VIII. PHYSICAL EXAMINATIONS

(Continued)

WHAT IS A PHYSICAL EXAMINATION?

JOHN SUNDWALL, Ph. D., M. D. Professor of Hygiene and Director of the Department of Hygiene and Public Health. University of Michigan, Ann Arbor, Mich.

To be of any value whatsoever, a physical examination must be thorough and painstaking. Furthermore, the examiner must be an expert. Not only must he be adept in determining whether organs and tissues are in order or out of order through the skillful utilization of the simple methods of physical diagnosis such as inspection, palpation, percussion and auscultation;; but he must be acquainted with the numerous laboratory methods, now at our command, which aid in making and in many instances determines the diagnosis. Blood counts and blood chemistry, Wassermann, urinalysis, kidney efficiency tests, protein sensitization, bacteriological and serological methods and analysis of various bodily secretions and excretions must be utilized at one time or another in order to make the diagnosis accurate and complete. Furthermore, the physical examiner should know when the X-ray, the electrocardiograph, the polygraph and basal metabolism determinations are of service in determining man's physical condition. Of course, it is not expected that all these methods and instruments are to be used in every physical examination. On the contrary, certain methods will be utilized only when the general subjective and objective examination reveals or suggests beginning abnormal changes that require further study by means of precise methods in the hands of specialists. Moreover, it cannot be anticipated that the general examiner should be able to go into the laboratory and make for himself these various tests. Specially trained men are required for special methods and for utilizing special instruments. The general physical examiner should know, however, when these are required and appreciate fully that in many instances the laboratory alone can detect early regressive changes such as the degenerative group of diseases.

To be able to make an efficient physical examination from the standpoint of preventive medicine and to be able to detect early beginning retrogressive changes, require on the part of the examiner un

usual scientific training and experience. In fact there is no other branch or phase of medicine that demands so thorough and so broad training. Medical schools should give this specialty-physical examinations for health and physical efficiency-an important part in the curriculum, for it promises to be a most important phase of future medical prac tice.

But the physical examination is only the beginning of a program for the individual health promotion. The findings must be interpreted to the individual in such a way that there will be, on his part, a lucid understanding of and a deep appreciation for the prevention of retrogressive changes or the correction of beginning abnormal alterations. Furthermore, records must be kept of these examinations. The findings of each successive examination should be appended to the records of previous examinations. In other words, a continuous health record beginning with childhood should be the priceless possession of each individual. During the school age, this record should accompany the scholastic record from kindergarten to the university.

Just what should be included in the standard physical examination is best stated by quoting from the Life Extension Institute, which has done far more than any other life saving agency to develop the "preventive medicine" features of physical examin ations.

"The Standard Examination is the foundation of the survey and determines the need for special research beyond the usual routine of the Unlimited Service. The Standard Examination and Service cover the following features:

"(1) Examination of the Eyes, Ears, Nose, Throat, Mouth, Teeth, Lungs, Heart, Circulation, Blood Pressure, Skin, Glands, Stomach and Abdominal Organs, and general bodily conditions, chemic and microscopic examinations of the urine, Hemoglobin blood test for anemia. (Other special details are covered in the examination of women and children.)

"(2) A study and review by our Medical Staff of the daily living habits, personal and family his tory, activities, past illnesses, and any other infor mation as to physical condition and health problems which the subscriber may care to submit to us for consideration in connection with the physical examination.

"(3) Four urine examinations a year, chemic and miscroscopic. The Institute will send special containers for these urine specimens.

"(5) Suggestions for corrections of errors in personal hygiene.

"(6) Suggestions as to proper diet, with appropriate diet lists.

"(7) Instructions covering appropriate exercise, with diagrams.

"(8) Other general suggestions and hygienic guidance.

"(9) Mid-year questionnaire calling for a statement from the subscriber covering any changes that have occurred since the examination and as to the need of any additional hygienic counsel and guid

ance.

"(10) Educational health literature, including appropriate Keep-Well Bulletins and the Institute's monthly journal, "How to Live." These bulletins cover suggestions for healthful living and personal hygiene generally, that is, eating, drinking, sleeping, working, play, exercise, posture, fresh air, etc., and timely information regarding the care of the mind and body.

"(11) Educational Department of the Institute. Members have the privilege of communicating with this department at any time for general information relating to personal hygiene and disease prevention."

FREQUENCY OF PHYSICAL EXAMINATIONS Just how many examinations are essential in the life time of an individual in order to assure his health and physical efficiency must vary. No fixed standards can be put down as to how often physical examinations should be made. Age, state of health, intelligence of the individual, illness and occupation are factors which should determine, in a large measure, when examinations should be repeated.

With a view of establishing an economic and scien. tific basis for physical examination of school children, the New York City Department of Health set out to determine the age and sex incidence of the occurrence of physical defects in school children. The purpose of the study were to determine (1) "When physical defects occur; that is, at what age they may be found for the first time. (2) How many physical examinations are necessary during the school life of the child. (3) When physical examinations are most necessary in relation to the age of the child." With a view of answering these questions, the Bureau of Child Hygiene of the Department of Health of New York City, in 1909, analyzed the physical defects found in a total of 356,292 children who had been examined. In 1921 a similar study was made of 139,770 children of age groups. The sex and age groups were 6-8 years, 8-10 years, 10-12 years, and 14 years and over. The prevalence of such common defects in school children as defective hearing, pulmonary disease, cardiac disease, nervous disease, defective nasal breathing, hypertrophied tonsils, defective vision, defective teeth and defective nutrition were tabulated for each of the age groups. The interesting summary and conclusions are as follows:

"In analyzing the results of this study in physical defects found in school children, the following points seem worthy of emphasis:

1. The less common and more chronic physical defects such as pulmonary disease, cardiac disease and nervous disease remain at about the same level

throughout school life, and are apparently influ enced little if at all by the school environment.

2. Defective hearing and defective vision show a steady and persistent increase from the entering age to the leaving age throughout the school life of the child. In the case of defective hearing, however, the increase is relatively small; in the case of defective vision, the increase is more marked.

3. Malnutrition, defective nasal breathing (implying the presence of adenoids), hypertrophied tossils or diseased tonsils and defective teeth show their highest incidence either at the entering age or at the eight to ten-pear period, thereafter showing a fairly persistent and regular decline.

4. While the incidence defects in all age groups is lower in the 1921 study than in the 1909 study, the relative age incidence remains approximately the same, the percentage of defects found at each age bearing about the same relative position in both studies.

5. The physical examinations and follow-up work for school children in the years intervening between 1909 and 1921 have evidently reduced the total number of physical defects, with a resultant raising of the health standards of the children examined. They have not, however, resulted in a change in the relative age ratio of the physical defects encountered.

CONCLUSIONS

"The conclusions reached as a result of this study

are:

1. The most important physical exaination to be made in the school life of the child is the one occurring at the time the child enters school for the first time.

2. In orer to make the work of health supervision of school children effective, a complete physical examination of each child should be made before eight to ten-year period. If this can be done with 100 per cent efficiency, combined with follow-up that is 100 per cent effective and 100 per cent of treatments obtained, it should not be necessary to make regular physical examinations after the eight to tenyear period, reliance being placed after that time upon the routine inspection of the children in the classroom. This routine inspection will permit the nurse, doctor or teacher to pick out the cases of physical defects that have been in any way overlooked during routine physical examinations or which have originated after the eight to ten-year period.

3. An annual test for defective vision is desirable.

4. Unless the amount of money appropriated for school medical inspection is large enough to allow a complete and thorough physical examination each school year, the officials in charge of such work are not justified in spending any money in having physical examinations made after the eight to ten-year period unless the full health needs of the children below that age period have been met.

5. A logical deduction that might be drawn from this study is that great emphasis should be placed hereafter upon the pre-school age period as the time when physical defects should be prevented or corrected.

6. To sum up the matter, this study would seem to show that the expenditure of time and money to make annual physical examinations of school children is not warranted and seems to be unnecessary. Analysis of the age and sex incidence of physical defects in this study shows that proper and adequate physical examinations made in the early life of the school child-that is, before the 8 or 10-year

period are essential, and if these are properly followed up and suitable treatment obtained, the appropriations for this work will be spent in the most Economical way, the child's health will be more thoroughly protected and future disease and the sequelae of physical defects be more adequately guarded against than by any of the present methods of school health supervision.

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From this extensive study it is readily seen that the most important age period for making thorough physical examination, so far as school children are concerned, is at the time that they enter school. Furthermore, we learn that with the possible exception of a marked increase of defects of vision during the school period, practically all the defects are present at the time the children enter school. Therefore, a thorough "over-going" is essential in an earlier age period of life. In fact, the first six years are the most important and there should be a series of examinations accompanying the growth of the infant, the acquisition of new functions and the development of new structures. The wise parent will see to it that the baby maintains its proper weight and growth and that the joints and bones are functioning properly when the child begins to walk. Furthermore, the mother will be concerned with the throat with a view of removing tonsils and adenoids which later on may cause the damaged heart. She will know the age periods when the temporary and permanent teeth appear and "see to it" that they are properly cared for. Each infectious disease of childhood and the convalescence therefrom will be carefully guarded by the physical examination.

To summarize then, early infancy should be characterized by a series of physical examinations accompanied by proper instructions to mothers as to prevention and correction of the defects which are so prone to make their appearance in early life. A thorough physical examination should be made of each child when it enters school and the defects should be corrected. Annual inspection of school children may well follow with particular reference to weight and growth, to posture, to the teeth and throat, to vision and to the general state of health. The annual inspections may well be made by the school nurse or the school health director.

The next age period in life when a thorough overgoing should be made is during early adulthood. Let us say from 18 to 20 or 20 to 22 years of age. Universities are beginning to require of all their entering freshmen this thorough physical examination before registrations are completed. Physical examinations are of especial value to the young man and young woman beginning their life work. Just how often these should be repeated depends in the very largest measure, on the vocation pursued, the habits formed, the intelligence of the individual, and his state of health. Owing to the fact that the degenerative diseases "crawl on" so insiduously and to the fact that the vast majority of mankind are found to be possessed with defects of which they

desires to live a long, active and useful life, to insist upon an annual overhauling.

Our relationships to the competent and painstak ing physician should be similar to our relationship with our dentists. The efficient dentist to whom we ascribe the guardianship of our teeth, let us say from infancy on up, would feel that he had been remiss in his obligations and in his practice provid. ing he is compelled to substitute plates for teeth in the average person. Perhaps in the near future we shall censure our physician, to whom we have given over the wardships of our health, for the occurrence and progress of 'retrogressive processes which the physician could have prevented.

TOO MANY DIPHTHERIA PATIENTS DIE

Why should there be any diphtheria mortality at all? Antitoxin is to this disease what water is to fire. The answer to the question is, therefore, that the antitoxin is not given soon enough or in sufficient quantity. Fire does not spread more surely or more rapidly among combustible materials than diphtheria in the tissues of the child attacked. The one supreme necessity is to head it off-put it out. A dose of 5000 units of antitoxin may or may not suffice. This dose should be the minimum and it is far better to give 10,000 or 20,000 units in one dose than in two.

Nature is helpless in many of these cases; her defensive forces are simply overwhelmed by the poison of the disease. Give the patient a full dose, a liberal dose, of antitoxin, and as many as may be required; arrest the poisoning process; and then nature, relieved, rallies her phagocytic forces and destroys the invading bacilli,

The mortality of diphtheria in this country, according to the Parke, Davis & Co., advertisement elsewhere in this issue, is 10 per cent. One patient out of ten dies. Save the tenth child!

AMERICAN SYNTHETICS

The Fordney-McCumber Tariff Bill, recently passed by congress, unfortunately does not provide sufficient protection for American-made medicinal chemicals, nor does it compensate for the extensive research work which has been done by American chemists.

The rates on medicinal chemicals were passed over the protest of the medical profession. It is now possible for the physicians to follow up their protest by using only American-made synthetics, and referring to them, at all times, by their American names, as suggested by the Council on Pharmacy and Chemistry of the American Medi

cal Association.

Among the important American-made medicinals which should receive the support of all American physicians, are Arsphenamine, Barbital, Cinchophen and Procaine. Literature on these products may be obtained by writing to The Abbott Laboratories, Chicago.

Editor and Business Manager FREDERICK C. WARNSHUIS, M. D., Sc. D., F. A. C. S. Grand Rapids, Mich.

GUY L. CONNOR, M. D., F. A. C. P.
Associate Editor, Detroit.

Entered at Grand Rapids, Michigan, Postoffice as second class matter.

Acceptance for mailing at special rate of postage provided for in Section 1103, Act of October 3, 1917, authorized July 26, 1918.

All communications relative to exchanges, books for review, manuscripts, news, advertising, and subscriptions are to be addressed to F. C. Warnshuis, M. D., 4th Floor Powers Theater Building, Grand Rapids, Mich.

The Society does not hold itself responsible for opinions expressed in original papers, discussions, communications, or advertisements.

Subscription Price-$5 per year, in advance

NOVEMBER, 1922

Editorials

Report Malpractice Threats Immediately to Doctor F. B. Tibbals, 1212 Kresge Bldg., Detroit, Mich.

IMPORTANT

Despite the fact that Medical Defense has been a part of the work of the Michigan State Medical Society for a dozen years and the proper procedure for the doctor threatened published many times in the State Journal, there remain many men who do not know what to do when trouble comes.

Many notify the State Secretary instead of the Chairman of the Medico-Legal Committee, some notify no one until the case is about to be tried.

One such case this year almost resulted disastrously from the fact that two doctors from the same community testified against him, for, a fee. The Medico-Legal Committee is frequently able to prevent this by educating the other members of the County Society as to their duty to themselves and their co-workers.

Then too, only hasty preparation is possible for our attorneys in these late calls of distress. Another thing which men do right along is to select their own attorneys whereas the selection of local attorney rests with our general attorneys, solely, the reason being that attorneys know better the qualifications and experience of other attorneys than those outside the legal profession can.

F. B. TIBBALS,

Chairman, Medico-Legal Committee.

THE ANN ARBOR CONFERENCE

In response to the call and request for a conference regarding a proposed establishment of a new nursing school in connection with the University Hospital at Ann Arbor, the following were present at the meeting held on September 20th:

President Burton; Dr. W. T. Dodge, President of the State Society; Dr. A. L. Seeley, Chairman of the Council; Councilors McLurg, Walker, DuBois, Le Fevre, Jackson, Clancy; Chairman Hume of the Legislative Committee, Chairman Frothingham of Committee on Civic and Industrial Relations; Dean Cabot and several members of the Medical Faculty, Regent W. H. Sawyer and some fifteen committee members of our standing committees.

Dr. Parnall, Director of the University Hospital, was not present. The Council did not receive any information or word as to why Dr. Parnall was absent.

The meeting was presided over by Dr. Seeley, Chairman of the Council.

The following statement was made by Dr. Dodge, President of the State Society:

Early in July Dean Cabot informed that the Board of Regents had been solicited to establish a department of the University for training nurses independ ent of the Medical School, governed by a dean and equipped with a faculty of its own. He also gave me an opportunity to examine a report of a com mittee on Nursing Education appointed by the Rockefeller Foundation and which I shall hereafter call the Winslow Committee after its chairman. He also permitted me to read a communication from Dr. Parnall, Superintendent of the University Hospital, to the president of the University, advocating the establishment of such a department, and his own reply thereto, in opposition.

Dean Cabot stated to me that he considered this project, if adopted, would prove very damaging to the Medical School and he requested me to take steps to bring the matter to the attention of the medical profession and obtain their views thereon, also to use any influence I might have to prevent final action on the proposition by the Board of Regents until an expression of opinion from the profession could be obtained. I, accordingly, wrote to Regent Sawyer requesting delay and requested the Secretary-Editor to direct inquiries to Dr. Parnall. I have also taken up the matter with the chairman of our Committee on Civic and Industrial Relations and the chairman of the Committee on Legislation and Public Policy. At their suggestion I have arranged for this special meeting of the Council and this Conference. In addition I have presented the proposition to every meeting of medical men I have had the pleasure of attending and have approved the publications that have been made in the Journal on this subject.

I am of the opinion that the proper policy would have been to publish the argument made by Dr. Parnall in favor of establishing this new department and Dean Cabot's reply thereto. Permission for such publication could not be obtained and Dr. Parnall declined to answer the questions put to him by the Secretary-Editor. His comment was that it would be obviously improper for him to issue unauthorized statements upon official matters pending

before the Board of Regents. He had been asked to give, for publication, his own opinions only.

I wrote to President Burton asking him to permit the publication of these communications, but as shown by the letter to me from the Secretary of the University, published in the August Journal, it was very rightly decided not to trouble the President with the matter during his vacation. The Secretary, however, comments as follows: "It is my judgment that it would be highly unfortunate for Dean Cabot or Dr. Parnall to publish their views on a matter which is at present before the Board of Regents." I do not agree with this statement. In my opinion the proper time to discuss a proposition of this sort, if it cannot be done earlier, is when it is before the Board of Regents. Better it would have been to have first submitted the proposition to the faculty of the Medical School and obtained their views before its presentation to the Board of Regents. Obviously the views of Dean Cabot and Dr. Parnall are far apart. Dr. Parnall says: "That the medical pro、 fession will be injured in so doing is unthinkable." Dean Cabot says: "To introduce into this rather delicately balanced machinery another facultywhich would very properly stand upon its rights→ and upon its dignity-might very easily deal a blow at the very root of medical education in this state." In discussing this proposition at meetings of med. ical men I have presented to them the substance of the Winslow report and its recommendations, and the criticism I have to make on that report is partly based upon the criticism uttered by others and partly based upon my own experience in the training of nurses. The report considers the subject of nurs ing training purely from a pedagogical standpoint and ignores the economical considerations relating to hospitals that have made the existence of the present hospital training schools possible. It also emphasizes the necessity, in the view of the committee, of liberal financial support for all forms of nursing education. This is the only profession I believe, in which students are admitted to training without the payment of tuition charges and where room and board are furnished free of charge, and where the student is, during a portion of the course, oftentimes paid a considerable stipend for the services she renders. To reimburse the hospital for these expenditures furthering her education the student nurse is expected to assist in conducting the affairs of the hospital, to assist in keeping it clean and to assist in caring for the patients. In this way, per. forming these duties under close supervision, she receives, in my opinion the more important portion of her instruction. In performing these duties she is frequently called upon to perform menial tasks which in the opinion of the Winslow Committee is derogatory to the dignity of the trainee. I have known medical students to perform menial tasks in order to make a living while pursuing their medical studies. I have never known that their dignity suffered or the good opinion of their associates was lessened thereby. In my opinion the principles of cleanliness and the "aseptic conscience" can be more thoroughly built up and established in the mind of a trainee, by practical work, under proper supervision, than by didactical instruction in the class room. The Winslow Committee proposes to lessen the period devoted to a nurse's education by the follow ing methods:

"It is fundamental to the success of nursing education that adequate funds should be available for the educational expenses of the school itself, and for the replacement of student nurses by graduate nurses and hospital help in the execution of routine duties of a non-educational character. With the necessary financial support, and under a separate board or training school committee, organized pri

marily for educational purposes, it is possible, with completion of a high school course or its equivalent as a prerequisite, to reduce the fundamental period of hospital training to 28 months and at the same time, by eliminating unessential, non-educational routine, to organize the course along intensive and co-ordinated lines with such modifications as may be necessary for practical application; courses of this standard would be reasonably certain to attract students of high quality in increasing numbers."

It will thus be seen that the committee would upset all the present economic factors connected with the training of nurses. The teaching faculty of a training school shall be independent of the clinical staff. The hospital shall be conducted by paid employes, students shall have the use of the wards for instruction purposes, patients shall be utilized as material, but the student nurse shall not be humiliated by the requirement to perform any menial tasks. Money is required to establish such a school but it is not intimated that the students shall be called upon to furnish it by the payment of tuition and board. Such training school as is described by the committee is utterly impractical and if adopted anywhere will result in producing a crop of stilted over-educated women who will be absolutely useless as nurses to care for the sick. Would it not be better to shorten the course of instruction by cutting down the mass of medical theoretical teaching that is now indulged in for the sole pur pose of fitting the student nurse to pass the state board examination? It is absurd to expect a nurse to be qualified to answer some of the technical medical questions now asked on examinations. knowledge of such subjects is only necessary to the medical man. The nurse who is taught to do as the physician directs and is taught in the fundamental principles of nursing the various classes of diseases, and who is inculcated with the "aseptic conscience," and who has performed the routine duties of the ward and operating room, under proper supervision, so many times that she can be safely trusted to do it without direct supervision, is better qualified to perform the duties of a private duty nurse than the one who is only given technical teaching in the lecture room will ever be.

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Then it is proposed that a group of nurses shall be still more highly trained for public health work: One of the principal reasons for the shortcomings in the present training of nurses is believed to be the lack of trained leaders and well equipped instructors in schools of nursing. The committee therefore finds "That the development and strengthening of university schools of nursing of high grade for the training of leaders is of fundamental importance in the furtherance of nursing education." This type of school should, in the judgment of the committee. be a separate and independent part of the university, cognate in rank and organization with the school of medicine or the school of law. More than a dozen colleges and universities now provide combined courses through which students may acquire both a nurse's training and a college degree in five years, two years being devoted to the regular college course, two years to intensive training in the hospital and a fifth year to one of the higher specialties of nursing-public health, institutional supervision, or nursing education. The numerical proportion of the nursing profession to be contributed by the university school will perhaps always be a small one, yet the role of these schools in setting standards and in the training of administrators, teachers, and public health nurses is considered to be of the greatest importance."

If a young lady takes this course of training, why should she be satisfied to be called a nurse? It is generally conceded that a public health administra