Popular Science Monthly/Volume 84/May 1914/The Practical Necessity of School Clinics

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THE PRACTICAL NECESSITY OF SCHOOL CLINICS
By E. H. LEWINSKI-CORWIN, Ph.D.

EFFICIENCY was defined by one of our great American engineers as "the relation between what is and what ought to be." Judging by this standard and agreeing on the premise that one hundred per cent, efficiency in medical school inspection means a complete discovery of all of the ailments and defects of the children followed by a prompt, rigorous and effective alleviation and cure of them, so far as they can be alleviated or cured, we must admit, in the light of established facts, that we have not only failed to reach the uppermost notch of efficiency, but that we are quite a good distance away from it. I shall not attempt to reproduce here the tables of statistics showing the number of defects noted in the schools of this and other countries and the corresponding statistics of treatments and results of treatments. They are in a general way known to all of us. In New York City in 1911, for instance, 166,368 children were found to be needing treatment, of whom 65,150—or not fully 40 per cent.—were reported as treated. We don't know how many of the defects noted were actually remedied, as there is, of course, a difference between reported treatment and actual cure. A single visit to a dispensary is considered as treatment, and there is no law whereby the Health Department of the city can enforce further action, even if in its opinion the treatment is inadequate. Nor is such a law desirable. We are evidently not accomplishing fully what we have set out to do. There is a serious gap between our aim and its fulfilment.

Efficiency depends almost wholly on the application of certain broad general principles. When our work proves to be falling short of efficiency we must either change our methods of procedure or revise the underlying principles governing them, or both. One of the principles of medical inspection of school children is to point out defects, leaving it to those most interested in the welfare of the children to have them attended to and treated—a perfectly reasonable expectation which, however, like many other social theories and assumptions, is, unfortunately, net being borne out by actual facts.

Many parents are ignorant, many negligent and indifferent, many are overworked and indigent. Campaigns of education and social reform will undoubtedly decrease the numbers of the ignorant and the indigent, but this is a slow process. If our faith in school medical inspection is justifiable and if we really mean to decrease the appallingly large amount of illness and physical discomforts among school children and conserve their health, thus promoting well-being and sound education, we must recognize that our underlying principles must be altered and actual conditions met more satisfactorily than by mere observation and noticing of defects.

Medical inspection of school children is in its infancy. Before a satisfactory method will be worked out many experiments must be tried out and many careful inquiries made. The present fragmentary study was undertaken on behalf of the public health, hospital and budget committee of the New York Academy of Medicine to demonstrate a method of testing the value of certain elements entering into the effectiveness of our medical school work, in order to determine whether school clinics are a practical necessity. Matters pertaining to the health of the school children of the City of New York are confided to the care of a dual authority—that of the Department of Education and the Department of Health. The sanitary care of schools, the instruction in physical training and personal hygiene, the segregation of backward and mentally defective children, are entrusted to the Department of Education; all the other elements of the medical school inspection are under the control of the Department of Health.

There are instances where the work of the two departments overlaps; there are instances where the two departments collide. There are opportunities for mutual dissatisfaction and irritation, which at times engender ill-feeling and refusal to cooperate on the part of individuals. We shall eventually come to the point, it seems to me, when we shall have to decide on some definite policy of procedure, which will eliminate any possibility of friction. We should like, therefore, to know precisely to what extent the full and complete cooperation of the teaching staff with the medical corps is to be counted on as a factor in bringing the efficiency of our school medical work to the highest possible pitch. Then, we have a great many dispensaries in the City of New York, varying in size and efficiency. The knowledge of the extent to which the proximity of a large and well-equipped dispensary affects our problem is also essential before a definite policy is adopted. Thirdly, we harbor within our city limits population composed of various races, of various degrees of intelligence and education and differing in economic status. We should like to know to what extent these factors enter into our problem.

Recognizing the importance of these elements, we have selected four schools in the Borough of Manhattan: One on the lower east side, in a section whose population is composed almost entirely of Russian, Austrian and other Jews, and where the cooperation of the school authorities with the health officers is known to be excellent. Then, another school amidst a mixed population—foreign to a great extent, where the interest of the principal in the work of the health department's officials was known to be slight. A third school was selected, again in a Jewish quarter, but in another section of the city, near a large and efficient dispensary, and a fourth school in a representative well-to-do district of the city. It was impossible for us to go over the cards for all the children of those four schools, so we decided to take as many cards as we could get for one class of each grade of the schools in question, endeavoring in this way to bring into the study children of all ages in each school. In all we have examined 1,452 records. From these closed records for the first term of 1912-1913[1] we have tabulated the number of children suffering from physical defects, but have not included cases of contagious diseases or communicable diseases of the eye and skin, as they are being treated in schools, so that our inquiry referred only to cases of defective vision, defective hearing; defective teeth, primary and permanent; defective nasal breathing; enlarged tonsils; defective nutrition; cardiac, nervous and pulmonary diseases; and orthopedic defects.

There were 1,617 cases of these defects alone noted for the 1,452 children whose records were examined. Bad teeth constituted two thirds of the defects. While the per cent, of all the defective children found among those investigated in the four schools, exclusive of bad teeth, was 41, it varied from school to school. It was 40 per cent, on the lower east side, 54 per cent, on the east side in the neighborhood of 30th Street; 21 per cent, in the well-to-do uptown district, and 50 per cent, on the upper east side near 103d Street. Of all the defects, bad teeth were most poorly attended to. In the school in the foreign district of the city where cooperation of the school with the medical corps was very good, 90 per cent, of the cases of defective permanent teeth were treated, but none of the 147 children with carious milk teeth received any treatment. In the school where cooperation was poor, 28 per cent, of cases with defective permanent teeth were treated and no primary teeth defects were reported remedied. In the school in the well-to-do section of the city, 56 per cent, of cases of bad permanent teeth were treated and 17 per cent, of bad primary teeth. For the school near the dispensary, 35 per cent, of bad permanent teeth is reported as treated, and out of the 239 cases of primary bad teeth only 1 is reported as having been treated. As to other defects the cooperating school reported 94 per cent, of children with defects receiving treatment as against 65 per cent, for the school whose attitude was antagonistic to the Department of Health. The well-to-do section school reported 80 per cent, of its defective children under treatment, and the school near the dispensary reported 86 per cent, under treatment. If the teeth defects be counted in, then the per cent, of treatments for all the defects, other than communicable eye and skin diseases, will respectively be: 47 per cent., 32 per cent., 54 per cent, and 41 per cent. As to individual defects, the following table shows the per cent, of treatment in the case of four chief classes of defects:

Table I

Defective
Vision,
Per Cent.
Defective
Nasal
Breathing,
Per Cent.
Enlarged
Tonsils,
Per Cent.
Teeth.
Primary,
Per Cent.
Permanent,
Per Cent.
School A: lower East Side, good co-operation 75 100 95 90
School B: neighborhood of 30th Street and 2d Avenue—bad co-operation 55 63 70 28
School C: uptown well-to-do district 90 91 80 17 56
School D: upper East Side near a dispensary 85 95 82 .4 35

The numbers of other defects are too small to be of use for comparative purposes. The table shows that eye troubles receive treatment in 55 to 90 per cent, of cases and that adenoids and tonsils are attended to in from 63 to 100 per cent, of cases. Evidently special stress, at times too much stress, is being laid on this class of defects. It is instructive to note that at times with full cooperation of the school authorities it is possible to attain 100 per cent, of treatments in certain classes of ailments. Teeth present the poorest showing as to amount of attention and treatment given, even in the well-to-do section of the city.

As has been already mentioned, reported treatment and actual results should be regarded as two distinct statistical categories. Under existing conditions, figures of treatments should be taken with great reservation as an indication of efficiency of results attained by medical inspection of school children. The school health records indicate the number of cases which in the opinion of the school doctor were cured or which improved under the reported treatment. Tabulating these statistics, I find as far as the cases are reported that, exclusive of teeth, out of 482 cases treated only 204, or 42.3 per cent., have been cured, and 96 cases, or 20 per cent, have improved. The remaining 37 per cent, are not recorded as cured or improved. Granting that among the defective children under treatment there were a number of incurable cases, and allowing for clerical errors of omission, 38 or 30 or even 25 per cent, of non-cures and nonimprovements in school children is a very high percentage. Aside from mere figures, experience shows that a large percentage of those reported treated do not improve, a condition which calls for serious consideration and which is due in a large measure to slipshod therapeutics in dispensaries as well as by some private physicians, especially in the poorer sections of the city.

Contrary to the prevailing notion of the abuse of dispensaries by patients able to afford a physician's fee, the statistics for the four schools as to source of treatment, show that 235 of the 482 cases treated for defects other than teeth went to consult physicians and only 228 made use of dispensaries. The remaining 19 are not accounted for.

Table II

Indicating Place of Treatment, of Defects Other than Teeth, as Reported on School Cards.

School Total Number
of Cases Treated
Treated by
Physicians
Treated in
Dispensaries
School A: lower East Side 104 47 56
School B: neighborhood of 30th St. and 2d Ave. 88 41 45
School C: uptown well-to-do district 94 54 31
School D: upper East Side 196 93 96
Totals 482 235 228

Table III

Indicating Place of Treatment of Defective Teeth, as Reported on School Cards.

School Total Number
of Cases Treated
Treated by
Physicians
Treated in
Dispensaries
School A: lower East Side 90 75 8
School B: neighborhood of 30th St. and 2d Ave. 24 11 13
School C: uptown well-to-do district 75 48 3
School D: upper East Side 39 22 16
Totals 228 156 40
 

The same to a much greater degree is true of dental work. 156 private dentists were consulted as against 40 in the clinics. It is a remarkable showing, considering that three of the four schools are in the poor sections of the city. The conditions can be ascribed to the following three causes: (1) parents do not want to pauperize their children in taking them to free dispensaries; (2) people have not strong faith in the effectiveness of dispensary treatment; and (3) the hours of the dispensaries are in many instances not suited to the convenience of the children and, furthermore, going to a dispensary, under the present conditions of overcrowding, entails long hours of waiting.

All of the figures quoted in this inquiry must, of course, be taken with many grains of salt. The element of negligence and error on the part of the physicians and nurses making out the records must be taken into consideration. Then, the four schools selected out of a total of 513 public schools of the city of New York may not reflect prevailing conditions adequately. These considerations lead one to insist on the importance of a similar study on a large and comprehensive scale where the element of error would be minimized and the conditions in a majority of schools in all parts of the greater city analyzed. Meanwhile, the present fragmentary study tends to indicate: (first) that although the difference in the economic and educational status of the various classes of the population is a factor to be reckoned with in adopting measures leading to efficiency of medical inspection of school children, yet the average percentage of defects treated in children of parents in better circumstances and of an average higher level of education is not materially different, if at times not smaller, than in children of the poorer sections of the city: in this connection it must be noted that the per cent, of children with defects other than teeth was much lower in the well-to-do section than in any of the three other sections; (second) that full and harmonious cooperation between the teaching staff and the medical corps is an element of extreme import in the efficacy of the work. In some instances, especially in cases of defects with reference to which a great deal of popular education has been undertaken, it is evidently possible to attain one hundred per cent, of treatments when the cooperation of the principal and teachers is genuine and wholehearted; (third) that the proximity to the school of a well-equipped and efficient dispensary tends to increase the usefulness and efficiency of the work of the medical school inspectors; (fourth) that in the case of children's ailments, parents, even of the poorer classes, resort in fifty per cent, of cases to the services of private physicians; (fifth) that over thirty per cent, of reported treatments of school children by private physicians and dispensaries do not result in cure or improvement; and (sixth) that teeth are of all the largest and most neglected class of children's defects.

Should a comprehensive study on the lines suggested in this paper bear out the above cited conclusions a thorough revision of the underlying theory and methods of our medical school inspection should be undertaken and serious attention given to the institution and organization of school clinics where efficient, competent and prompt work would be done.

School clinics are being tried in various parts of the country and abroad. In New York City we have dental, nose and throat, and contagious eye diseases clinics for children, maintained by the Department of Health. The number of these clinics is small and their location is not planned to meet the peculiar needs of certain sections. The only therapeutic work done in schools of New York City is by nurses who treat minor skin and eye troubles like scabies, ringworm, favus, impetigo and conjunctivitis. This measure alone has decreased the number of school exclusions from 57,665 children in 1903 to 3,361 in 1911, but what is more important than mere school attendance, it has effected positive cure in thousands of cases.

It is my personal opinion and belief that school clinics, if adopted on a broader scale, should be established if not in every school, then in schools centrally located, so that children from other schools in the vicinity could easily reach them. The clinic districts should not be made too large, that the evils of overcrowding may be avoided and the children not subjected to waiting long and many hours. The treatment in school clinics for those who need it and are unable for one reason or another to secure the services of conscientious practitioners should be given not as a gratuity, but as a legitimate part of the functions of the school, just as a physical training or baths or recreation.

There will, no doubt, be opposition to them at first. We attempted once to enucleate tonsils in schools and we had street riots in the Italian section of the city. There will be other sources of opposition. Every new experiment or departure from established routine is bound to invite opposition, but as the clinics demonstrate their usefulness and efficiency, the opposition to them will gradually wane.

A number of sources has been suggest id to secure the means necessary for the maintenance and operation of such clinics: budgetary provision by the municipality, special assessments, voluntary per capita contributions of a couple of cents weekly by the parents of the children, and, finally, the establishment of branches in school buildings by dispensaries caring to reach out. Each of those suggestions has its merits, but the last two may prove impractical. A system of collecting small contributions is cumbersome and costly, and establishing of children's clinics in schools by dispensaries is not very probable; furthermore, the extension of the field of the gratuitous service of the physician is impractical and unjust. Physicians must be paid for their work and paid adequately. If the establishment of school clinics proves to be a public need then, not one class or classes, but the community as a whole must defray the expense of their maintenance and operation.

  1. In the case of School No. 171, the cards for the year 1911-12 were used, because the records for the first term of 1912-13 were unsatisfactory