School Clinics for Free Medical and Dental Treatment
The Psychological Clinic Copyright, 1912, by Lightner Witmer, Editor. Vol. Y. No. 9. February 15, 1912. :Author: Lewis M. Tebman, Ph.D. Stanford University, Cal.
Dr H. H. Hogarth, assistant medical officer of education for the London County Council, has made an observation in his excellent book on the medical inspection of schools, to the truth of which all experienced school doctors will assent. “Every school doctor,” he says, “goes through the same process of reflection and education. At first he enters the school as a novice, recognizing that his duty is to inspect, not to treat; that his own position is open to attack on the part of his brother practitioners; that he may be interfering with the rightful responsibilities of parents. He is so absorbed in the new work, the new ideas, so interested in the children, the educational system and the teachers, that, as soon as he has notified parent and teacher that a child is suffering from some particular disease, leaving them to take whatever further action may be necessary, he considers he has done his part. It is not until he returns a year later, that he realizes how completely his advice has been ignored. Then he begins to think. (3, p. 210.) i . ,
As everyone knows, medical inspection of schools, m t e beginning was little more than inspection. The early New York inspectors found that 94 per cent of their notifications failed to bring results. In England, likewise, where the work is newer, the evils more numerous, and poverty more widespread than with us, the results were so disappointing as to awaken everybody concerned to a realization of the utter futility of any system of inspection which takes no steps to ameliorate the evils it discovers. Hogarth says that in London not over one-third of those nrged to seek medical advice do so, and that not one-tenth are adequately treated. Although conditions on the Continent and in the United States are somewhat less discouraging, medical inspection everywhere encounters a vast amount of ignorance and apathy. Casting about for means to abolish this evil, school authorities have discovered a number of remedies of various degrees of effectiveness. One of these is the system of school nurses. Another remedy, supplementary to school nursing, and of even greater portent for preventive medicine, is the school clinic. The school clinic is a clinic controlled by the educational authorities and supported at public expense for the purpose of permitting a thorough examination, and in some cases also treatment, of defects revealed by the routine inspection. In many cities of the United States, the work of the clinic is confined to the first of these functions. The school doctor on his rounds finds children whose condition merits a more thorough diagnosis than can be given in the preliminary and rather superficial survey. The parents of such children are asked to bring them to the clinic for examination and advice. If grave defectiveness or disease is found the parents are urged to secure the necessary treatment from the family physician, or, in some case of extreme poverty, the school doctor may arrange with the local hospitals or dispensaries for gratuitous service. Clinics for this diagnostic and advisory purpose have everywhere rapidly followed the introduction of medical inspection. In cities above 15,000 or 20,000 they are fast coming to be looked upon as a standard requirement. The purpose of this article, however, is to describe a somewhat different type of school clinic,?a clinic designed to afford more or less of treatment as well as diagnosis. This type of clinic, though by no means unknown in the United States, has had such a remarkable development in England and Germany in the last few years, as to suggest the desirability of enlarging the usefulness of our own clinics along similar lines.
Dr Lewis “Williams’ account (13) of the school clinic at Bradford, England, gives an excellent idea of the significance of this new medico-educational institution. Bradford is a manufacturing city of about 300,000 population, that is, about as largo as Cleveland or Buffalo or Los Angeles. The school clinic was opened about two years ago in the hope that it would make possible the treatment and cure of that large majority of children who, because of indigence or parental neglect, had received no benefit from the mere inspection of their defects. The staff consists of three physicians, one dentist, two nurses and two clerks, all en full time. Treatment is free except that parents, when able, are required to pay the actual cost of eye-glasses. Although attendance is voluntary, objection to treatment is very seldom met with. The reason for this lies partly in the absence of expense but perhaps still more in the psychological difference between persuading parents to do something and merely securing their consent to have it done. The former violates the principle of human inertia, the latter takes advantage of it. The following table shows what the Bradford clinic accomplished in 1910:?
Number treated. Defective vision 650 External eye disease 576 Ringworm of head 623 Ringworm of body 122 Verminous heads 360 Scabies and impetigo 419 Otorrhea 285 Defective teeth 450 Stammering 150 Infectious disease 1052 Of the 5000 who secured free treatment at the clinic, certainly very few would have received any other attention whatever. Ringworm of the head was treated by the X-ray method, one application being sufficient in over 92 per cent of the cases; 559 pairs of glasses were supplied at a cost of from 30 to 65 cents each. A special teacher was employed to give breathing exercises and other treatment to stammering children. In 1908 a clinic was opened in the Poplar School, London, organized by Miss Margaret MacMillan and endowed by Mr. Joseph Fels. This is interesting as showing what can be accomplished by a small clinic drawing its cases from only about 1000 children from a single school, (9). During the two years from December, 1908, to December, 1910, 450 pupils came under treatment in this clinic, or nearly half the total enrolment of the school. An analysis of 210 of the 450 cases shows a number of interesting facts. Twenty-three cases were treated daily for ear discharge until cured. Roughly speaking, the number of months required to cure a discharging ear about equalled the number of months the ear had been neglected. The clinic recommended 3o cases of adenoids or enlarged tonsils for operation and out of this number met only two refusals. Fifty-five children were treated for anaemia or debility of whom 32 were either cured or distinctly improved. Of the 210 cases analyzed, cure was effected for 94, 21 were improved, 67 were still under treatment when the report was made, 8 had been transferred to a hospital and 9 had left school. All of this was accomplished with no interference in attendance and at slight expense. Similar school clinics have been established in England at Bow, York, Brighton, Sheffield, Southampton, and other cities, though the movement can hardly be said to be more than three years old.
The development of school dental clinics is remarkable enongh to deserve separate mention. Beginning in Strassburg, Germany, in 1902, they have rapidly spread to nearly all the cities of the empire and to a less extent have gained a foothold in all other civilized countries. The first school dentist was Dr Jessen, of Strassburg, who has done more, perhaps, than any one else to convince the educational world of the grave importance of the “Disease of the People” (dental caries) and to promote the institution of free dental clinics as a means of combating it. The following table shows the extent of the work done by the Strassburg clinic for the first four years, together with the total cost:
No. available No. treated. for treatment. Total cost. 1st year 2666 17,119 $1355.00 2d ” 4967 17,054 1685.00 3d ” 6828 18,073 2135.00 4th ” 7491 18,607 2250.00 Attendance is entirely voluntary and the above table shows a large increase in patronage from year to year. The children like to be treated and seldom refuse to attend when advised to do so. The annual cost is seen from the above table to be but little over twenty-five cents for each pupil treated. The German Congress of School Hygiene which met in 1904, after consideration of the Strassburg clinic, passed a resolution “that the authorities of the nation should combine to put the teeth of all the children in order, and that this should be done by the establishment of school dentistries for free treatment.” Due partly to the impetus thus given to the work, by 1907 about 33 cities of Germany had established free dental clinics and at present nearly all have done so. In the United States school dental clinics arc conducted in many of the larger and a few of the smaller cities, but on a different basis from those of Germany or Switzerland. With us the work is carried on entirely for the benefit of indigents. It 19 frankly a charitable institution belonging in the same category a9 orphanages, poor houses, etc. Ours are also different in the fact that much of the dental service is gratuitously rendered by the local dental association. Unlike the Germans, we have not yet yet formed any adequate conception of the possibilities of this field of preventive medicine. Dental caries is the most widely spread of all known diseases and one that is intimately related to numerous kinds of physical disability. It is also largely a disease of childhood and adolescence. If the teeth are well cared for during the period of growth they will need relatively little attention later. Investigations, furthermore, prove that only a small minority of children ever visit a dentist unless for the extraction of an aching tooth. In one of Boston’s most aristocratic suburbs, 75 per cent of the school children had never been to a dentist. In the face of such conditions it is surely superfluous to argue for the principle exemplified by school dentistry. It would be folly to permit an a priori theory of social or economic control to blind us to the essential facts.
The most important and common defects and diseases revealed by medical inspection are defective vision, discharging ears, adenoids and hypertrophied tonsils, tuberculosis, enlarged glands, carious teeth and malnutrition. The purpose of medical inspection being to combat racial degeneracy and to conserve vitality, its sole justification lies in the contribution it makes to this end. This may sound trite, but it is fundamental. The following are illustrations of the difficulties met in the accomplishment of this purpose.
Discharging ears present a condition of great seriousness and need in most cases to have daily attention, such as syringing, washing, etc. But experience proves that frequently parents will not, even when urgently and repeatedly advised by the school doctor or nurse, secure for the child so afflicted the proper medical care. As a rule they lack the knowledge of hygiene and medicine which would enable them to appreciate the situation. Apathy in such matters usually betokens ignorance. Others, and these are very numerous, cannot afford the services of expert oculists or aurists at current rates and are reluctant to accept as charity what they have not the means to command. Even when the aurist is consulted for a discharging ear the tedious treatment which ensues, lasting often for many months, is seldom carried out by parents with the needed regularity and carefulness. Physicians find that in most cases it is simply folly to expect a cure by this method. The only assurance of success in this direction is for the child to be taken daily to the physician’s office or to the hospital for the necessary treatment. Aside from the question of expense or the prejudice against charity, it is useless to expect that this will be done. Each visit may consume from two to four hours of time. Whether rich or poor, people are too busy and impatient to submit to such a tedious ordeal. The result is that nine-tenths of the cases of ear discharge among school children have been neglected. Theorize as we may about the danger of tampering with parental responsibility by the support of school clinics for free treatment, we are confronted by this fact of neglect. With the inauguration of the school clinic the whole problem vanishes. The child goes daily to the nearby clinic, often in the building where he attends school, and receives necessary treatment at the hands of nurse or doctor. There is no waste of time, no loss of school attendance, and a mere bagatelle of expense. Eest of all, the treatment brings cure.
Most of the other forms of defectiveness present with greater or less variation the same problems and the same solution. In the case of defective vision, for example, to secure parental action requires, in about 50 per cent of the cases, from two to four home visits by the school nurse. In the case of 15 to 30 per cent nothing is ever accomplished. Many who respond, do so by seeking the inexpert advice of opticians. A few take their children to a reputable oculist and have them correctly fitted -with glasses at an expense of from ten to thirty dollars each. A still smaller minority seek for or permit assistance through laws for relief of the poor The sum total of results is disappointing, notwithstanding its cost of time and energy. Upon the establishment of the school clinic of the English type the situation is completely changed. When a child is discovered with defective vision, instead of hounding the parents of the child with arguments and pleadings that an oculist be consulted, the child is sent to the clinic and is tested for glasses. The clinic even secures for the child necessary lenses and frames at special rates arranged for by the school authorities with a reliable optician. The cost ranges from Is. 3d. to 2s. 6d., and is met by the parents if they are able, if not, by the school board. In English cities, such as Bradford, about 80 per cent arc paid for by the parents. But the important points are that the eyes actually receive treatment, that the treatment is slcillful and that the cost is inconsiderable.
In like manner, enlarged glands, tuberculous tendencies, throat occlusions and many other defects require either more skill” ful or more constant attention than they are likely to receive from the family doctor. The X-ray treatment for ringworm is a good illustration of the efficiency that may be secured by the introduction of wholesale methods into medical practice. Only a few practitioners have the equipment for treatment, those who have it charge high fees, while the disease is common only among the poor. Left to such a combination of circumstances the disease would flourish indefinitely. The properly equipped school clinic practically eradicates it from a middle-sized city within a few months and at an expense which is almost negligible.
The only opposition to this kind of clinic comes from practicing physicians and dentists, some of whom look with apprehension upon every social movement which seems to point toward an ultimate socialization of their respective professions. We need only remember, however, that disease should be conceived as an evil to be eradicated and not as a resource to be conserved for the benefit of any profession. Partly by his own fault and partly for social and economic reasons, the family doctor has not succeeded in keeping the people well. The family doctor institution need not be abolished, but it must be supplemented. What it Jias not done at all, or what it has done only with huge waste of effort, presents a legitimate field for organized social endeavors. For the medical profession to stand in the way of such an effort would be to adopt a dog-in-the-manger policy. In fact there is no likelihood that any respectable portion of physicians will oppose the general introduction of the school clinic. A committee of physicians commissioned by the local medical association to inquire into the bearing of the Bradford clinic upon private medical practice reported as follows:?”Your committee consider that the school clinic as carried on at Bradford has not hitherto proved detrimental to the interests of practitioners of that district.” What the school clinic accomplishes is pure gain.
It is hardly necessary, interesting as it would be, to speculate upon the final outcome of the school clinic. Whether it will lead to the complete socialization of medicine and dentistry, just as education has been socialized, is a question it is impossible to answer. It is certain, however, that the social control of matters pertaining to the health of its children will be strengthened in the future rather than weakened. Intrinsically there is nothing more radical in the principle of free medical and dental treatment than in the American scheme of public education or free text books. From the beginning the cry about weakening parental responsibility has been raised against both. Gradually we are learning that it is less a question of parental responsibility than of children s rights. Private enterprise has done too little for the health of our children to justify any claim to a monopoly of the business.
REFERENCES
1 R. H. Crowley, M.D., The Hygiene of School Life, 1910, pp. 1G7-183. 2 A. W. Grant, L.D.S., Dental Inspection and Treatment of School Children at Cambridge, School Hygiene, July, 1911. 3 H. H. Hogarth, The Medical Inspection of Schools, 1909, Chapters 14 and 15. 4 Dr Jessen, The Care of the Teeth in School. Proc. of International Cong, on Sch. Hyg., 1907, p. 515 ff. 5 Dr Jessen, Kostenpunkt einer stiidtischen Scliulzahnldinik. Internat. Arch, fur Schulhyg., Vol. IV, 1908, pp. 432-43G. 6 Dr Jessen, Schulzahnpflege u. Schule. Proc. of International Cong, on School Hyg., 1907, pp. 495-502. 7 Dr Jessen, Die Zalinschularztliche Behandlung der Volksschulkinder. Internat. Arch. f. Schulhyg., Ill, 1907, pp. 205-222. 8 George S. Schlegel, D.D.S., The Reading (Pa.) Free Dental Dispensary, The Psychological Clinic, Feb., 1910. 9 R. Tribe, Results of Treatment at the Poplar School Clinic (London), School Jlygiene, May, 1911. 10 J. E. W. Wallin, Medical and Dental Inspection in the Schools of Cleveland. The Psychological Clinic, June, 1910. 11 C. E. Wallis, Recent Progress in School Dental Hygiene. School .Hygiene, June, 1910. 12 Lewis Williams, M.D., School Clinics, in Kelynack’s “Medical Inspection of Schools.” Chapter XIII, 218-231. 13 Lewis Williams, M.D., School Clinics, School Hygiene, March, 1911.
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