Childhood Diseases

CHILDHOOD DISEASES. Due to a number of anatomical and physiological peculiarities of the child's organism, its functional instability and pronounced plasticity, the onset, course, and outcome of childhood diseases often present such distinctive features that fully justify the isolation of childhood diseases as a special scientific discipline. Moreover, since both the occurrence and course of childhood diseases are also conditioned by a whole range of social factors, childhood diseases constitute a special chapter in social pathology. Due to these peculiarities, all external harmful influences and pathogenic agents sometimes produce completely unique reactions in the tender child organism. Many of the factors that have disrupted the physiological state of the organism damage it to such an extent that they make complete restitutio ad integrum impossible and affect further life, development, and functions of individual organs. From this it is clear of the exceptional importance of pathology of early age for the growing organism. The necessity of paying special attention to the question of childhood diseases also follows from data on the age composition of the population, from which it is seen that children (0-14 years) constitute 30-40% of the total population. Table 1. Age composition of the population of the European part of the RSFSR according to the 1926 census (in %). Age In urban settlements In rural areas m. d. 11.33 7.08 9.38 11.40 m. o- 4 years . . 5-9 » . . 10-14 » . . 15-19 » . . 12.58 7.62 9.59 10.57 16.90 11.14 13.17 12.16 14.83 9.96 11.64 11.97 I. Classifications of childhood diseases. The question of studying childhood morbidity is closely connected with the question of the classification of childhood diseases, without which it is impossible to make such a count of cases of disease as would be suitable both for obtaining scientific conclusions and for orientation in practical questions of social hygiene and prevention of childhood diseases; unfortunately, we have to state the fact that the question of the classification of childhood diseases is little developed as a whole. Only No-becourt made an attempt to give guiding indications on the principles of classification of childhood diseases according to the specificity and frequency of these diseases in childhood; he proposes to distribute all childhood diseases into the following 3 sections: 1) Diseases and disorders specific to childhood, even for each period of childhood separately (such as: in the newborn, difficult child, in middle and older age). 2) Diseases that occur at all ages, but have a special appearance and are more common in childhood. 3) Diseases that occur less frequently in childhood than in other periods of life, but in childhood have interesting peculiarities. - The need for such a classification with time became more and more definite, and the thought of pediatricians was first directed towards the classification of the most frequent diseases of the first group of No-becourt. At the II All-Union Congress of Pediatricians in 1923, the following classification of disorders of nutrition and digestion in early childhood was adopted as a temporary practical classification. A. Chronic disorders - puro-trophia, atrophia B. Acute disorders of digestion and nutrition-dyspepsia, decompositio 1) Purely alimentary, constitutional 2) Alimentary-constitutional 3) Post-infectious 4) Mixed 1) Alimentary 2) As a partial manifestation of infection 3) Of mixed origin Concentration of attention on the development first of all of the classification of nutritional and digestive diseases has particularly important significance in connection with the extraordinary prevalence of these diseases in early age and the specificity of their course and outcome. The classification of disorders of growth and development is especially important in that it is precisely growth and development that are the most characteristic features of children compared to adults, to which No-becourt pays special attention in his approach to the classification of childhood diseases.

a special section of pathology. Statistical study of morbidity in general, and of childhood morbidity in particular, is possible only with the existence of a classification of diseases accepted on an international scale. Such a classification exists for all diseases (regardless of age), and modern statisticians already use it. II. Statistics of Childhood Diseases. As for the statistics of childhood morbidity, despite its generally recognized great importance, it is poorly developed. The greatest interest is presented by those data that shed light on the question of childhood morbidity in large territorial units with subdivision of the material by sex, age, social groups of the population, by urban, factory and rural areas, but such works are very few. There are many valuable works that detail the morbidity of certain selective groups of children who have passed through consultations, polyclinics, clinical institutions, etc., but these data do not cover the entire population. Of great interest are the data published in 1929, compiled by the Statistical Bureau of the Moscow Health Department for 1926, but in them, the grouping of morbidity by social groups of the population and by industrial districts has not yet been carried out. Nevertheless, even in the form as these data are developed (by sex and age in Moscow city and Moscow province), they are unique among all recent data on population morbidity not only in the USSR, but also beyond its borders. From these data, it is fully determined that in early age groups (from birth to 4 years), along with epidemic diseases, morbidity of diseases of the digestive organs, respiratory organs, skin and subcutaneous tissue is particularly high; in preschool age and in the first school age, epidemic morbidity, morbidity of diseases of the respiratory organs, skin and subcutaneous tissue (in Moscow city and province) and morbidity of diseases of the digestive organs (in Moscow city) significantly decrease. In school age (from 10 to 14 years), the tendency of decreasing morbidity continues for epidemic diseases, but there is a certain increase in morbidity of diseases of the digestive organs, skin and subcutaneous tissue and to some extent—diseases of the respiratory organs. Morbidity from general disorders of nutrition, metabolism and internal secretion, diseases of the nervous system and diseases from external causes increases from early age groups to adolescent age (14-19 years); a similar phenomenon is observed in relation to the increase in morbidity with age of diseases of bones, joints and muscles. A special place in age-specific morbidity is occupied by the earliest age (less than 1 year): here the exceptionally high morbidity of diseases of the digestive organs (up to 622 per 1,000 population), diseases of the respiratory organs (up to 294) and diseases of the skin and subcutaneous tissue (up to 265) attracts attention; in this same age, up to 22 developmental defects per 1,000 population were registered, while in subsequent age groups the number of developmental defects did not exceed 4 per 1,000 population. This is largely due to the fact that children with developmental defects die during the first year of life. Upon detailed examination of the data in this table, certain features of the morbidity of residents of Moscow city and Moscow province are revealed. According to individual sections of childhood morbidity in Moscow city and Moscow province, the following is observed. Epidemic diseases by age were distributed as follows: Table 4. Diseases Less than 1 year 10-14 years Measles . . . Scarlet fever Whooping cough . . Diphtheria Influenza . . . Parotitis Dysentery Erysipelas . . . Measles . . . Scarlet fever Whooping cough . . Diphtheria Influenza . . Parotitis Dysentery Erysipelas . . . 31,7 30,1 5,0 4,6 10,9 23,1 2,4 1,7 219,3 200,9 5,5 3,8 10,7 10,3 4,3 5,5 45,2 6,9 24,9 2,5 240,4 1,8 1,9 4,9 45,6 8,4 28,9 3,0 246,3 2,0 2,5 5,3 23,9 ! 11,4 14,5 3,1 126,4 4,8 6,7 1,5 63,9 29,5 31, 4, 230, 3,2 1,6 24,4 11,1 17,7 2,6 125,8 4,1 5,5 1,6 29,8 36,0 3,6 227,2 5,4 2,7 1,6 In boys 8,6 8,8 2,9 2,6 0,3 7,7 8,8 2,7 3,5 0,9 6,4 7,6 1,0 1,3 0,1 0,9 1,0 0,4 0,5 0,2 54,5 63,3 58,6 73,7 108,7 8,5 7,3 10,7 9,2 1,6 0,7 0,8 0,4 0,7 0,7 0,5 0,7 0,7 1,0 1,2 In girls 24,2 25,5 14,5 2,3 101,4 14,7 0,7 1,0 4,5 7,8 1,2 0,7 65,4 13,9 0,4 1,4 4,8 8,9 1,8 1,1 76,7 11,8 0,5 2,0 0,6 2,4 0,09 0,2 99,3 1,1 0,6 1,7 0,5 0,9 0,1 0,3 101,9 1,5 0,6 2,7 0,7 2,3 0,1 0,5 69,3 0,9 0,4 2,8 DISEASES

From this table it is evident that measles, whooping cough, and dysentery are predominantly diseases of early age groups, whereas mastoiditis affects the school age group to the greatest extent, and scarlet fever is more prevalent in middle age groups. Specifically: the maximum morbidity rate per 1,000 population under 1 year is 8.4, from 15 to 19 years - 2.4, and from 1 year to 9 years in Moscow reaches 29.8. Among the diseases of the 'nutrition disorders, metabolism and internal secretion' group, rickets and anemia attract attention. Table 5. Morbidity from rickets per 1,000 population (in parentheses, figures for girls). Age Moscow Moscow Province Less than 1 year.... 12.7 (11.3) 13.3 (9.4) 21.0 (14.7) 11.1 (8.6) 1-4 years....... 5-9 years....... 10-14 years....... 15-19 years....... Age-specific morbidity from anemia is characterized by a steady increase with age, as seen in table 6 (per 1,000 population, in parentheses, figures for girls). Table 6. Age Moscow Moscow Province Less than 1 year....... 1-4 years....... 5-9 years....... 10-14 years....... 15-19 years....... 2.9 (2.7) 22.6 (24.1) 38.3 (47.8) 29.6 (53.9) 46.0 (59.4) 6.6 (6.5) 11.3 (13.9) 19.5 (29.6) 33.8 (57.9) 41.1 (74.9) Girls show an incomparably higher morbidity rate from anemia compared to boys, which is particularly noticeable in the age group from 10 to 19 years; this is undoubtedly associated to a large extent with greater exploitation of labor and deprivation of fresh air for school-age girls and adolescents due to their involvement in household chores. In the 'diseases of the respiratory organs' group, the morbidity figures for respiratory tract diseases attract special attention. Table 7. Morbidity from acute bronchitis by age (in parentheses, figures for girls). Age Moscow Moscow Province Less than 1 year....... 121.6 (117.0) 1-4 years....... 106.9 (103.6) 5-9 years....... 32.1 (33.4) 15-19 years....... 19.8 (8.8) 185.4 (177.7) 88.8 (92.0) 16.9 (19.1) 16.2 (16.7) 21.6 (13.0) The particularly high figures for respiratory tract diseases in children under 1 year (especially in Moscow Province) and from 1 year to 4 years are very characteristic; starting from the 5-9 year group, morbidity from respiratory tract diseases sharply decreases and remains at relatively low figures throughout all subsequent years of childhood and adolescence. In the 'diseases of the digestive organs' group, it is necessary to focus on dental diseases (table 8). Here, the data on the extremely large difference in morbidity from dental diseases of children and adolescents in the city of Moscow compared to Moscow Province attract special attention. The most pronounced increase in dental diseases in the city of Moscow is observed from the group under 1 year to the 1-4 year group and from this group to the 5-9 year group, while in the province - from the group under 1 year to all subsequent age groups. From the diseases of this group, it is also necessary to particularly focus on helminthiasis. Table 9. Morbidity from helminths (per 1,000 population) by age (in parentheses, figures for girls). Age Moscow Moscow Province 10-14 years....... 0.9 (1.1) 22.1 (25.9) 23.8 (29.6) 10.8 (20.9) 2.5 (4.5) 3.9 (4.8) 26.7 (34.8) 20.5 (32.9) 17.3 (35.9) 6.6 (11.1) From these data it is clear that among the population of the province (which includes rural areas), morbidity from helminths is significantly higher compared to the city of Moscow, whose residents have less contact with animals. Along with this, there is a sharp jump in figures towards an increase in helminth morbidity from early age (under 1 year) to the following age group and a sharp jump towards a decrease in helminth morbidity from the 10-14 year age group to the 15-19 year age group. The final data on age-specific morbidity (per 1,000 population) for all diseases (in parentheses, figures for girls) are also of great interest: Table 10. Age Moscow Moscow Province 1-4 years....... 1,332 (1,344) 1,432 (1,370) 1,015 (1,010) 982 (1,106) 1,416 (1,142) 1,848 (1,689) 958 (947) 538 (604) 740 (866) 1,141 (1,142) These data indicate a significantly higher morbidity rate in children from 1 year to 14 years in the city of Moscow compared to Moscow Province, and conversely, a significantly higher morbidity rate in children of Moscow Province under 1 year compared to the city of Moscow. When considering data on childhood morbidity, it is necessary to understand the peculiarities of childhood mortality, as this can help in understanding the causes of increased or decreased morbidity in children. III. Childhood mortality as an indicator of the ratio of biogenic and sociogenic factors in childhood morbidity. Very indicative data on childhood mortality are available in the latest Russian statistics; from them, the extraordinary variability of morbidity in the child population depending on different local socio-domestic conditions is evident. There is no doubt that the combination of biogenic and sociogenic conditions ultimately results in certain values of high or low childhood morbidity and mortality (especially in the 1st year of life), a high or low percentage of stillbirths. It turns out that in urban settlements of the RSFSR in 1926, 0.83 stillbirths were registered per 1,000 residents, while in rural areas - only 0.22. Table 11. Fluctuations in figures in individual districts. Districts Urban population Rural population Leningrad province and Karelian Central industrial district Central-chernozemny 0.86 0.89 0.38 0.92 0.43 1.41 0.90 0.88 0.74 0.83 0.62 0.52 0.21 0.09 0.22 0.10 0.81 0.45 0.09 0.13 0.12 0.15 Middle-Volga district Lower-Volga district These figures in individual provinces, for example in urban settlements, fall to 0.26 (in the North Caucasus region) and rise to 1.69 (in Cherepovets province and in Votsk autonomous region). In the city of Moscow, this indicator is expressed by the figure 0.92, in Leningrad - 0.93. When processing the tabular data of the statistical collection ('Natural movement of the population of the RSFSR for 1926', published by the Central Statistical Administration of the RSFSR, M., 1928) for the RSFSR, the following interesting figures (Durnovo) were obtained, indicating the type of morbidity in children under 1 year in the largest cities. Of the total number of deaths under 1 year, the following died (in %). Table 12. Cities From congenital weakness From intestinal disorders From infectious diseases Ivanovo-Voznesk Nizhny Novgorod Saratov 20 27 22 24 22 22 16 22 23 21 22 22 17 38 16 19 24 20 18 17 11 When these data are distributed by age groups, a vivid characterization of the mortality of weak-born in the first month of life and the increase in the number of infectious diseases in the following months is obtained. If, for example, we take only the data for Moscow, Leningrad, and the average data for all urban settlements of the RSFSR, then mortality in this age in 1926 in % of the total number of deaths will give the following figures (see table 13). Although the data of this mass statistics do not claim to account for exact diagnoses, nevertheless with large numbers they are very indicative. Extremely indicative data on survival and childhood mortality are available in the old statistical literature. Thus, according to Erisman's data, survival to certain ages in Germany in 1870-81 was Table 13. Cities and causes of death At 1 month 2-5 months 6-11 months In Moscow from congenital weakness from infectious diseases 77 5 9 16 * 1 28 In Leningrad from congenital weakness from infectious diseases 77 5 7 17 i | 34 In all urban settlements of the RSFSR from congenital weakness from infectious diseases 61 4 12 15 4 . 24 as follows - out of 1,000 live births in Germany in 1870-1881, the following number survived to the specified ages: Table 14. Age Boys Girls Difference Under 1 year 2 years 3 years 4 years 5 years 10 years 15 years 20 years 747 698 675 659 648 620 608 592 782 732 708 692 681 652 638 623 35 34 33 33 33 32 30 31 From this table it is evident that sexual differentiation in terms of the degree of resistance to various adverse influences manifests itself from an early age: the female half of the human race shows higher survival coefficients to higher ages. This tendency is revealed in an even more vivid form from the data on the mortality coefficient by age, as one of the indicators of general age-specific and sexual morbidity (according to Erisman's data for 1881-90 in England and Wales). Table 15. Age groups Male mortality coefficient Female mortality coefficient Percentages by which female mortality is lower (-) or higher (+) than male 0-5 years 5-10 years 10-15 years 15-20 years 20-25 years 61.69 5.34 2.94 4.30 5.71 51.99 5.25 3.09 4.40 5.51 -15.7 -1.7 +5.1 +2.3 -3.5 The mortality coefficient for boys is higher than for girls in most age groups, with the exception of the 10-15 year and 15-20 year age groups. This is particularly noticeable in the 10-15 year age group. This is largely due to the fact that this age in girls includes the period of puberty, during which the body's resistance to external harmful influences is physiologically reduced.

As for the morbidity and mortality of newborns by months of the year, according to statistics in various countries of northern and western Europe, the following is indisputable: morbidity and mortality sharply increase in June, July and August and just as sharply decrease by September, reaching their lowest values in October, November and December. In these indicators of age-specific mortality and survival (by sex), the combined influence of bio- and sociogenic factors is reflected. The predominant influence of socio-domestic conditions on mortality is particularly clearly revealed from the following data of Gertsenshtein. The number surviving to the fifth year out of 1,000 born differs significantly in families of the rich, middle class, and poor, as can be seen from Table 16. Table 16. Families

560 In Erfurt for the years 1848-69, the following number of children died (in %). Table 17. Age From children From middle From upper working classes classes 0- 1 year...... 30,5 17,5 8,9 1- 2 years .... 11,5 5,5 1,9 3-5 » .... 13,6 6,8 2,6 | 6-10 » .... 6,8 6,8 1,3 Ill-14 » .... 2,5 0,8 An extremely sharp difference in child mortality is visible in cities and in rural areas. For example, data on child mortality in Sweden was taken, where under the best living conditions in the village compared to other Western European countries, even mortality under one year turns out to be lower in rural areas compared to cities, not to mention other age groups. Per 1,000 children of corresponding age groups died. Table 18. Boys Girls Age In cities In villages In cities In villages Under 1 year 1- 5 years . . 5-10 » . . 226,0 54,0 12,9 159,0 31,0 9,2 222,0 53,0 12,9 139,0 29,0 8,6 In this data, the reflection of physiogenic and sociogenic factors is visible. IV. The role of constitutional peculiarities and endocrine components in the manifestation of C. d. 6. When considering the factors that determine the type of childhood morbidity, the development of C. d. and their outcome, it is necessary first of all to dwell on various anomalies of constitution, in which in many cases lies the source of one or another predispositions to diseases. In this case, we are dealing with the presence of hereditary-innate, as well as acquired, persistent inadequacy of either the body as a whole or individual tissue and organ systems. According to Martius's formula, disease is directly proportional to external harmfulness and inversely proportional to the body's resistance; resistance, in turn, is inversely proportional to predisposition. Constitutional anomalies may be in a latent state, making themselves known at certain age periods depending on the functional age peculiarities or under the influence of certain changes in the living conditions of the child. An extremely common constitutional anomaly is the so-called asthenic anomaly (not to be confused with the normal asthenic type of Kretschmer!), characterized by general constitutional weakness. This anomaly (according to Maslov) is observed in infancy in 1% of cases, in preschool age - in 10%, and in school age - in 30%. In this case, there are undoubtedly phenomena of hereditary-innate inadequacy, complicated by the influences of the external environment and especially by the influence of tuberculous intoxication and the increasing demands on the body from the environment in which the lives of children proceed. In second place in prevalence is the exudative-catarrhal diathesis. This anomaly is explained by the inadequacy of connective and epithelial tissues, their insufficient resistance to external harmful influences. This anomaly is observed in early age in 31% of cases, in preschool age - in 21%, and in school age - in 8%. The decrease with age in the number of children with this anomaly is explained by the fact that some children die from diseases that have developed on the basis of the inadequacy of the body's protective mechanisms, as well as by the fact that with age, some children develop adaptability to the struggle for existence. The lymphatic-hypoplastic anomaly is observed much less frequently. Its basis is the inadequacy of connective tissue, in particular adenoid tissue and follicular elements. According to Maslov in Leningrad, in infancy this anomaly is observed in 2-3%, in preschool age - in 6-9%, and in school age - in 1,4-4%. The significant increase in the number of cases of this anomaly in preschool age must be explained mainly by the intensification of infectious effects on the glandular elements in connection with the complication of the child's interactions with the environment. By school age, there is already a sufficiently strengthened adaptability of the protective glandular mechanisms, which gives a sharp decrease in the number of lymphatic-hypoplastic children. The neuro-arthritic diathesis is also relatively rare, occurring in about 1-2% of all children; in school age it occurs much more often (up to 8% of cases). The basis of the neuropathic constitution is the inadequacy of the nervous system. The functional manifestations of this anomaly are extremely diverse, but the most typical are manifestations of increased excitability of the nervous system, which is associated with a decrease in the body's level of adaptability to the struggle for existence. This anomaly is detected from the earliest age, intensifying in the future, especially under unfavorable living conditions. The detection of this anomaly is particularly striking during the period of puberty. The hemorrhagic diathesis is encountered less frequently than any other diathesis, the basis of which is the weakness of tissues forming the vascular system and reduced blood clotting. In the pathology of childhood, disorders of the functions of the endocrine glands and the autonomic nervous system are also of great importance. As for the predominance in childhood of vagotonia and sympathicotonia phenomena, there are great disagreements in the literature; along with assertions about the sympathicotonicity of early childhood children, there are observations indicating that among early childhood children there are also pronounced manifestations of vagotonia. V. Tuberculosis and syphilis in childhood and the role of social factors. On the basis of hereditary-innate peculiarities of children and their constitutional predispositions, under the influence of factors of the external environment (infection, social-domestic harmfulness, etc.), various diseases develop. Of all diseases, it is necessary to dwell especially on tbc and syphilis as socially determined diseases. Tbc is now considered mainly as a childhood disease, in that infection with tbc occurs predominantly in childhood, and the course of tbc in childhood presents outstanding features compared to the period of human maturity. According to Medovikov's data at the dissecting table, the presence of tbc in children in Leningrad was established by years in the following percentage of cases. Table 19. Age /o Age % 0- 1 year...... 20,0 5- 7 years...... 34,7 1- 2 » ..... 34,0 7- 9 » ..... 2- 3 i>..... 41,0 9-11 » ..... 44,4 3- 4 »..... 40,6 11-15 » ..... 40,0 4- 5 years...... 34,5 Other researchers (Kisel') indicate even greater values. In any case, it can be fully stated as a fact that during the period of puberty, the number of infected should be determined at around 60-65%. From the data of the "Experience of pedological dispensarization of the mass school" in Saratov, it is seen that out of 220 children of the surveyed primary school (1925-26), 27.7% were found healthy, 29.6% without signs of tbc but with other diseases (malaria, anemia, diseases of the lungs and heart, etc.) and with signs of tbc - 42.7%. This last group consisted of the following subgroups. Table 20. Chronic intoxication (compensated process) ...................... 13,1% Chronic intoxication (subcompensated process).................... 7,8% Tbc of bronchial glands (compensated process) .................... 7,8% Tbc of bronchial glands (subcompensated process).................. 1,9% Tbc of external lymph glands (compensated process) .................. 0,5% Tbc of bones (subcompensated process) . 0,5% Tbc of lungs (stage I, compensated process) 4,8% Tbc of lungs (stage I, subcompensated process).................... 5,3% Tbc of lungs (stage II, compensated process)..................... 0,5% Tbc of lungs (stage II, subcompensated process).................... 0,5% Interesting are the data from a special in 1927 Children's demonstrative Table 21. Mortality from tbc in New York in 1913-17 (Hess). N y o- Total number of tbc cases Including (in %) Age Lung |_Pr- f₀r_M forms 0- 1 year . 1- 2 years 2- 3 » 3-4 » 4- 5 » 5-9 » 10-14 » 15-19 » 1.269 1.151 702 440 354 197 168 586 16 16 14 18 21 32 67 87 33 j 13 | tuberculous dispensary of the People's Commissariat of Health of a complete survey of three households in Moscow (Zamoskvoretsky district) with 68 families, in which there were 75 children - from newborns to 16 years old. The predominant composition of the surveyed families - workers and artisans (63%) and employees (37%). It turned out that among these 75 children, a specific diagnosis of tbc was established in 72. From the latest data on the prevalence of tbc in early age, collected during a special survey through the same dispensary of 204 children from 0 to 2 years, the following is visible. 0-6 months. Chronic tuberculous intoxication . Various forms of tuberculosis .... 6-12 months. Table 22. 12-18

months. 15(9%) 42(25%) 61(36.2%) 50(29.8%) 1(2.8%) 6(16.7%) 19(52.8%) 10(27.7%) From these data, the reflection of socio-domestic conditions on the peculiarities of the course of tbc in early childhood is extremely vividly revealed, namely: Table 23. With a monthly income per family member Number of tuberculous children found (in %) with chronic intoxication with local process 30 13 10 On the basis of the developed data (Durnovo) from the same dispensary for its entire existence (from 1909 to 1929), a large number of asthenic children were revealed under the influence of tuberculous intoxication, namely: with variational-statistical calculation among children with a mild degree of intoxication at the first measurement, asthenic types were found in 12%, with severe intoxication - 16-35%; and in subsequent measurements after several years in the same children, asthenic types were found among children with a mild degree of intoxication in 16-20%; and with severe intoxication - in 47-51%.-Regarding the degree of spread of syphilis among children, only general approximate data are given below. The percentage of congenital syphilis, according to different authors, ranges from 0.5% to 4% of the total number of children under 1 year of age who passed through the consultation for early childhood. The spread of syphilis in childhood through various domestic routes of infection is of immeasurably greater importance. The degree of prevalence of syphilis among children can be seen, for example, in rural areas from data for the Voronezh province for 1925-26. During the examination of 106,831 people, 6,472 cases of syphilis were detected, i.e., in 6% of the population. Among the detected syphilitics, there were 1,367 children under 14 years of age, i.e., 21% of the total number of syphilitics (Tkachev). In this case, syphilis in children should be considered as a result of unfavorable living conditions (unsanitariness, low cultural level, weak development of medical services, etc.), since congenital syphilis occupies a secondary place compared to domestic factors.

VI. Features of childhood morbidity (according to data from special examinations of preschool, school-age children and adolescents). Particularly indicative data on childhood diseases are available in special works by physicians of OZD (protection of children's health), pedological cabinets, and preventive children's outpatient clinics. These materials contain not only statistical data in tabular form, but also their analysis, which allows to a certain extent to illuminate the question of the ratio of the influence of bio- and sociogenic factors on childhood morbidity. These data are of great interest also because on their basis the practical health-improving work in the mass school is planned and developed. As an example, data from a special examination of second-year repeaters in the schools of the Northern Railway in 1928 (Durnovo, Brainina) are given. It turned out that among children who remained in the class for the second and third year several times, the morbidity is much higher compared to children who remained in the second year only once during their studies; at the same time, it turned out that among second-year repeaters there are more children Table 24. Second-year repeaters, remaining in the same class several times, (in %) of both sexes, second-year repeaters who remained in the same class only once, of both sexes (in %) Factors of underachievement Factors socio-genic (unfavorable living conditions). Raw, dark and cold rooms Frequent undernutrition..... Irregular nutrition . . Family discord ...... Extreme overload with home work {^₀^ь_ч^ч_ки 16 22 Hunger in early childhood ; Factors biogenic (pathological hereditary predisposition). Alcoholic heredity . . . Tuberculous heredity . . . Tuberculous and alcoholic heredity Mental illness in the family ........... from families burdened with path. heredity and living in difficult conditions. Table 25. Data from somatic examination Random second-year repeaters (in %) Second-year repeaters who remained in the same class several times (in %) boys girls boys girls Tuberculous intoxication...... Various signs of anemia Nosebleeds .... Difficulty in nasal breathing Reduced hearing Purulent discharge from ears..... Headaches. Increased nervous excitability. Bedwetting . . Poor development of subcutaneous fat 11 11 13 35 8 15 16 29 16 20 21 26 17 17 ?⁵ 22 26 17 From these data it is clear that among girls compared to boys, a significantly larger number of children were found with various signs of anemia, with nosebleeds, with headaches and with increased nervous excitability. This depends mainly on those living conditions in which girls in the family are exploited for various household chores to a greater extent compared to boys, as well as on the fact that girls are to a greater extent deprived of the opportunity for wide communication with the outside world, which makes them less adapted to fight the harmful effects of the external environment. From these data it is also seen that the reduced level of success in school work depends on the reduced level of children's health and on the reduced socio-domestic conditions in which the lives of schoolchildren proceed. Among the defects that are usually associated with school work conditions, curvature of the spine, headaches, reduced visual acuity, etc. are listed. Undoubtedly, the school as such is one of the significant factors causing these phenomena, but not to the extent that was attributed to it by hygienists at the dawn of the development of school hygiene. The extremely great importance is also attached to those complex bio-social components that have no direct connection with the school: The question of the level of nervous and mental health of modern preschool and school-age children is of great interest. The developed data of the Preventive Children's Outpatient Clinic of NKZdr. in Moscow for 1922-24, covering about 10,000 children from 5 to 18 years, are as follows. tabl. 26. Symptoms 1922 1923 1924 Headaches. Dizziness 26.9% 11.6% 29.9% 15.5% 36.0% 18.0% Headaches and dizziness were observed in girls compared to boys approximately 2 times more often. All children in whom complaints of headache were noted were distributed by age as follows: Table 27. 7 years 8 years 9 years 10 years 12 years 13 years 15 years 17 years 1.4% 5.6% 8.4% 11.3% 15.0% 10.3% 9.6% 5.5% Complaints of dizziness have a similar age distribution. The number of complaints of headache and dizziness increases as the end of the school year approaches. It turned out that a large number of children have a severe disturbance of sleep. Insomnia and anxious sleep in boys and girls were observed almost to the same extent. Night terrors were noted in 4.1% of children. Bedwetting was noted in 1921 in 5.9% of children, and in 1924 - in 6.8% of children. All registered enuretics were distributed by age as follows: Table 28. 6 years

7 years 8 years

7.2% 25.8% 18.5% 10.4% 2.2% Enuresis occurs twice as often in boys as in girls. Stuttering, as one manifestation of childhood nervousness, was observed in 0.8% of the total number of children. Based on the collected data, it can be concluded that children healthy in terms of the nervous system constitute an average of 28% of the total number of children examined in 1923-1924. As for mental diseases, the processing of data on 11,000 children yielded the following data (in %). Table 29. Age Psychopathy Epilepsy Cyclothymia Hysteria Psychasthenia 8 years 9 » 10 » 11 » 12 » 13 » 14 » 15 » 16 » 17 » 8.0 7.0 7.5 7.7 4.4 3.0 5.3 4.2 2.0 1.2 0.2 0.7 0.2 0.4 1.5 0.3 0.9 2.4 1.3 0.2 0.7 0.2 0.9 0.3 0.5 0.6 0.9 0.9 1.2 0.4 0.5 0.4 1.5 0.5 0.5 0.9 0.9 2.0 1.9 0.2 0.2 0.1 0.4 0.5 0.3 : 1.3 1.9 Cases with individual signs of constitutional as well as reactive psychopathies were included in the "psychopathy" category (Borisov). Even if we take into account that due to insufficient differentiation of cases included in this group, too high a percentage was obtained, the figures remain alarming. The number of oligophrenics among the examined children and the ratio between their number and the number of pedagogically backward children (in % to the number of children in each group) are given in table 30. The data presented is interesting to compare with the materials available in the form of a summary of world literature data by Troshin ("Childhood Abnormality in the Last Hundred Years"). Particularly large material was collected in England in 1894-95, where 100,027 schoolchildren were examined. The results of this survey are as follows: children with abnormal manifestations of the nervous system constituted 10%, with mental retardation - 7%. As for children needing special schools for the mentally retarded, the number of such children in different countries ranges from 1½% to 2½% of the total number of school-age children. The data on children of Moscow, Table 30. Pedagog.- Backward. Mentally retarded. Age 9 »...... 14.6 6.2 1.9 10 »...... 19.5 7.7 1.6 11 »...... 18.0 1.0 1.1 12 »....... 21.4 10.2 1.3 13 »...... 13.4 6.1 1.1 14 »...... 14.5 5.2 0.3 15 »...... 10.7 5.8 0.5 16 »...... 13.1 6.9 - 17 »...... , 4.4 2.3 as can be seen, are extremely high. The reason for this undoubtedly lies mainly in the socio-domestic conditions associated with the great upheavals experienced (imperialist war and civil war, famine, epidemics, the breakdown of the entire way of life, etc.), as well as in the overload of the nervous system of children that existed earlier and has by no means been overcome to this day, and in the unfavorable conditions in which children's life takes place, especially in large cities (housing crisis, etc.). In the USSR, along with examinations of children of early, preschool and school age, numerous examinations of adolescents have been conducted in recent years in connection with the widespread implementation of preparation for a healthy working class that will have to bear on its shoulders the entire burden of state construction and the development of the country's productive forces. As an example, data on the results of examinations of working adolescents in Leningrad are provided. The examination of working adolescents in Leningrad in 1923-1924 (6,165 children of both sexes aged 14 to 19 years) sheds light on the factors of morbidity among the Leningrad working youth. Along with unfavorable socio-domestic conditions, unsatisfactory working conditions, etc., hereditary predisposition plays a significant role: in 23.1% of cases there is data on severe heredity; of the entire mass examined, alcoholic heredity was found in 8.5%, tuberculosis - in 14.9%; for individual types of parental work, the percentage of alcoholic parents is significantly higher: among leatherworkers - 20%, among woodworkers - 12.1%; the same can be noted regarding the presence of tbc in the parents of the examined adolescents: among textile workers - 19.9%, among chemists - 18.9%, among leatherworkers - 15.8%, etc. Abnormal socio-domestic conditions and working conditions push young people to smoking and drinking alcohol; it turned out that the sharp increase in the number of those who started drinking and smoking occurs during the period of puberty (14-16 years). Of the total number examined, those who started drinking and smoking did so at the following ages (see table 31). S18 Table 31. I Age Smoke Drink Smoke AND DRINK 8 » ............ 0.7 5.1 3.5 9 » ............ 7.2 4.6 9.1 10 » ............ 20.0 13.2 6.0 11 » ............ 1.8 0.4 4.5 12 » ............ 0.3 1.6 4.5 13 » ............ 4.5 2.0 5.2 14 » ............ 6.5 13.6 26.5 15 » ............ 15.0 11.1 0.0 16 » ............ 8.3 0.8 1.6 17 » ............ 5.7 1 18 » ............ 19 » ............ 2.4 ] 0.0 j Age not specified .... 16.7 Due to the same conditions, this youth also begins sexual life early, which of course adversely affects both the adolescents and even more so their future offspring. Table 32. ¹ Age Total number examined Number living sexual life (in parentheses-%) m. f. m. | f. 14 years and less 15 » .16 » ) 17 » 18 » 19 and more . 111 419 1.037 1.440 859 361 89 210 469 673 355 142 14 (3.3) 86 (8.3) 225 (15.6) 218 (25.4) 149 (41.3) 4 (4.5) 14 (6.7) 17 (3.6) 59 (8.8) 21 (5.9) 35 (24.6) Total . . 1.938 : 692 (16.4)1 150 (7.7) As for the question of certain specific features of morbidity among working adolescents, the following picture emerges from the examination of Leningrad adolescents. The examined adolescents working in various industries, in terms of morbidity (both sexes), as a percentage of the total number of adolescents in each industry, were distributed as follows (see table 33). table 34. Diseases Male sex Female sex Both sexes (in percentages) Suspicion of tuberculosis ..... Other, diseases of the respiratory system . . Diseases of the nervous system. Diseases of the circulatory system 14.57 1.11 11.88 18.45 3.22 2.15 13.41 0.93 8.67 12.13 1.34 1.14 14.11 1.07 10.87 )6.45 2.63 1.93 Total diseases Table 33. ! Profession Tuberculosis Anemia Diseases of respiratory organs Nervous diseases Diseases of blood system Other Total number of diseases li Textile workers .... i Leatherworkers..... 1 Tailors...... 21.05 18.54 16.02 14.32 13.15 11.98 8.80 10.53 17.06 20.51 19.26 29.46 4.80 7.00 27.37 8.03 11.74 11.60 9.47 10.52 8.58 1.05 1.73 4.70 2.72 1.53 0.40 ,0.68 0.99 2.82 0.49 0.53 1.73 2.48 3.16 4.33 6.98 6.18 9.02 4.44 7.45 63.16 50.68 62.77 54.57 63.68 33.82 34.99 When breaking down the morbidity data by gender, a certain difference between the genders is revealed, with male adolescents showing greater unfavorable conditions in all main nosological groups, which is largely associated with the fact that female adolescents do not participate in industries with high morbidity (woodworkers and metalworkers). As can be seen from these data, for all diseases, the indicators for male adolescents are higher compared to the female gender. VII. Measures to combat C. d. The anatomical-physiological features of children, their high morbidity and mortality force special attention to be paid to the fight against diseases in childhood. Since in the plan of population health improvement one must first think about the healthy younger generation, it is quite natural that the fight against C. d. is expressed primarily in measures that prevent diseases and increase the resistance of the child's body. As the highest form of prevention, care for the health of a child begins with antenatal protection, protection of the mother's health, with which the child's well-being is so closely connected. These considerations form the basis of measures in the field of mother and child protection (see): the establishment of legislation aimed at protecting the rights of the pregnant mother and child, maternity insurance associated with the release of the parturient from work before and after childbirth, providing the best conditions for childbirth itself, organizing consultations for women, houses of mother and child that ensure the health of the woman during the period associated with motherhood and that spread the concept of pregnancy hygiene among the broad masses of the female proletariat and peasantry. Maternity homes, houses of mother and child, houses of infant (up to 1 year), houses of child (1-3 years), children's homes (for older children), consultations for women, consultations for children with patronage and milk kitchens, play a huge role in the prevention of diseases of early childhood. In relation to older children, adolescents-prof. outpatient clinics, forest schools, colonies, children's towns, health grounds and finally the dispensarization of the child population are preventive measures in the field of health protection of children (see) and adolescents. Physical education plays a huge role here, which has taken on very large dimensions in the Union of SSR.

The proper organization of nutrition and care for infants, preschoolers, and schoolchildren, along with broad sanitary education for parents, which helps the latter to consciously approach and actively participate in the struggle for the life and health of the child, constitutes a solid foundation for this preventive work. All the measures listed have already produced quite tangible results in the form of reduced infant and early childhood mortality and morbidity, and an increase in the average health level of older children. As for treatment measures, qualified assistance to the child population comes first. Children's consultations not only carry out preventive work but also provide treatment assistance for nutritional disorders, rickets, syphilis, tbc. The establishment of children's preventive outpatient clinics with departments for various specialties—surgery, otiatry, eye diseases, skin diseases, etc.—ensures assistance for older children. Inpatient treatment is concentrated in children's hospitals with special departments for infants, departments for infectious diseases, children's tuberculosis hospitals, tuberculosis and venereal dispensaries, and children's sanatoriums. Among the measures to combat Childhood Diseases should also be included special institutes for the protection of motherhood and infancy and the protection of the health of children and adolescents, which aim to study the child's body in healthy and diseased conditions, as well as to train medical personnel with specialized education. Lit.—see lit. to the article Pediatrics.