of age. Medical science is constantly placing in our hands, weapons for the control of the infectious diseases of childhood. Already our statistics are beginning to show the effects of toxin-antitoxin in the control of diphtheria. The death-rate from this disease in New York City, for example, has declined from 36 per 100,000 in 1900 to 12 per cent 100,000 in 1924. Scarlet fever, whooping cough, and other infectious diseases of childhood are now being studied in the health laboratories of the country in the hope that they too will soon be brought under control. The better organization of our health departments is year by year gaining ground in the saving of life and the conservation of health. A vast network of visiting nursing service over the country is bringing to the people everywhere the information and help which medical science affords. The schools, realizing their responsibility in safeguarding the health of the child, have developed a school hygiene program and technique which is constantly growing in effectiveness. The early idea that school sanitation and the prevention of the spread of the contagious diseases were for the purpose of making the child a "fit subject for education" has given way to something better. Health is regarded now as the right of every child. The schools are interesting themselves in the health of the children not merely because healthy children learn better, but because it is the duty of the school to assist them in the attainment of health for present efficiency and greater future usefulness. There is fairly general agreement on the three main essentials of a health program for the school today: first, proper sanitation of the school plant and hygienic school administration; second, periodical inspections and physical examinations and the correction of physical defects which are thus disclosed; third, the molding of the habits, interests, and ideals of the child by health teaching and health training both within and outside of the school. Sanitation of the school plant and hygienic school administration have reached a high point of efficiency in many of our schools. Sanitary drinking fountains or individual paper cups have taken the place of the old tin dipper. Toilet facilities are generally good. Lighting is usually arranged so as to avoid eyestrain. Even textbooks for elementary grades are now being standardized with regard to type, paper, and margin to conserve the eyesight of young people. Adjustable seats and desks are eliminating some of the defects of posture which were so often caused by improper seating arrangements. Much thought is also being given to methods of ventilating the classrooms, heating of school buildings, and many other details. Medical inspection of school children, both for the purpose of controlling contagious disease and for the detection of the more obvious physical defects, plays an important rôle in the daily practice of school hygiene. According to a recent government report, thirty-nine states now have laws providing for medical inspection. In many states, however, the law is permissive only, and many local communities have as yet failed to make even a beginning. Because of the difficulty of securing financial support, adequate medical personnel is lacking. Much of the work of routine inspection is frequently delegated to the school nurse and occasionally to the grade teacher. These assistants, after some training, can usually select from a large group of children those who appear to show marked deviation from the normal regarding either vision, hearing, posture, or symptoms of malnutrition. They can also detect some of the marked symptoms of contagious disease. The children thus selected are referred to the school doctor, if there is one available, for final diagnosis. He makes recommendations to the family or to the family physician. The advantage of calling upon nurses and teachers to assist in making routine inspection is that such arrangement gives the school doctor more time to make really thorough examinations and to deal adequately with those children who present serious medical problems. Some of our state laws require a medical inspection or examination for every child once a year. Unfortunately, however, very few communities have as yet provided adequate medical personnel to make such annual examinations really worthy of the name. The result is that the doctors are in most cases obliged to do a very superficial job. In order to cover the ground, the doctor must often examine as many as three hundred children in a forenoon. In such an examination the doctor has no opportunity to use his skill and training to the best advantage in order to discover many important defects. We therefore find ourselves today facing the fact that three-fourths of all our children have remediable physical defects which interfere with proper growth and development. Is this not an indictment of our present methods in child care? According to the report of the National Education Association in 1918, the following estimate is given of the prevalence of physical defects: 50 to 75 per cent of our school children have defective teeth; 25 per cent have defective vision; 15 to 25 per cent have adenoids and diseased tonsils and glandular defects; 25 per cent are undernourished; 1 to 2 per cent have organic heart disease. It must be remembered that these figures are the result of cursory medical inspections, and it may be reasonably assumed that more thorough physical examination would reveal many more serious conditions. The program of thorough health examination is still in its infancy. The few studies which have been made clearly indicate that such examinations not only reveal a larger number of obvious defects but, more important still, they discover more of the serious impairments than could possibly be discovered by cursory inspection. In 1920 the Association for the Improvement of the Condition of the Poor made a study of the findings of the examination of 2,186 Italian children in New York City whose ages ranged from two to sixteen. The study showed that 43 per cent of the children had nose and throat defects. Thirty-eight per cent were undernourished, and 3 per cent had serious involvement of the lungs. A study made by the Life Extension Institute of 326 children whose average age was nine years found that 36.5 per cent of the children had faulty posture; 32.2 per cent had constipation; 5.5 per cent showed definite or marked traces of albumen in the urine, while a slight trace of sugar was found in the urine of 6.2 per cent of the children. While considerable progress has been made in perfecting and extending our school medical inspection, very few of our children are receiving the benefit of a thorough health examination. It is this phase of the health program for school children which is still seriously neglected. The value of the periodical health examination has been amply demonstrated in our program in infant welfare. Pediatricians have recognized it as a most effective form of procedure in the care of infants. In health centers, "well baby" conferences, and baby clinics it is an important part of the routine. These agencies are gradually extending their work to include children of preschool age. The periodic health examination of the adult is also being rapidly recognized as a valuable means of maintaining and improving health and of extending human life. Such data as has been collected by the Life Extension Institute and the Metropolitan Life Insurance Company bear eloquent testimony of what can be accomplished through periodical health examinations. Among 6,000 policyholders who for six years availed themselves of periodical examinations by the Life Extension Institute there followed a saving of 24 per cent on the expected mortality. This obviously meant a saving of the companies' money through deferred death claims during this period. Indeed, it is estimated that on the basis of the cost of the examination the Company made a profit of 200 per cent. Many industries have instituted health examinations of their employees solely for the purpose of increasing efficiency and of reducing labor turnover. If industrial leaders find that this method more than pays for itself in conserving the health of its employees, surely the community cannot afford not to include periodical health examinations in its child health program. The technique of health examinations for apparently well children is still in an early stage of development. The trend of medical education in the past has been to train physicians to care for the sick. The newer idea of prevention is, however, slowly gaining ground. The practice of thoroughly examining apparently well children for the detection of impairments which while unsuspected may lead to ill health is an important step in preventive medicine. Further progress of medical inspection in schools may eventually lead to the provision of periodic health examinations. In certain localities in England, school medical inspection has almost reached this point. The practice there is to provide a very complete inspection at school entrance and three times thereafter during the elementary school career of the child. The type of inspection called for and the time allowed for its performance in the English school system allows the school doctor to give a reasonably thorough medical examination. In many communities in America such a program is impossible, if the time of the school doctor is reserved solely for strictly medical examination by delegating to the nurses the bulk of the task of routine inspection. There is much difference of opinion, however, as to whether the schools should provide a thorough periodic health examination or whether this should be left to the private physician and the parent. Many health officers and supervisors of child hygiene take the stand that it is the responsibility of the schools merely to sort out the more obvious defects, to report these conditions, usually through the school nurse, to the parents, and to assist wherever possible in securing the necessary medical treatment. Complete examinations and final diagnosis must be left, they claim, to the family physician or to private clinics and dispensaries. One cannot escape the feeling, however, that the advocates of this policy are largely influenced by the difficulty of securing adequate financial support necessary to furnishing a high-grade medical service, and also by the very serious problem of providing adequate supervision to insure proper medical standards for the work. The correction of defects becomes a real problem just as soon as medical inspection is effective in discovering them. To secure prompt and adequate treatment many have advocated school clinics for defects of teeth and even those of nose and throat. While many admirable school clinics are conducted in England and on the Continent with a fair degree of success, practice in this country so far has favored leaving the corrective work to the private practitioner or to well-organized clinics and hospitals. An exception is often made in the case of dental clinics. Dental clinics, where the work is restricted to prophylaxis and to repairing the first permanent molars among younger children, have had an excellent educational effect in training children in the care of the teeth and in the habit of going regularly to the dentist. Such clinics are regarded not as a means for correcting defects, for dental defects have a way of not staying corrected, but as an effective means of teaching oral hygiene and of preventing serious dental trouble later. Our schools have undertaken, however, to provide special classes for physically handicapped children. Open-air classes for anemic and so-called pretuberculous children, sight-conversation classes, and classes for children with cardiac defects are provided in our most progressive schools. It is obvious that children with physical handicaps must receive at school special care and instruction in order to make normal progress through the grades and to conserve their health and strength. It is the feeling of many progressive educators and health workers, however, that the school can and should serve as means of preventing the occurrence of many of the common physical defects. This feeling has grown out of the realization that the school, more than any single institution, is qualified to instil in children the practices, attitudes, and ideals essential to healthful living. Efforts are already being made to include in the training of teachers a knowledge and appreciation of the essential facts of healthful living and the acquiring of a technique of health teaching. It has been discovered that health training can be integrated with the entire school curriculum to the profit both of education and health. Even this brief survey indicates that while during the past quarter of a century great progress has been made in protecting and conserving child life there are still certain needs which must be met before every child is assured of his birthright of health. They may be summarized as follows: first, we need more and better physical examinations and better followup of children of all ages; second, we need a standardized and uniform procedure for health examination of children which should be consistent with the best medical standards possible and yet practical enough to lend itself to wide application; third, provision should be made in our medical schools for the adequate training of our physicians in the value and technique of the periodical health examination of apparently healthy children; fourth, the schools and all other agencies should be utilized for establishing higher standards of community health and for imparting knowledge to both parents and children regarding the essentials of healthful living. |