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teeth, and the fallacy of lack of care under the assurance that they will soon fall out, while in the meantime the child may be gathering infection or because of tenderness improperly masticating, resulting in lowered resistance or the beginning of a serious underweight condition; thyroid and its important relation to the building of bone and fat; and last, malnutrition with its varied serious effects and treatment. Dr. Emerson, of Columbia University, states that 90 per cent of children are underweight from physical defects, especially naso-pharyngeal obstructions, lack of home and personal control, overfatigue, faulty food habits and improper food, and poor hygiene.

In conclusion, I emphatically state that this valuable information is worthless unless used, not only until the child is as physically and mentally perfect as it is possible to make him, as thoroughly educated in health habits as his mentality permits him to become, but until this knowledge is so thoroughly disseminated in his home as to establish proper health habits and bring about a recognition of the need of periodic health examinations for the entire family. Only thus have we actually insured his health and given our organization the right to carry on child welfare work.

CONTINUOUS HEALTH SUPERVISION

Mary E. Murphy, Director, Elizabeth McCormick
Memorial Fund, Chicago

The title of this discussion indicates a different point of view on the care of children from that familiar to most of us a few years ago. It is distinct from the attitude with which a child caring agency brings to the attention of the hospital or dispensary the physical needs of children when symptoms of abnormality have already appeared. Continuous health supervision means a program of regular checking on the condition of children so that a healthful condition may be maintained or deviations from normal may be noted and corrected.

It is presupposed that the point of departure is the normal child, and that the program of health supervision is organized with a view to arriving at this goal of normal childhood.

Of course, a fundamental in this continuous health supervision is the physical examination, and with this distinct health point of view health supervision should provide a type of physical examination which not only notes real defects, but notes also such deviations from the normal as may have a direct influence upon the child's health. Such an examination can be made only by a physician who is familiar with the characteristics and the standards of development of normal children, and who also regards as important the whole program of the child in its relation to this physical development.

As an example of this type of thing, let me quote from the findings and recommendations made by the physician in connection with the examinations of

children in some of the work which we are doing in Chicago. Our work in this connection has included cooperation with United Charities in the continuous health supervision of their allowance families, and with the juvenile court in connection with the children of pensioned mothers. It is also included active cooperation with the Day Nursery Association in health supervision in regard to day nurseries.

In the case of Rose A. the findings were as follows: three carious teeth; tonsils large and cryptic; anterior cervical glands; nutrition fair. The recommendations were: dental care; watch throat; more milk; cereal for breakfast; stop tea and coffee; sleep with windows open.

It is evident that such notations on the part of the physician indicate that from his point of view a knowledge of the program relating to diet, sleep, fresh air, and exercise is an important factor in the diagnosis, and the correction of details in the program essential to the proper care of the case. Since this is true, it seems highly desirable that as a factor in this continuous health supervision the mother should be present at the physical examination, since it provides a most excellent means of education for her in the care of her child. This standard once established in her mind will then be re-emphasized by the nutrition worker or nurse, who follows through on the suggestions made by the physician.

Besides the first examination with its complete record of the social history, stock-taking of the habits of the child and of the family, and thorough physical history, there should be periodic examinations, which will probably take far less time, to indicate whether corrections have been made and whether progress is being made. Since it is now generally conceded that the growth record, especially relating to weight and height, is an important index of the child's physical condition, no program of health supervision can be considered complete which does not note regularly growth progress. A continuous record of a child with reference to weight and height should be a part of the physical record, and failure to make normal progress deserves attention.

This type of supervision, which is aiming at the normal child, depends upon very complete cooperation of all individuals who touch the life of the child. The child itself, of course, must be interested; the mother must cooperate on the program suggested; the physician's contribution has already been noted, and the nutrition worker or nurse provides the educational stimulus to both child and mother to carry out the suggestions. In addition, the social worker making contact with the family must be in spirit a health worker who cooperates closely with the physician and nutrition worker in re-emphasizing to the mother in the home the value of the advice given.

Our method in working with the agencies already mentioned is not to duplicate social visits to the home, but to expect the mother to attend the monthly or weekly meetings with the children. In the majority of cases the social worker is also present. If she is not, the nutrition worker and the social worker later communicate in regard to the essentials in the program to be followed

out, and the social worker then makes the necessary contact with the family. For the family agency, health supervision includes not merely the child whose condition indicates the need of special attention, but a regular health inventory of the entire child population.

THE USE OF CENTRAL CLINICS FOR CHILD
CARING AGENCIES

Alice H. Walker, Chief, Social Service Department,
Harper Hospital, Detroit

Wide variations are found in the policies of child caring agencies regarding the most effective and economical plan of providing physical examination and medical supervision for their wards. The establishment of a small clinic within the department seems to be the most common plan. While highly commendable if no better service can be obtained, such a clinic is wholly inadequate when compared with the well-organized out-patient department of a hospital, made up of eighteen or twenty clinics representing all branches of medical service, and with the most complete modern equipment providing for all patients scientific examination and skilled treatment.

Outstanding physicians of recognized ability and wide experience are in charge of the clinics. The entire dispensary service is correlated, physician consulting with physician, and with a central record system assembling all records, laboratory and X-ray reports in one folder, this unified study passing finally into the hands of one physician for interpretation, final diagnosis, and recommendation for treatment. The facilities for making this study possible are under one roof, with hospital beds at hand for the acutely ill or for those who should remain under observation. The appointment system insures for each person sufficient time for an unhurried, complete examination.

It is extremely difficult to obtain the right type of well-trained, progressive physician to serve in an independent clinic, since hospital connection is of such vital importance to him. Furthermore, few physicians working alone in a meagerly equipped clinic, without X-ray, laboratory facilities, or opportunity for consultation, are competent to make an accurate diagnosis of illness in the early preventable or readily remedial stages, particularly if the symptoms are somewhat obscure.

Nor should the examination cover the mere physical condition alone. For the child caring agency it is essential that the personality of the child in the light of his past history and his present mental and social make-up should be studied if he is to be placed in the community to best advantage. A psychological study is particularly imperative for the difficult child who presents a behavior problem, in order that wise social treatment and proper community adjustment may be effected.

children in some of the work which we are doing in Chicago. Our v connection has included cooperation with United Charities in the health supervision of their allowance families, and with the juvenile nection with the children of pensioned mothers. It is also incluc operation with the Day Nursery Association in health supervisio day nurseries.

In the case of Rose A. the findings were as follows: thre tonsils large and cryptic; anterior cervical glands; nutrition f mendations were: dental care; watch throat; more milk; cere stop tea and coffee; sleep with windows open.

It is evident that such notations on the part of the phys from his point of view a knowledge of the program relating air, and exercise is an important factor in the diagnosis, a details in the program essential to the proper care of the cas it seems highly desirable that as a factor in this continuo the mother should be present at the physical examinatic most excellent means of education for her in the care of he once established in her mind will then be re-emphasized or nurse, who follows through on the suggestions made

Besides the first examination with its complete rec stock-taking of the habits of the child and of the fami history, there should be periodic examinations, whic less time, to indicate whether corrections have been i is being made. Since it is now generally conceded: pecially relating to weight and height, is an imp physical condition, no program of health supervisio which does not note regularly growth progress. A with reference to weight and height should be a p failure to make normal progress deserves attenti

This type of supervision, which is aiming upon very complete cooperation of all indivi child. The child itself, of course, must be inter on the program suggested; the physician's con and the nutrition worker or nurse provides child and mother to carry out the suggestic making contact with the family must be in s closely with the physician and nutrition wo in the home the value of the advice given

Our method in working with the a duplicate social visits to the home, but monthly or weekly meetings with the social worker is also present. If she is

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malnourished, enuretic, and those suffering from skin conditions, vaginitis, post-encephalitis, and the various deformities. General children's institutions are out of consideration, as they are entirely unsuitable for the care of these classes. Private home placements, hospitalization, or special institutions are the only facilities to be considered. The question arises as to which is the most desirable and effective mode of care. There are those who claim that the physically handicapped child, if permitted to be cared for in a normal environment, will develop an inferiority feeling on account of his handicap. On the other hand, there are those who hold that segregation in hospital or sanatorium or specialized institution makes the adjustment of the child in the community after the period of treatment so much more difficult.

Of all the classes mentioned the one most difficult to deal with is vaginitis. Opinion as to its nature, effect, treatment, cure, and prevention varies so greatly that a consistent policy is impossible or not even desirable. The claim is made by some physicians that vaginitis results in sterility, while others discount its seriousness and claim it disappears at the age of puberty without harm. There is also a difference of opinion in regard to method of treatment, and the only unanimity that exists is as to contagion. It is a question in my mind if any single children's organization can ever cope with vaginitis successfully until the medical profession itself comes to some decision in the matter. I wonder whether a social agency especially organized for the accumulation of material would not be the most effective way of getting to the bottom of the whole problem. Perhaps such an organization as the Elizabeth McCormick Foundation, of Chicago, which has done an unusual piece of health work for children, would undertake the care and treatment of children suffering from vaginitis for the purpose of such a study.

A practical medical arrangement for a children's agency, it seems to me,' would be to tie up with a clinic of good standing; to include on its staff paid physicians, part or full time according to the extent of the work and the resources of the organization. Such a physician should have the responsibility of the first and recurrent general examinations, the supervision and check-up on refers to special clinics, and arrangements for consultations, etc. The board of directors should have one or more physicians to constitute a medical advisory board. In addition, if the organization is large enough, the responsibility for supervision of the work with the physically handicapped should be placed with one person.

Quality, rather than quantity, should be the keynote of the private children's agency. The physically normal child can well be left to the usual community resources and public agencies. If the private organization used better judgment in intake and discharge its population would decrease to a considerable extent, thus liberating funds for the more intensive work with the physically handicapped child.

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