health has been achieved we find that the initial impetus, as well as most of the later progress, has come from the organized activities of the medical profession. This is true not only of those discoveries as to methods of disease prevention for which we naturally must look to men of professional skill and equipment. It is equally true in the broader sphere comprehended within the application of facts of established truth and general acceptance to the cause of health promotion. It becomes pertinent, therefore, to ask ourselves if those who live by the presence and prevalence of disease find it worth while for the sake of humanity and social progress to labor for the conservation of public health, whether it is not high time that we, the public, who profit by these efforts, should extend to them a heartier and more general measure of co-operation and support.

To gain a better grasp of the situation and also perhaps some light upon the problems which will be brought to a readier and earlier solution by a broader measure of cooperation between the public and the medical profession, it may be worth while to consider briefly some of the directions in which the activities of the medical profession have been expended in advancing the cause of public health. For this purpose we may take as an illustration certain features of the work of one of the most influential medical organizations in the country, the New York Academy of Medicine.

The Code of Medical Ethics, adopted in 1847 by the American Medical Association, recognizes physicians as conservators of public health and declares that "it is a delicate and noble task, by the judicious application of Public Hygiene to prevent disease and lengthen life, and thus to increase the productive industry, and, without assuming the office of moral and religious teaching, to add to the civilization of an entire people."

Early in its history the Academy of Medicine stated in its constitution that one of its four objects was the promotion of public health and in 1852, following the precept already quoted, it created a standing Committee on Public Health. After undergoing several metamorphoses this committee became, in 1911, the Public Health, Hospital, and Budget Committee, with a membership of eighteen eminent and public-spirited men. Apart from its constructive social and scientific value, the work of this committee constitutes an instructive example for medical

societies of other communities, and is full of interest and value to the lay citizen to whose welfare its work is devoted.

As illustrating two of the elementary yet vastly important fields of public welfare work in which there is still room for improvement in the most progressive communities, and to which in many localities scarcely any attention is paid as yet, a brief résumé will be given of the work done by the Academy of Medicine in New York in bringing about an efficient general medical inspection of schools and the adoption of a more complete and trustworthy system of registering vital statistics.

MEDICAL INSPECTION OF SCHOOLS

Recognition of the interdependence of the mental and physical conditions of normal human beings constitutes the foundation of and excuse for medical school inspection, which, originating independently in various European cities, has spread all over the Continent and England, established itself in 1898 in this country, and has reached South America, Egypt, and Japan. An educational system which does not develop health, intelligence, and health habit in children is unsound and impractical. Having adopted the principle of compulsory school attendance, we have taken upon ourselves impliedly the responsibility for the health of the children whom we keep in schools during the most tender and sensitive years of their existence. The bases and purpose of medical school work are everywhere the same; the differences lie in the thoroughness of performing the work and in administrative details. School hygiene work has been carried on in New York more extensively than in any other American city, and its problems, methods, and achievements therefore are of general interest, particularly at this time when the whole subject is brought under discussion by the great International Congress on School Hygiene at Buffalo.

EXTENT OF THE PROBLEM

Of the total number of 230,243 schoolchildren examined in the public schools of New York in 1911 for non-contagious defects, 72.2 per cent were found to need treatment of some sort. Of these, 135,843 were found to have defective teeth. In the case of over 39 per cent this was the only trouble, while almost one-third were found to have other defects in addition to bad teeth. The children

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. It was

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.

ELEMENTS OF EFFICIENT MEDICAL SCHOOL 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

entity. 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.

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 it. 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

of all the activities of the Department of Education pertaining to health; there is no uniformity of policy, as the administration is scattered; and there is no localization of responsibility. Experience has shown that these requirements should be provided for in the organization or reconstruction of a medical school service.

CO-OPERATION OF PARENTS NEEDED

The second condition stipulated as a necessity of effective medical school work is the co-operation of the parents and of the medical profession and dispensaries. It is obvious that unless parents heed the recommendations of the medical school attendants and take steps to have the defects of their children remedied, nothing can be accomplished unless children are treated in the schools, a measure which, outside of dental and communicable eye and skin disease clinics, has not been tried in the city of New York. Private physicians and dispensaries in the past have not taken very keen interest in the medical school work, an attitude which is detrimental to efficiency, as the Department of Health considers a case closed when a notice is received from a physician that the child suffering from a defect is under his treatment. There is no law by which the Department of Health can undertake any further action even if, in the opinion of its inspectors, no treatment is given or the treatment is inadequate. Unfortunately, parents not infrequently are far more ready to evade health orders than to obey them. An instance has been reported in New York where a druggist carried on a business in selling certificates signed by a physician which could be exhibited as proof that children were under treatment, and it is said that he even advertised at moving-picture shows his readiness to supply such certificates. The existence of such conditions indicates the need of interesting parents in the medical work and of educating them to its practical value, and it suggests a field in which the intelligent portion of the lay public might render effective aid to the health authorities and school officials.

A provision that undoubtedly would add to the efficiency of the treatment of children requiring medical attention would be the establishment, by dispensaries, clinics, and out-patient departments of hospitals, of consultation hours for school-children in the late afternoon, together with arrangements for

regular reports of progress and results of

treatment.

THE USEFUL FIELD OF THE SCHOOL NURSE

The third essential prerequisite of successful medical inspection of school-children is a rigorous follow-up system. This, of course, has an important bearing upon the problem of securing the co-operation of parents. It is obviously useless and wasteful to stop with the mere discovery of defects. To secure effective results, not only should the attention of parents be called to the condition of their children, but notifications to that effect should be followed at short intervals by gentle but persistent insistence that the necessary treatment be applied. This is a proper and fruitful field for the activities of the school nurse. In New York, in addition to her other duties in the school, the nurse visits the homes of the children; explains the defects of the child to the parents; gives advice as to personal and home hygiene, and urges that a physician be consulted; or, in the case of poorer people, that the child be taken to a dispensary.

If the parents are too ignorant or inert to follow her advice, or if they are so employed that they cannot spare the time to take the child to a dispensary, the nurse does this, or should do it, herself. The activities of the school nurse are an essential part of effective medical inspection. In spite of the fact that the city of New York spends about $300,000 for that part of medical school work which is carried on by the schools, the force of inspectors and nurses is still inadequate to meet all the demands of the community.

As at present organized in New York, the work of the Department of Health in supervising the health and comfort of school-children is carried on through the Bureau of Child Hygiene; that of the Department of Education through a number of committees. The working corps of the Bureau of Child Hygiene is composed of physicians and nurses. The former make physical examinations, diagnose suspected cases of contagious diseases, and make absentee and other home visits; the latter make class inspections, exclude suspected cases of contagious disease, and do follow-up work in the homes. Except for the inadequacy of its facilities for the task provided, the operation of this division of the work seems to be reasonably effective. Of the branches of the work that have been left to the schools themselves, only the provision

for physical training may thus far be regarded as adequate. The chief recommendations of the Public Health, Hospital, and Budget Committee of the Academy of Medicine, based on a study of existing conditions, are the enlargement of the working staff of the Child Hygiene Division, and a concentration of responsibility and control in the medical work of the Department of Education. It is pointed out that more thorough physical examinations, more frequent inspections, and an extension of the follow-up work, to secure better cooperation from parents and medical practitioners, are necessary. In view of the prevalence of physical defects, the Committee recommends that there should be one school nurse to every 2,500 children, and one physician to every 7,500.

Of the necessity, value, and importance of medical school inspection, the mere statement of the extent to which physical and mental defects abound in the schools is sufficient proof. When over seventy per cent of the pupils in the schools of a great city are found to be in need of treatment, and forty-three per cent are afflicted with communicable diseases, it is obvious that medical inspection and treatment advance to a position of equal importance with the mental training for which the schools are primarily conducted. But unless this work is so organized and conducted as to be comprehensive and thorough, much of the effort will be wasted. To secure a high degree of efficiency it is important that the public attitude be changed from the present one of general indifference to one of active interest and co-operation. Medical inspection of schools is work of the most direct and practical public value. It not only adds to the efficiency of those who are preparing to take up the work of the world, but at the same time it is helping to lighten the load of disease and dependence that oncoming generations otherwise must carry.

IMPORTANCE OF ACCURATE VITAL STATISTICS

While the relation between medical inspection of schools and the registration and compilation of vital statistics may not be particularly close, the two subjects are treated together here because both are fields in which the organized efforts of the medical profession have resulted in such progress as has been made and in which intelligent co-operation on the part of the public will contribute much to further progress and greater efficiency.

Vital statistics and demography have aptly

been termed the bookkeeping of the public health movement. The importance of having such statistics and of making them as complete and comprehensive as possible is so evident that it seems impossible to give any reasonable explanation of the fact that at the present day such statistics are recorded. even partially, for only fifty-five per cent of the population of the United States. It is equally mortifying to be compelled to confess that the statistics recorded even for this portion of the American people are in great part so inaccurate and so incomplete that they are of comparatively slight use in furnishing a satisfactory guide to our progress in matters of health. While we maintain elaborate organizations and complete machinery for collecting and compiling elaborate records of manufactures, trade, and transportation. in this most vital and important matter we remain in the dark ages as compared with the leading nations of Europe.

In certain sections of the country, particularly in some of the older States and larger cities, very encouraging progress has been made in recent years toward the creation of an adequate system of health accounting. Such progress as has been achieved has resulted almost entirely from the efforts of medical organizations or of public health officers who themselves are, of course, members of the medical profession. To provide a comprehensive and widely useful system of vital statistics applicable to the whole country and useful for comparative studies, however, will require joint, or at least harmonious, action on the part of the Federal Government and the States as well as by municipalities. To bring about such a result the backing of a strong body of enlightened public sentiment is almost essential. Here is another field, therefore, in which it is important that the co-operation and support of the lay public, whose members will derive the benefit from the inauguration of an adequate system of vital statistics, shall be given to the medical profession, upon whose members will fall most of the work of making such a system effective.

While the health records of New York City are recognized as being more comprehensive than those of most American municipalities, they cannot compare in point of completeness with those of the leading cities of Europe. The Paris statistics, for example, contain much more detailed information and offer more bases for correlation than the New York

tables do. They classify births not only as to living and stillborn, and as to sex and the ages of the parents, but they specify also the duration of marriage; they give the relation of age to fecundity; they report marriages by conjugal status before marriage and by the degree of consanguinity of husband and wife, and they convey a variety of other information helpful in charting the great movement of racial development and the causes contributing to its progress or decadence. By contrast with this the vital statistics report of New York has only two tables for births and only one for marriages. Similarly, in comparison with London, the New York reports are not only less detailed but are deficient in descriptive analyses.

INADEQUACY OF AMERICAN STATISTICS Much valuable information even now exists in the offices of departments of health in American cities which is not being utilized, and in hardly any city is any persistent effort made to interest the public in this subject, which transcends in public importance many of the questions on which a vast deal of discussion is lavished. If an exceptionally high or low birth rate or death rate is recorded for a given period, that fact may receive brief mention in the newspapers, but beyond this little attention is paid to reports dealing with the records of vitality. One reform urgently needed is the preparation of official health publications in such form, and the presentation of the conclusions and inferences which their figures justify in such a way, as to appeal to the average reader, for whom they should be primarily intended.

With very little additional effort in the compilation of records now collected in many cities, reports could be made to throw much light upon such vital problems as the relation between morbidity and occupation, between the vitality of children and the age and occupation of their parents, between the proportion of stillbirths and the employment of mothers. The relation of mortality to the density of population, the influence of immigration upon birth, death, and morbidity rates, the effect of consanguinity upon the fecundity of marriage, the incidence of disease upon the various elements of the population, and the relation between infantile diseases and the ages and occupations of parents, could be shown. Needed illumination could be given to important social problems such as race suicide.

On all of these subjects certain popular beliefs and opinions are current, but few of these have been put to a comprehensive statistical test. It would be exceedingly valuable to have bases for definite conclusions on these and other related subjects.

In 1911 the Health Department of New York City, realizing the deficiencies of its vital statistics, appointed a committee of statisticians to advise them in the matter.

The committee made a few simple but highly practical recommendations. They suggested that the existing Bureau of Records be enlarged into a Bureau of Vital Statistics with three subdivisions-one of Records, one of Research, and one of Publicity. The increased cost to the city of this reorganization was computed at only $40,000; but the proposal was rejected by the Board of Estimate and Apportionment of the city on the plea of economy.

In order to urge upon the city the necessity of appropriating the necessary means for the reorganization of the Bureau of Records, and also to impress the medical profession as well as the lay public with the importance of complete and exact, promptly published, vital statistics, and their service to science as well as to administration, the Public Health, Hospital, and Budget Committee of the New York Academy of Medicine has prepared a report on vital statistics and health reports of New York City. In this report it indorsed the recommendations of the Committee of Advisory Statisticians for a reorganization and enlargement of the present Bureau of Records; but it went further, and gave a detailed outline of what, in its judgment, the reports of the Bureau should contain. The Committee urged the appropriation of the needed funds, and made an appeal to the medical profession for co-operation in the prompt and exact recording of births, deaths, and sickness. In spite of all the efforts of the Department of Health, only ninety-five per cent of births are registered with the Department, while the per cent of reportable cases of contagious and communicable diseases is very much less. The value of our vital statistics depends, in a large degree, upon the good will of our physicians.

The Committee has also recommended that instruction in the methods and principles of medical and vital statistics be given in the medical colleges, and, following this up, it prepared an outline of such a course, with broad social and administrative bearings, which was