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entity. In addition to the efficiency and conscientiousness of the school medical staff, three conditions are absolutely essential for the success of school medical work : first and foremost, complete harmony of the medical authorities with the school authorities; secondly, the co-operation of the parents. of the medical profession, and of the dispensaries; and, thirdly, the adoption of the follow-up system.

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afflicted with defective vision were over 10 per cent ; 0.6 per cent suffered from defective hearing ; and nearly 12 per cent were found with defective nasal breathing, while 15 per cent had enlarged tonsils. Out of the total of 674,667 children in public schools in 1910, 286,591, or 43 per cent (dangerously near one-half), were found to have communicable eye and skin diseases, including trachoma, ringworm, conjunctivitis, scabies, and others.

It was estimated recently that, if the condition in New York is typical of the schoolchildren in the whole United States, there must be in the schools of this country about 9,000,000 children with bad teeth. stated with authority that “ bad teeth, decayed teeth, or the loss of teeth during childhood, its concomitant discomfort, pain, depression of spirit, and lack of appetite, produce that physiological poverty which renders the delicate system of the child not only more prone to tuberculosis, to the invasion of the germs of serious, acute, contagious diseases, such as measles, diphtheria, scarlet fever, etc., but also more susceptible to nervous afflictions, such as hysteria, chorea, and St. Vitus' dance." It is easy to realize what an effective and complete system of medical work in the schools means in increased happiness, decreased suffering, and greater mental and physical efficiency in the rising generation.

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QUESTION OF SINGLE OR DUAL AUTHORITY

In the great majority of the smaller American communities where school medical inspection is of comparatively recent date, the medical work is under the control of the school departments, where it logically belongs. Under such an arrangement, the first of the above-named requirements, that of harmony between the school and the physician, is fulfilled, and the duty of caring for the health of the children devolves entirely upon the schools, and they are directly responsible for

In larger cities, where medical inspection has been carried on for a longer time, the work is often performed by two city departments—the Department of Health and the Department of Education. This division of authority and responsibility is a result of the gradual growth of appreciation of the need of health control of the children and their school environment—of taking up first one thing and then another-and is based on the theory that the control of contagious and communicable disease belongs to the Departments of Health, which are possessed of the proper administrative machinery for the performance of such work and with police power to enforce their orders.

In New York City the dual system of control prevails, and there are certain conditions that make effective and harmonious action particularly difficult. These arise from a variety of causes, one of which is the cumbersome organization of the Board of Education, which carries on its work through a number of separate committees. The three factors in the health environment of the school-children for which the Department of Education is responsible are: (1) the sanitary condition of schools ; (2) instruction in physical training; and (3) the segregation and care of backward and mentally defective children. The first of these is under the supervision of three distinct committees; the second and third are directly under the city Superintendent of Schools. There is no concentration

WORK

The health work in the schools is very complex and many-sided. Apart from the medical examination of school-children for contagious and non-contagious defects and the elimination of children suffering from communicable diseases, it is the task and duty of the medical and nursing staff to instruct the children in personal hygiene, to call the attention of parents to remediable defects, to direct the children to physicians or dispensaries for treatment, to follow them into their homes to see that treatment is given and instructions are obeyed, to examine the children joining in athletic sports, to instruct them in physical training, to segregate the backward and the mentally defective, to provide special training for those who are crippled or otherwise handicapped, and to supervise the sanitary conditions of schools. A well-rounded and efficient system of school work must recognize all these elements and correlate them into one organic and elastic

THE USEFUL FIELD OF THE SCHOOL NURSE

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of all the activities of the Department of regular reports of progress and results of
Education pertaining to health ; there is no treatment.
uniformity of policy, as the administration is
scattered ; and there is no localization of re-
sponsibility. Experience has shown that these The third essential prerequisite of success-
requirements should be provided for in the ful medical inspection of school-children is a
organization or reconstruction of a medical rigorous follow-up system. This, of course,
school service.

has an important bearing upon the problem of

securing the co-operation of parents. CO-OPERATION OF PARENTS NEEDED

obviously useless and wasteful to stop with The second condition stipulated as

the mere discovery of defects. To secure cessity of effective medical school work is effective results, not only should the attention the co-operation of the parents and of the of parents be called to the condition of their medical profession and dispensaries. It is children, but notifications to that effect should obvious that unless parents heed the recom- be followed at short intervals by gentle but mendations of the medical school attendants persistent insistence that the necessary and take steps to have the defects of their treatment be applied. This is a proper and children remedied, nothing can be accom- fruitful field for the activities of the school plished unless children are treated in the

In New York, in addition to her schools, a measure which, outside of dental other duties in the school, the nurse visits the and communicable eye and skin disease clin- homes of the children ; explains the defects ics, has not been tried in the city of New of the child to the parents; gives advice as to York. Private physicians and dispensaries personal and home hygiene, and urges that a in the past have not taken very keen interest physician be consulted; or, in the case of in the medical school work, an attitude which poorer people, that the child be taken to a is detrimental to efficiency, as the Depart. dispensary. ment of Health considers a case closed when If the parents are too ignorant or inert to a notice is received from a physician that the follow her advice, or if they are so employed child suffering from a defect is under his that they cannot spare the time to take the treatment. There is no law by which the child to a dispensary, the nurse does this, or Department of Health can undertake any should do it, herself. The activities of the further action even if, in the opinion of its school nurse are an essential part of effective inspectors, no treatment is given or the treat- medical inspection. In spite of the fact that ment is inadequate. Unfortunately, parents the city of New York spends about $300,000 not infrequently are far more ready to evade for that part of medical school work which health orders than to obey them. An in- is carried on by the schools, the force of instance has been reported in New York where spectors and nurses is still inadequate to meet a druggist carried on a business in selling all the demands of the community. certificates signed by a physician which could As at present organized in New York, the be exhibited as proof that children were work of the Department of Health in superunder treatment, and it is said that he even vising the health and comfort of school-chiladvertised at moving-picture shows his readi- dren is carried on through the Bureau of ness to supply such certificates. The exist- Child Hygiene; that of the Department of ence of such conditions indicates the need of Education through a number of committees. interesting parents in the medical work and The working corps of the Bureau of Child of educating them to its practical value, and Hygiene is composed of physicians and nurses. it suggests a field in which the intelligent The former make physical examinations, diagportion of the lay public might render effect- nose suspected cases of contagious diseases, ive aid to the health authorities and school and make absentee and other home visits ; officials.

the latter make class inspections, exclude susA provision that undoubtedly would add pected cases of contagious disease, and do to the efficiency of the treatment of children follow-up work in the homes. Except for the requiring medical attention would be the inadequacy of its facilities for the task proestablishment, by dispensaries, clinics, and vided, the operation of this division of the out-patient departments of hospitals, of con- work seems to be reasonably effective. Of sultation hours for school-children in the late the branches of the work that have been left afternoon, together with arrangements for to the schools themselves, only the provision

for physical training may thus far be regarded been termed the bookkeeping of the public as adequate. The chief recommendations of health movement. The importance of havthe Public Health, Hospital, and Budget Com- ing such statistics and of making them as mittee of the Academy of Medicine, based on complete and comprehensive as possible is a study of existing conditions, are the en- so evident that it seems impossible to give largement of the working staff of the Child any reasonable explanation of the fact that Hygiene Division, and a concentration of at the present day such statistics are recorded. responsibility and control in the medical work even partially, for only fifty-five per cent of of the Department of Education. It is pointed the population of the l'nited States. It is out that more thorough physical examinations, equally mortifying to be compelled to confess more frequent inspections, and an extension that the statistics recorded even for this porof the follow-up work, to secure better co- tion of the American people are in great operation from parents and medical prac- part so inaccurate and so incomplete that titioners, are necessary.

In view of the they are of comparatively slight use in furnishprevalence of physical defects, the Com- ing a satisfactory guide to our progress in mittee recommends that there should be one matters of health. While we maintain elabschool nurse to every 2,500 children, and one orate organizations and complete machinery physician to every 7,500.

for collecting and compiling elaborate records Of the necessity, value, and importance of of manufactures, trade, and transportation, medical school inspection, the mere statement in this most vital and important matter we of the extent to which physical and mental remain in the dark ages as compared with defects abound in the schools is sufficient the leading nations of Europe. proof. When over seventy per cent of the In certain sections of the country, particupupils in the schools of a great city are found larly in some of the older States and larger to be in need of treatment, and forty-three cities, very encouraging progress has been per cent are afflicted with communicable dis- made in recent years toward the creation of eases, it is obvious that medical inspection an adequate system of health accounting. and treatment advance to a position of equal Such progress as has been achieved has importance with the mental training for resulted almost entirely from the efforts of which the schools are primarily conducted. medical organizations or of public health But unless this work is so organized and con- officers who themselves are, of course, memducted as to be comprehensive and thorough, bers of the medical profession. To provide much of the effort will be wasted. To secure a comprehensive and widely useful system of a high degree of efficiency it is important vital statistics applicable to the whole country that the public attitude be changed from the and useful for comparative studies, however, present one of general indifference to one of

will require joint, or at least harmonious, active interest and co-operation. Medical in- action on the part of the Federal Government spection of schools is work of the most direct and the States as well as by municipalities. and practical public value. It not only adds to To bring about such a result the backing of the efficiency of those who are preparing to a strong body of enlightened public sentitake up the work of the world, but at the ment is almost essential. Here is another same time it is helping to lighten the load of field, therefore, in which it is important that disease and dependence that oncoming gener- the co-operation and support of the lay pubations otherwise must carry.

lic, whose members will derive the benefit

from the inauguration of an adequate system IMPORTANCE OF ACCURATE VITAL STATISTICS

of vital statistics, shall be given to the medWhile the relation between medical inspec- ical profession, upon whose members will tion of schools and the registration and com- fall most of the work of making such a pilation of vital statistics may not be partic- system effective. ularly close, the two subjects are treated While the health records of New York City together here because both are fields in which are recognized as being more comprehensive the organized efforts of the medical profession than those of most American municipalities, have resulted in such progress as has been they cannot compare in point of completeness made and in which intelligent co-operation on with those of the leading cities of Europe. the part of the public will contribute much to The Paris statistics, for example, contain further progress and greater efficiency. much more detailed information and offer

Vital statistics and demography have aptly more bases for correlation than the New York

STATISTICS

tables do. They classify births not only as On all of these subjects certain popular to living and stillborn, and as to sex and the beliefs and opinions are current, but few of ages of the parents, but they specify also the these have been put to a comprehensive duration of marriage; they give the relation statistical test. It would be exceedingly valuof age to fecundity; they report marriages able to have bases for definite conclusions on by conjugal status before marriage and by these and other related subjects. the degree of consanguinity of husband and In 1911 the Health Department of New wife, and they convey a variety of other York City, realizing the deficiencies of its information helpful in charting the great vital statistics, appointed a committee of movement of racial development and the statisticians to advise them in the matter. causes contributing to its progress or deca- The committee made a few simple but dence. By contrast with this the vital statis- highly practical recommendations. tics report of New York has only two tables suggested that the existing Bureau of Records for births and only one for marriages. Simi- be enlarged into a Bureau of Vital Statistics larly, in comparison with London, the New with three subdivisions—one of Records, one York reports are not only less detailed but of Research, and one of Publicity. The inare deficient in descriptive analyses.

creased cost to the city of this reorganization

was computed at only $40,000 ; but the proINADEQUACY OF AMERICAN

posal was rejected by the Board of Estimate Much valuable information even now exists and Apportionment of the city on the plea of in the offices of departments of health in economy: American cities which is not being utilized, In order to urge upon the city the necesand in hardly any city is any persistent effort sity of appropriating the necessary means for made to interest the public in this subject, the reorganization of the Bureau of Records, which transcends in public importance many and also to impress the medical profession as of the questions on which a vast deal of dis- well as the lay public with the importance of cussion is lavished. If an exceptionally high complete and exact, promptly published, vital or low birth rate or death rate is recorded statistics, and their service to science as well for a given period, that fact may receive brief to administration, the Public Health, mention in the newspapers, but beyond this Hospital, and Budget Committee of the New little attention is paid to reports dealing with l'ork Academy of Medicine has prepared a the records of vitality. One reform urgently report on vital statistics and health reports of needed is the preparation of official health New York City. In this report it indorsed publications in such form, and the presenta- the recommendations of the Committee of tion of the conclusions and inferences which Advisory Statisticians for a reorganization their figures justify in such

way, as to

and enlargement of the present Bureau of appeal to the average reader, for whom they Records ; but it went further, and gave a should be primarily intended.

detailed outline of what, in its judgment, the With very little additional effort in the reports of the Bureau should contain. The compilation of records now collected in many Committee urged the appropriation of the cities, reports could be made to throw much needed funds, and made an appeal to the light upon such vital problems as the relation medical profession for co-operation in the between morbidity and occupation, between prompt and exact recording of births, deaths, the vitality of children and the age and occu- and sickness. In spite of all the efforts of the pation of their parents, between the pro- Department of Health, only ninety-five per portion of stillbirths and the employment of cent of births are registered with the Departmothers. The relation of mortality to the ment, while the per cent of reportable cases density of population, the influence of immi- of contagious and communicable diseases is gration upon birth, death, and morbidity very much less. The value of our vital starates, the effect of consanguinity upon the tistics depends, in a large degree, upon the fecundity of marriage, the incidence of dis- good will of our physicians. ease upon the various elements of the popu- The Committee has also recommended lation, and the relation between infantile that instruction in the methods and principles diseases and the ages and occupations of of medical and vital statistics be given in the parents, could be shown. Needed illumina- medical colleges, and, following this up, it pretion could be given to important social prob- pared an outline of such a course, with broad lems such as race suicide.

social and administrative bearings, which was

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submitted to the Council on Medical Educa- cians are deprived of this important source tion of the American Medical Association. of technical skill and exact knowledge.

While eighty to ninety per cent of the perAUTOPSIES AND PUBLIC HEALTH

sons dying in English, Canadian, German, Closely connected with the problem of and Austrian hospitals come to a necropssi ! correct vital statistics is the question of med- the per cent of autopsies in the largest hos. ical competency. Many death certificates do pitals in this country is about ten, and in not give the true cause of death because of some instances it is considerably less than the carelessness, neglect, or intent of the that. Studies of the number of correct cliniphysician ; many, however, and these are cal diagnoses as revealed by autopsies show numerous, are faulty because of the igno- that many important diseases fall below fifty rance of the physician as to the real cause per cent in recognition, and some even below of death. Definite proof in many instances twenty-five per cent. The trustworthiness of can be furnished only by autopsies.

some of our death statistics, under the circumThis brings us to a subject in connection stances, may easily be conjectured. Prowith which it is entirely within the facts to fessor Bashford, director of the Imperial say that the advancement of medical science Cancer Institute in London, asserts that and the promotion of public health is greatly returns from Ceylon with regard to cancer, hampered in the United States by the are more reliable than those of New York! groundless though understandable prejudice The same is true of other important diseases. of the general public against the extension of There is a general belief, which is supported the privileges of hospitals in the matter of by such statistics as we have, that certain performing autopsies. This prejudice arises diseases, such as cancer, affections of the largely from ignorance of the importance of kidneys, and heart disease, are rapidly inpost-mortem examination and from popular creasing in this country. Whether they actuconfusion of autopsies with anatomical dis- ally are increasing at any such rate as seems sections. Unfortunately, there is a continu- to be indicated cannot be determined until ous effort on the part of zealous but mis- provision is made for far more ample postguided individuals and organizations to mortem examinations. In view of this fact, increase this prejudice by misrepresentation the Committee has recommended that a camof the facts.

paign of education be undertaken by medical The great value of autopsies, not only to organizations to acquaint the public with the the medical profession but also to the mem- dependence of medical progress and educabers of the general public whom that pro- tion upon the extension of post-mortem exfession serves, is beyond question.

aminations in hospitals, that effort be made wish to add to our store of medical knowl- to secure legislation similar to that of Euroedge, if we wish to turn out good physicians, pean countries in reference to this subject, if we are to have reliable mortality statistics, and that meanwhile hospital rules be so there must be more post-mortem examina- framed as to facilitate the performance of tions in the hospitals. A comparative study

A comparative study autopsies in cases where they are likely to of this subject which the Public Health, prove of value. By aiding in this movement Hospital, and Budget Committee of the New

the public at large will serve its own interests York Academy of Medicine recently pub- by helping to advance the cause of medical lished shows to what extent American physi- progress.

If we

(This article will be followed in the next issue of The Outlook by another

on the same general subject, written by the same authors.)

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