14

A PLEA FOR THE ESTABLISHMENT OF STUDENT HEALTH SERVICES IN OUR

UNIVERSITIES AND COLLEGES.

By JOHN DUF~Y.

I F it be accepted that the fundamental educational purposes of

a university are concerned with the transmission of the accumulated knowledge, culture, and wisdom of the race ; with

the discovery of new truths; and with the uses and application of this knowledge for the benefit of society, it seems obvious that it should keep abreast of advances in the field of preventive medicine and apply them within its own community for the benefit of student health. The preservation and maintenance of physical fitness amongst the student body has always been regarded as a funda- mental duty by the authorities of our universities and colleges. The provision of extensive playing-fields and the encouragement of and well-known interest in games displayed by so many college pro- fessors are all ample testimony of this. If, however, the principle of the safeguarding of student health be followed to its logical out- come, and considered in all its implications, it will be at once realised that the provision of games and athletics is not only not enough, but is really only one part or aspect of any progTamme which purports to preserve and maintain a high standard of student health. The completion of such a programme comprehends the adoption of one of the more recent advances of preventive medicine, namely, the periodic health examination of all students, and the medical supervision of all student activities, whether academic or athletic. The college which provides the one and withholds the other is not doing strict justice to its students. One could even go furher and assert that unrestricted activity in the matter of games and athletics, without adequate medical supervision and pre- scription is in many cases harmful, and is often totally subversive of their ultimate object. Consequently it follows that in order to discharge fully the .responsibility which devolves on a college in the matter of student health, it is necessary to provide periodic health examination for all its students.

The grave necessity for such medical supervision of students is very evident to medical practitioners, and especially to tuberculosis officers working in a university town. The breakdown in health which is so well known to occur in a certain number of students during their course and also after graduation is invariably caused by tuberculosis. Their vulnerability is not due primarily to the fact that they are students, but is largely accounted for by the fact that they belong to an age-group from which a high toll is exacted by tuberculosis all over the world, and that these years are often the most anxious and trying, and certainly those of most active student life. I t is really because of the high incidence of this crippling (and in many cases killing) disease that those observers

ESTABLISHMENT OF STUDENT HEALTH SERVICES 15

who have witnessed its ravages have come to sponsor the proposal o~ student health examination, which would fulfil the dual purpose of building up a healthy graduate community, and at the same time instil in the latter sound principles of preventive medicine. For, tim university student of to-day is likely to become the nation builder and community leader of to-morrow; hence college authori- ties should organise and maintain a college hygiene programme that will effectively assist students in preparing themselves physically, mentally and socially for healthful living, for wholesome home- building, and for wise leadership in the formation and maintenance of high standards of individual and community health.

In a word, the higher work of a university is to turn out good citizens. Primary and instinctive amongst all interests of citizen- ship is the desire for physical health and well-being. This desire must not be allowed to displace intellectual attainment on the one hand, nor be sacrificed to it on the other. It is no gain to a university to know that a certain number of its graduates die off year by year of preventable disease. Hence, the time is long over- due to stop this drain on the intellectual resources of the country.

What has been known for years to every practising clinician is apparent also from statistical evidence, namely that the diagnosis of tuberculosis in the minimal stage is far from being the rule. Of all cases admitted to 247 United States sanatoria in 1931 only 16 per cent. were in the minimal stage; 30 per cent. were moderately advanced; and 54 per cent. were far advanced (Whitney). This being so, those countries with progressive public health programmes have long ago adopted the tuberculosis case-finding method of young-adult group-testing with tuberculin, and radiological exami- nation of all positive reactors. This method has been found best and most economical, and has been endorsed by the American Student Health Association, the Chairman of whose Tuberculosis Committee for 1931-1936, Dr. Lee H. Ferguson, states:

" We have come to the conclusion t ha t a programme based on tuberculin ~s~ing and x-raying all the positive reactors is about the best me thod of approach ~o this problem. There are some inst i tut ions which s imply x-ray all their entering s tudents , bu t I have never felt t h a t this was as desirable a method as doing tuberculin test ing and x-raying the positive reactors. The reason for this is t h a t an individual migh t have an entirely negative chest x-ray and still have a positive tuberculin, representing a recent contact with an open case of tuberculosis. From the epidemiological s tandpoint tuberculin test ing is highly desirable."

Pioneer work in the application of this method in the examination of university students has been done in America, notably by Myers in Minnesota, Lee H. Ferguson in Western Reserve, Soper in Yale, Opie and Landis in Philadelphia, as well as by Heimbeck in Norway, and the authorities of Strasburg, Miinster, Munich, Paris, and other continental universities. Surveys from all this work are now to hand, and are mounting year by year, so that the literature is no~v considerable. From these surveys some idea may be gained of the incidence of tuberculosis amongst university students in various countries. In Miinster 1.14 per cent. of students examined were

16 IRISH JOURNAL OF MEDICAL SCIENCE

found to have active tuberculosis; at Munich 1.27 per cent. Stiehm found that in the University of Wisconsin 1.50 per cent. of all tuberculin-tested students had adult-type tuberculous infiltration, and of these one-fifth needed sanatorium treatment. Statistics from the United States are very interesting as showing the falling inci- dence of tuberculosis in a country whose universities and colleges have active and increasing health services in operation now for some ten years or more. The following are some figures available :

1932-33 38,932 students 0.67 p.c. active tuberculosis 1933-34 71,611 ,, 0.56 p.c. ,, ,, 1934-35 85,428 ,, 0.57 p.c. ,, ,, 1935-36 91,186 ,, 0.42 p.c. ,, ,,

In a recent three-year survey carried out at University College Hospital, London, Morland found 12 cases of early disease in 417 students examined, and of these 5 cases (1.20 per cent.) were active and were advised to have sanatorium treatment. From the figures cited above one could safely assume that the incidence of the diseas~ in this country is at least such as would warrant the investigation which is pleaded for in this short communication. I t would set a head-line to our public health authorities by introducing young adult group-testing as the most progressive method of case-finding in tuberculosis, and apart altogether from its immediate objective of life-saving in our young graduate population, its educational and propaganda value would be far-reaching, especially amongst the more highly educated classes of the community, who would leave the university with a true idea of what preventive medicine really means. " Student Health Services are performing a most unusual function in the field of health. Not only do they aid the individua~ student, but they instruct the student body regarding health, so that many of the graduates of our colleges and universities go out as influential citizens with the proper attitude toward the importance of health and its maintenance to the individual, the community, and the nation. In the campaign against tuberculosis, I know of no greater potentiality than that which exists in the students' heaRh services of America." (Myers.)

The cost would be relatively small, namely, the cost of two x-ray examinations during each student's college course. From the only figures available the cost of fully developed Student Health Services in America (including a full-time medical director) works out at slightly more than s per student. In this country the cost should not be so high, and could be met by part of the college fee. By starting in a very modest way it is estimated that much could be done for the expenditure of five shillings per student per year. By the utilisation of the latest technical advance in this field, namely, the application of miniature screen photography to mass radio- graphy, large numbers can be x-rayed at a cost of approximately one penny each. (Bentley and Leitner.)

The introduction of some such programme would mean that the

E S T A B L I S H M E N T OF STUDENT H E A L T H S E R V I C E S 17

ten to twenty students per year in each college who, as matters stand, are destined to come down sooner or later with clinical tuberculosis would be diagnosed and advised in time to prevent what must be, for some of them at least, an appalling catastrophe in their lives.

Bibliography.

Bentley, F. J . and Leitner, Z. A. : (1940) Brit. Med. Jo. 1, 879. Burnet , E. : (1932) Qu. Bull. Health Organ., League of Nations, Geneva,

1, 489. Ferguson, L. H. : (1937) Amer. ~ev. Tub., 36, 487. Heimbeck, J. : (1929) K$in. Wchnschr., 8, 1206. Meyers, J . A . (1932) Amer. Rev. Tub., 26, 530. Morland, A. : (1940) Brit. Jo. Tub., 34, 73. Opie, E. L. : et al. (1931) Jo. Amer. Mea. Assn., 96, 2063. Soper, W. B. and Wilson, J . L. : (1932) Amer. Rev. Tub., 26, 548. Stiehin, R. H. : (1935) Amer. t~ev. Tub., 32, 171. Steidl, J . : (1932) Amer. Rev. Tub., 26, 98. Whitney, J. S. : Nat. Tub. Assn. t.:ulr. - " Tuberculosis TIospitalization in the

Uni ted States."

TUBERCULOUS PERICARDITIS .

H. He imann and S. Binder (Brit. Heart Jo., 2, 165, 1940) write on the diagnosis of tuberculous pericarditis. The first consideration is the diagnosis of peri- carditis and then to establish i ts tuberculous nature.

The main points establishing the former are as follows : - -

(a) In the acute s t age - -The presence of a pericardial rub. (b) In the effusion s t age - - ( l ) The absence of a visible or palpable apex

beat. (2) The enlarged pear-shaped area of cardiac dullness. (3) The presence of Rotch ' s angle. (4) The typical radiographic picture of pericardial effusion. (5) Pericardial aspiration.

(c) In the adherent s t a g e - ( l ) Evidence of cardiac incompetence. (2) Evidence of venous engorgement. The condition is most difficult to diagnose a t this stage and systolic re t ract ion of the ribs has been seen only once.

The following signs are in favour of a pericarditis being tuberculous :

(1) A pa t ien t suffering from a chronic wasting disease. (2) Fever, in te rmi t t en t or remit tent , with frequent inverse manifesta-

tion. (3) Pulmonary tuberculosis or active tubercle elsewhere (almost

conclusive). (4) Congestive cardiac failure, wi th a febrile char t and bilateral pleural

effusions, wi thout organic cardiac murmurs or evidence of hyper- tensive disease or coronary thrombosis. Also swelling of the face wi thout kidney damage.

(5) H~emorrhagie perieardial fluid. (6) Radiography and probably kymography af te r pneumpericardium,

showing the small hear t and thickened pereardial wall. (7) The finding of tubercle bacilli in the perieardial fluid.