Popular Science Monthly/Volume 80/March 1912/Professional Training for Child Hygiene

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PROFESSIONAL TRAINING FOR CHILD HYGIENE
By LEWIS M. TERMAN

ASSISTANT PROFESSOR OF EDUCATION, STANFORD UNIVERSITY

NO one acquainted with the problems of professional education can read Mr. Abraham Flexner's expose of the status of medical education in the United States and Canada without a feeling of profound gratitude. His description of conditions is so masterly and variegated as to give the impression of utter completeness. It would seem that nothing had been forgotten. On further consideration, however, this appears far from being the case. Mr. Flexner has confined himself to an exposition of the shortcomings of medical education with exclusive reference to the ideals, purposes and standards of the best present-day medical schools. The social sufficiency of these ideals and purposes he seems to take for granted. For him, as for the practising physician, the main business of medical education is to train men in the scientific diagnosis and therapy of existent disease. The yet more important duty of the medical school to train men for scientific work in the several prophylactic fields of child hygiene is not even suggested. Let us glance briefly at this neglected aspect of preventive medicine.

Civilization has necessitated a tremendous readjustment of life habits. The factors which controlled and directed the evolution of the human organism have in large part become inoperative. Our modes of sedentary life tend less and less to bring into play the physical traits which were of most teleological value in the primitive struggle for existence. Instead, excessive burdens are laid upon functions and organs never intended by nature to endure them. If only the intentions of nature were respected during the period of growth and development the problem would by no means be so serious. The youth who had been brought into possession of his full psycho-physical inheritance would be in a position to conserve this inheritance in the face of great odds. This we do not permit. The introduction of universal education has changed the whole life of the child from one of active to one of sedentary occupation. As stated by Gulick, "so extensive a readjustment of the life habits of the young of a species has never before been attempted." Nor is it reasonable to suppose that man presents any exception to the biological law that the ultimate survival of an organism is threatened whenever it is subjected to conditions of environment widely different from those which directed its evolution. We have taken the child out of its natural habitat, of open air, freedom and sunshine and for half his waking hours we are subjecting him to an unnatural regimen which disturbs all the vital functions of secretion, excretion, digestion, circulation, respiration and nutrition. Even the very anatomy of the bones themselves, both gross and fine, is markedly affected.

The fact that the school doctor has been called in to examine and advise does not signify that the gravity of the situation has been apprehended. Teachers have simply found physical defects an impediment to the pupil's school progress and desire their removal. The school doctor spends some three to six minutes in the examination of each pupil, looking only for the gross and external symptoms of defectiveness. Having strictly the point of view of the physician, his search is for disease. His training has not fitted him to scent out delicate, incipient deviations from the normal nor to see the necessity of doing so. He does not have a biological conception of the functions of child hygiene. To appreciate the importance of the school health officer we need only to enumerate some of the problems most in need of investigation by men scientifically and specifically trained for the purpose. The following are some of these questions—not one of which can be satisfactorily answered in the light of our present information.

What is the exact nature and extent of the effects of school life upon the vital processes and upon growth? What changes, for example, does the child's blood undergo during the school year in number of red and white corpuscles and in percentage of hæmoglobin? What happens to the blood during a well-spent summer vacation? How does the sedentary work of the school affect the growth of the heart and its muscular force? How common is malnutrition among school children, and what are its causes? To what extent is the school responsible for the curse of constipation? What is the relation of book work to lung capacity, and just how seriously does sub-normal lung capacity menace the future health of the child?

What physiological changes are induced by the high temperature and low humidity of ordinary school-room air? Is it true, as recent experiments suggest, that the goal for which the mechanical engineer strives in the ventilation and heating of a school building, that is, the maintenance of an absolutely even temperature and the avoidance of perceptible draft, is the worst possible condition that could be secured? Is it true that keeping the relative humidity of the schoolroom air up to 50 or 60 per cent., the temperature down to 60 degrees or below, and permitting perceptible drafts which will keep the skin practised in the exercise of vaso-motor control should be matters of far more concern than avoiding the usual slight depletion of oxygen or the excess of carbon dioxide? Is respired air poisonous? If so, by virtue of what properties?

What are the special characteristics of school dust? Which kinds are most injurious? What part does dust play in the dissemination of school diseases? What are the exact results following the introduction of the vacuum cleaner in the school? What are the indirect effects of pure air on the processes of nutrition and growth? Can school air be made hygienic? What results from the combination of deep breathing and dust in the average indoor gymnasium? Is exercise thus taken better in the long run than none at all?

Is it true, as certain recent researches suggest, that forty or fifty per cent, of all school children contract tuberculosis at least once before the end of the school course? How does the incidence of tuberculosis among school children vary with different climatic, social and industrial conditions, and with different methods of school sanitation? Probably two million children now in our public schools will die of this disease. Would systematic researches make possible the earlier diagnosis of active cases, or even the certain detection of constitutional predisposition to the disease? Does any one know that we could not by segregation of such pupils in open air schools and by carefully regulating their diet save the lives of half or three fourths of this two million?

What produces hypertrophied tonsils and adenoids? Are they connected with the disturbances of lymphatic circulation and of nutrition due to the sedentary school life? By what mechanism do they produce such deplorable stunting effects on body and mind? To what extent, as statistically determined, do they predispose to tuberculosis and other throat and lung diseases? Are they a necessary incident in the growth of 10 or 15 per cent, of our children? Is it sufficient merely to wait for their appearance and then call in the school doctor to remove them?

What is the relation of the school to the neuroses? Is the school a factor in the undoubted increase of insanity? Does school overpressure, as some psycho-pathologists believe, lay the last straw in the case of those predisposed to neurasthenia, hysteria, or dementia præcox? Of the 18,000,000 children now in the public schools, the lives of probably a half million will be rendered miserable failures because of one or another of the neuroses. May we hope that scientific research in the etiology of nervous diseases will make it possible to segregate the "emotive" cases and apply a psycho-prophylaxis which shall lead them to a normal mental life?

Over half of the pupils fail to progress through the grades at the expected speed. What are the causes of retardation? To what extent is it an expression of congenital mental deficiency? How many mentally deficient children are in our schools? What are the respective values of.heredity and environment in the etiology of feeble-mindedness? How common is the moron, that is, the grade of intelligence lying between the merely "dull" and the "feeble-minded"? What proportion of morons become criminals? What kind of education must they receive to insure that they shall not become social burdens or pests? By what means shall we classify them and on what bases? What connection, if any, has moral instability to such physiological abnormalities as impacted teeth, irritating conditions of sexual organs, nasal occlusions, intestinal parasites and circulatory stagnations due to over-much sitting? What is the relation of mental and physical deficiency of children to alcoholism, syphilis, tuberculosis, or long continued dietary insufficiency during the period of growth?

What is the relation of oral hygiene to general health? What factors underlie the individual differences of children in predisposition to dental caries? How is this "disease of the people" related to nutrition, both as cause and effect? How is it related to school progress and morals? Is Osier justified in asserting that the problem of oral hygiene is of more consequence to racial welfare than is the alcohol problem?

What influence upon educational practise may we expect from the modern methods of roentgenographic determination of anatomic and physiological age differences? How large are such differences among children of the same chronological age? Does mental growth correlate with skeletal development, or with physiological age as determined by dentition and sexual maturity, or with chronological age, or with none of these? Current methods of promotion tend to a gradation by chronological age. Is it certain that this has more to commend it than a classification on the basis of height or weight? What percentage of school failures is due to subnormal physiological maturity? Should we always appeal to the roentgenograph to help decide doubtful cases of promotion? How frequently is nervous overstrain connected with a neglect of physiological age differences?

What are the physiological effects, ultimate, as well as immediate, of current methods in physical training? How are we to explain the surprisingly unfavorable showing of athletes in life-insurance statistics? Is it frequently justifiable to subject children to "corrective" gymnastic exercises in preference to free play? Just how, physiologically, does exercise which is enjoyed differ in its effects from exercise which is not enjoyed? Is the difference comparable to the difference found by Pawlow in the secretion of saliva and gastric juice under varying emotional conditions? What sports can safely be indulged in by children of different ages? Can any one state authoritatively what percentage of 16-year-old boys ought to attempt the five mile run? Might not research (research along these lines is now as rare as it is precious) teach us more reliable methods of diagnosticating athletic fitness and unfitness? (Professor Clark Hetherington is authority for the statement that not one physician in a thousand can make this determination.) What are the permissible limits of athletic specialization? What is the relation of muscular power to mortality and morbidity? Is current playground and gymnastic instruction sufficiently differentiated for age and sex differences? How far may physical training for girls safely be modeled after that for boys? What time in the day should exercise in physical training be given? How should it alternate with other school studies? Can it ever safely replace the old-fashioned free "recess"? Just what does it mean, physiologically, for a muscle to be "trained"? Which of the half dozen or more theories is the correct one? How far can training be bunched? Does training produce fatigue bodies and anti-bodies, as Weichardt thinks he has demonstrated?

How many hours daily should children study? Can any one disprove Dr. Weir Mitchell's assertion (which seems to be the belief of most psycho-pathologists) that children could accomplish as much as they do now if the school day were only half as long? What is the most favorable alternation of work and rest periods in mental hygiene? What is the diurnal course of mental (also moral) efficiency? When is the assignment of home study justifiable? How do the results of home study compare in quality and quantity with school study? Is there much or little ground for the frequent charges of overpressure made against the schools? Is school overpressure responsible for any of the recent and marked increase in child suicides?[1]

Investigations into the sleep of school children show that they sleep on the average nearly 25 per cent, less than "authorities" have usually set as a safe norm. Is there a real sleep insufficiency of 25 per cent., or has the amount needed been overestimated? In the matter of sleep what are the safe limits of habit adaptation? What is the relation of sleep to school progress, nutrition, morbidity and conduct?

The human eye was evolved to satisfy the demands of ordinary vision—that is, to make on the average 15 or 20 movements per minute, under conditions which permit frequent shifts of accommodation and convergence. The work of the school demands of the immature eye that it execute for several hours a day an average of 150 to 200 separate movements per minute with as many rifle-aim fixations and with a uniformly intense strain of the muscles of accommodation and convergence. What is the relative importance of these factors as compared with heredity in the etiology of ocular defects? How does malnutrition affect the eye? How much truth is there in Dr. George M. Gould's assertions regarding the reflex effects of eye-strain upon general health? What is the minimum size of type that should be permitted for children of different ages? What are the optimum norms for width of stroke, spacing of letters and words, length of lines, color of paper, and intensity of light? Is the complete conservation of vision possible?

What conditions of health obtain among the one-half million school teachers in the United States? What kind of physical constitution does the profession attract? How many are tuberculous? What proportions suffer from insomnia, obsessions, neurasthenia, eye-strain, headaches, heart-disturbances, indigestion, constipation, or other functional derangements? What constitutes overwork of the teacher, and what are its reflective effects upon the pupils? What is the status of personal hygiene practise among teachers? How many of them are in the "patent-medicine-stage" of ignorance? What fraction of them do not appreciate the difference between an oculist and an optician? Is it vain to hope that our half million teachers may yet be made so many missionaries of public health? If so, through what methods of teaching hygiene in the schools? How do different methods of teaching physiology and hygiene differ in their effects upon life habits? What is the best approach in teaching "scientific temperance," or the still more difficult subject of sex hygiene? Should the latter be taught in the public school? At what age? What should be the content of such instruction?

The greatest problem of conservation relates not to forests or mines, but to national vitality, and to conserve the latter we must begin by conserving the child. Let it again he emphasized that hardly a single one of the above questions is fully answerable to-day. Not many of them will be fully resolved until they have been attacked on a broad scale by systematic and scientific methods of research. To secure proper scope for such research the schools must be thrown open to it; to insure adequate support it must be made a public undertaking. The school instead of causing sickness and deformity must be made to preserve the child from all kinds of morbidity, repair his existent deformities, combat his hereditary predispositions and the bad conditions of his social environment, in a word fortify his constitution and render him physically and mentally fit for the struggles of life. The value of research carried on for this purpose will depend most of all upon the type of man intrusted with it. The teacher can not do it; the superintendent or principal can not do it; no more can the average school physician.

Who is the school physician and what has been his training? With a few notable exceptions he probably differs little from the average practising physician, and since the merciless brochure of Mr. Flexner it is unnecessary to dwell at length on the positive unfitness of the average physician for any research, to say nothing of the highly specialized kinds here advocated. Suffice to say that Mr. Flexner finds only about 30 respectable medical schools in the entire country; that twenty years ago there was not one; that a large fraction of our physicians "walked into the profession from the street"; that over one half the schools require less than a high school-course for entrance; that half or more have little or no laboratory facilities for physiology, pharmacology or bacteriology; that many do not even teach the use the microscope; that the teaching of anatomy and pathology is often entirely didactic; that clinical facilities are usually inadequate and in many cases practically lacking altogether; that many are squalid, "reeking with commercialism," and "without a redeeming feature of any kind." Such has been the making of a large numerical majority of our physicians. Additional comment would be superfluous.

But what of those physicians whose medical training, as such, is above reproach? It would be unjust to confound them with the average practitioner who is ignorant alike of the principles of medical science and of child hygiene. Nevertheless, it must be said no less emphatically that the ideal equipment for the school health officer is vastly different from that required for the successful practise of medicine. The physician is "long" on certain qualifications of little value to the school health supervisor and as much "short" on others extremely important. When he enters the school he leaves his obstetrics and his pharmacology behind. On the other hand, he needs to know a great deal about such questions as those propounded in the first half of this article, the solution of many of which is in no way made easier by the best medical equipment. As a matter of fact and common sense, if the work of the school health officer is to remain confined to the hasty and superficial kind of examination usually given by the "medical inspector," then we had better forego the luxury of physicians and employ trained nurses instead. After a few months apprenticeship the nurse could make the usual tests of sight, hearing, etc., as well as the physicians are making them. Already in some of the large cities (San Francisco and Oakland, for example) nurses are actually doing, under supervision, practically all the routine work of examinations. As for the ordinary tests of vision, the teacher of average intelligence can make them as successfully as the physician who is not also oculist. A considerable number of the best oculists in the country have officially taken this stand.[2] The point is not that the work should be narrowed to what the teacher can do, but rather that it should be extended beyond the functions of the physician.

The physician, after all, is only a physician, which is as much as to say that he is not a hygienist in point of view. He has learned something of the science and art of discovering and curing disease. At best he has also learned a little of the general principles of preventive medicine, but of the many special relations of preventive medicine to the school he knows extremely little. He is ignorant of the technical aspects of education, of child psychology, of the psychology of mental deficiency, and of a host of common developmental abnormalities. If he knows anything of mental hygiene and psycho-prophylaxis it is not to the credit of his medical school, for not a half dozen in the country have yet taken any account of the late epoch-making developments in psycho-pathology, wrought by such investigators as Freud, Jung, Prince, Sidis and Adolf Meyer. The situation may be summed up in a sentence: The physician's training does not qualify him for the many sided tosh of adapting the program and environment of the school to the health and growth needs of the pupil. The main purpose of this article is to suggest tentatively and somewhat roughly some of the more important lines of professional preparation necessary for those who are to work in any field of child hygiene in the public schools.

Educational hygiene has four chief aspects: (1) "Medical Inspection," including routine examinations for physical defects and consequent follow-up service; (2) supervision of physical training, including free play, gymnastics, and athletic sports; and (3) child psychology, including clinical work with mentally and morally atypical children, the hygiene of instruction, etc.; (4) researches in school heating, lighting, ventilation, seating, sanitation and other externals affecting the health of the child. Each of these divisions has of course its logical subdivisions but as only the very largest cities could employ a more specialized stafE than this scheme calls for it is unnecessary to carry the classification further. On the other hand, the majority of school health officers will probably for some years to come have to serve more or less in all these capacities. Assuming, however, the four separate lines of specialization above designated let us examine the general and special courses of study which would be necessary for their successful pursuit.

To begin with, it would seem that the time requirement could not reasonably be placed below seven years in addition to a four year high school course. This corresponds to the usual allotment for the doctorate of philosophy and to that for the doctorate of medicine in our sixteen best medical schools. Using the seven-year basis for our calculation, the course falls naturally into three divisions. The first three years would be given to regular college work in which the elements of physics, chemistry, biology, physiology, psychology, paidology, sociology and at least one modern language would be taught. The next three years would be ample time in which to give all that is needful for the school health officer out of the present medical curriculum, besides leaving a fair margin for collateral work in psychology, paidology, and the technical aspects of education. The last year would be reserved for carefully supervised clinical practise in the public schools. Proof of ability to read both French and German should be required a year before the end of the course, for most of the important researches in school hygiene are in these languages.

Physicians will of course object to the time allotment for the second division. How, they will ask, can you condense a medical course into three years, to say nothing of a margin to be left for psychology and paidology? The answer is more in terms of elimination than of condensation. Pharmacology, materia medica and therapeutics can be discarded in a lump, with a consequent saving of a full half year. Doing the same for the obstetrics, gynecology and most of the surgery effects a further saving of three-quarters of a year. This makes a year and a quarter off the present medical course. Further, for the purpose here in question, minor savings could be effected in several subjects, as, for example, anatomy, in which the minimum of 400 hours required by the best medical schools could here be taken for the maximum. Finally, the additional year of clinical experience in the schools would take the place of most of the usual courses in the hospital and dispensary, so that almost half of the second three years would be left for psychology, paidology, education, sociology, school hygiene, gymnastic sports, etc., the amount of each being dependent upon the student's choice among the four special lines above named: medical inspection, clinical child psychology, physical training and school sanitation. Throughout the course time would be saved and effectiveness promoted by never losing sight of the professional nature of the courses. Physiology, pathology and bacteriology, as well as psychology and sociology, would have to be taught in their relations to the ultimate work to be done, not as so many unitary and complete sciences. Even the first three years ought to be conscious of the professional end.

A school health officer, the product of such a school, would be of far greater service to education than is the usual school physician and would probably be worth more to society in the long run than a dozen well-trained practitioners. At least one such specialist in child hygiene is needed for every 2,000 school children. California needs 300, the United States at least 7,000. What university will be the first to undertake their production?

Finally, could men be found in sufficient numbers who would be willing to pay the price in time and strenuous effort involved in such a training for the modest remuneration the schools would offer? No reason appears why there should be any dearth of candidates. The pay frequently ranges from $2,000 to $3,000 per year and occasionally goes as high as $4,000. Medical inspection, though spreading at a tremendous rate, is still new with us, and doubtless as the profession becomes more specialized and more standardized it will receive as well as merit higher remuneration. As things are, it compares not unfavorably with professorships in colleges and normal schools, for which we have a constant oversupplying of young Ph.D. candidates willing to serve an indefinite period of apprenticeship as underlings, if only the coveted promotion with permanency of tenure can be reasonably hoped for in the end. Indeed, the rising young profession compares in its rewards not unfavorably with the practise of medicine itself, thanks to what Flexner calls the "enormous over production of physicians."

  1. See Albert Eulenberg, "Schülerselbstmorde," Zt. f. Päd.-psych., 1907, pp. 1-81. Also Louis Proal, "L'éducation et le suicide des enfants," Paris, 1910.
  2. See Gulick and Ayres, "Medical Inspection of Schools," pp. 105-6.