The Doctor in the Public School, by John J. Cronin, M.D.

THE DOCTOR IN THE PUBLIC SCHOOL.

THE BENEFICENT RESULTS OF A MEDICAL EXAMINATION OF CHILDREN.

BY JOHN J CRONIN, M.D. (footnote 1)

ONE of the most important duties of the Department of Health of the City of New York is to prevent the spread of contagious diseases in and through the schools. Nearly all epidemics have their origin at school, and the spread of contagion among children usually takes place through the intimate association of a large number of pupils representing different strata of the population.

In 1897 the Department of Health appointed a corps of medical school inspectors, - physicians chosen after a rigid competitive Civil Service examination. The duties of the inspectors consisted in visiting their respective schools every morning at a stated hour and in examining any children sent to them by the teachers for suspected contagious diseases. The inspectors excluded children found to be affected with such diseases, and readmitted them only after a second examination and after the premises where these children lived had been disinfected. This phase of the work is still continued in all the schools of the city, and the result has been a greatly diminished number of cases of contagious disease.

In 1901, under the Low administration, a, corps of nurses was added to the corps of inspectors. The duties of the school nurses consist in promoting the cleanliness of the children and in treating minor ailments of the skin and eyes, under the direction of the inspectors. The corps of physicians was also enlarged and its work extended so as to include a visit to each classroom once a week. The children were then passed before the doctor and their general appearance, the condition of their hair, face, eyes, mouth, and throat were noted, and records were kept of the minor contagious conditions which the nurses treated at the school. This work resulted in a great improvement in the cleanliness and healthfulness of the children, and through this agency one of the most dangerous forms of contagious eye disease (trachoma) was greatly reduced in frequency among the children. The number of cases of trachoma in the schools of Manhattan Borough on March 31, 1905, was 17,710. A year later, on March 15, 1906, a careful census showed only 12,000 cases. (The above statistics are used with the permission of Dr. Thomas Darlington, Commissioner of Health, under whose administration this new work was established.)

DIAGNOSING IN TIME TO CURE.

In the course of their weekly visits the school physicians had noted many pale, improperly nourished, and apparently sick children, some of whom presented such marked characteristics of disease that no further examination was needed to know what ailed them. Some of these, with hollow eyes, flat chests, and emaciated frames, were evidently suffering from tuberculosis. Others, with subdued manner, pale lips, and breathlessness on mounting stairs, bore the outward and visible signs of heart disease. Thousands of children with the typical expression of the "mouth breather" were encumbered by soft growths in the vault behind the soft palate (adenoids) and showed impaired hearing and retarded mental and physical development, simply because a comparatively trifling procedure, - the removal of these growths, - had not been thought of. As they went from class to class the inspectors also noted a large number of children whose tense brows and suffused eyes, whose blinking lids and close-range reading, meant nearsightedness and eyestrain, and whose languid and "headachy " manner was the despair of their teachers and the mockery of their fellows. They noted, too, in almost every class, one or more children with an insatiate desire for motion, children who were constantly reproved for being " fidgety," but who in reality needed treatment for St. Vitus' dance, or for kindred nervous affections.

Saddest of all, the doctors in every school came across pupils whose defective mental and moral make-up should have from the first excluded them from association with normal children. These were the weak-minded children of all grades, from the "backward child," that could never do the simplest sums, to the imbecile and the idiot, whose presence was obviously an offense against the normal children among whom these defectives were obliged to sit day after day.

It was evident that if the parents of these children were notified as to the existence of

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these manifold infirmities, and if in each case the necessary medical treatment were applied, a great improvement would result, not only in the health of the school children, but also in their capacity for school work, to say nothing of the lasting benefit to them in after-life conferred by timely treatment at an early age. Accordingly, in March, 1905, the doctors of the corps began examining each school child individually, going over a school about once a year. These examinations include the consideration of the child's general health and strength, of the condition of his heart and lungs, of the presence of nervous disease, mental deficiency, deformities of spine or limbs, as well as affections of the teeth, throat, nose, eyes, or ears. The physical record of each pupil is noted on a card filed at the Department of Health in such a manner as to be accessible at any time. If any disease or defect be found, the parents are notified by mail and are advised to consult their family physician.

While these notifications are purely advisory, and no compulsion is attached to the matter, the authority of the Department of Health is such that few parents of intelligence neglect the warning. In the great majority of instances the advice of the school physician is followed at once. Of course, there are always some people who raise the cry of " paternalism," and who object to any interference in their "private affairs" by officials of the city. Such people insist upon their alleged inalienable right under the Constitution of the United States to have diseased or weak-minded children and to allow them to grow up as defective citizens. The same hue and cry was raised, it will be remembered, when compulsory education was first discussed in this country. Compulsory care for the child's health is just as necessary as compulsory school attendance. With our present system of public dispensaries and clinics, lack of money is no excuse for parental neglect, and such negligence should be punishable as a misdemeanor, just as a parent is now punished for neglect to provide medical attendance for a minor child under his care in case such neglect results in the death or permanent disability of the child. The school children must be educated to regard the law as to compulsory treatment as one to be obeyed, and thus the feeling that some of the children are charity patients attending a dispensary will be replaced by the simple view that they are obeying a general salutary law, like that providing for compulsory vaccination.

DEPLORABLE CONDITIONS FOUND.

While the great need for the new work of physical examinations was perceived before this work had begun, no one had expected the astonishing percentages of sick and defective children that were revealed in the first few months after the new system had gone into effect. Of 99,240 children examined in the schools of the Borough of Manhattan from March 27, 1905, to September 29, 1906, 65,741, - or about 65 per cent., - needed some form of medical treatment. Of those 99,240 children, about 30 per cent. (30,958) required correction of defects of sight, in most cases by eyeglasses. A still larger percentage (39,778) needed attention to their teeth. There were 38,273 children with swollen glands in the neck, indicating some present or past trouble in the throat, nose, ear, or some abnormal constitutional condition. Enlarged tonsils, with their baneful effects, including liability to tonsillitis and diphtheria, were found in 18,131 children. About 10 per cent, of all the children examined (9850) were found to have adenoid growths in their throats, - a condition which predisposes to affections of the ears, the nose, and the lungs, and which interferes most seriously with the child's general health and mental development. Heart disease was found in 1659 children; disease of the lungs in 1039, deformities of the body or limbs in 2347. Of the children thus far examined 2476 have been found mentally deficient; but probably the percentage of such children in our schools is slightly greater, as the figures thus far quoted include largely the primary grades, in which the mental development of the children is not so easily judged as in the upper classes.

When these figures were first made known even the officers of the Department of Health stood aghast. Doubts were expressed in some quarters as to the accuracy of the results. It may be said here that the corps of school inspectors now working under the Department of Health is a body of picked men, who represent the most thoroughly trained school physicians in this country. The positions are coveted, and of 800 doctors who applied for the places only 250 succeeded in passing the examinations, and of these only a few secured places.

Nowithstanding this, in order to be absolutely sure of the results, a special commission was appointed to re-examine a large number of children taken at haphazard in different sections of the city. The results showed that the figures given by the inspectors had been, if anything, too conservative. The result of a large number of eye examinations conducted by some of the foremost specialists of the city showed identical percentages with those found by the school physicians, and thus the accuracy of their findings was verified.

RESULTS OF PHYSICAL EXAMINATIONS.

The work of examining the school children of the city had not proceeded far when letters of appreciation began to come in at the office of the Department of Health. Hundreds of parents had got their first inkling of an oncoming illness or of a serious physical defect from the postal cards sent out by the medical inspectors. In some cases cataracts that in the course of time would have permanently blinded the children were discovered during the examination, and the parents had been unaware that anything was wrong with their child's eyes. About 8000 children are now wearing glasses as the result of the examinations, and the principals and teachers are enthusiastic over the improvement in the work of these pupils. The following extract from a teacher's letter is only an example:

Since the last physical examination of my class seven girls have been fitted with glasses. The girl that was the last to be induced to go to the dispensary has shown marked improvement. Although always sitting in the front row, she seemed never to see the board and was absentminded. Now there is no girl in my class more alert or more nearly up to the standard. She always had good reasoning- powers, so I could not understand why she was deficient in reading, writing, and spelling. She could not see the blue lines on white paper, but always wrote in the spaces between them. Now all this is corrected since she has the use of eyeglasses. In fact, her spelling is now perfect every day.

While the examination of vision at the dispensaries of the city is free, there is always a charge (and in some cases a sum out of the reach of the poor) for the eyeglasses prescribed. There is, therefore, an urgent need for funds to be provided by the city to supply school children with eyeglasses. School books and other school supplies are now provided free of charge by the city, and eyeglasses for those that require them are just as essential as books.

Even the children themselves have now come to appreciate the value of the examinations, especially those whose failing eyesight has been discovered and corrected. One little girl in a school on the lower East Side came triumphantly to school with the report: "I have got glasses; I had my tonsils cut, and my ringworms cured."

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But perhaps the most striking results in the way of physical and mental improvement have been noted in the children who have had adenoid growths or large tonsils removed. The amazing change which these children have undergone can scarcely be believed unless actually witnessed. From dullards, many of them have become the brightest among their fellows, after the operation. The following letter from one of the inspectors shows the transformation of a boy who underwent the operation:

This boy, aged seven years, was regarded by his teacher as a hopeless idiot, and his appearance justified her opinion. His was a case of most pronounced nasal obstruction, had an acrid, persistent discharge from both nostrils, his mouth was always open, and tongue and mucous membrane of the mouth were dry and covered with crusts of mucus. Hearing was defective, apparently about 8-16 in both ears. Mentally, he seemed hopeless; he would sit in his seat gazing blankly around the room, answering questions indifferently, and playing aimlessly with articles on his desk. He did not romp or play with other children, and his motions were sluggish and dull.

He was operated on, and at once improved in activity, both mental and physical, - the 'discharge disappeared, his expression brightened, and he became possessed with such exuberance of spirits that he became the most mischievous boy in the class.

The brilliant results attained in various parts of the city in children operated upon at home or at the dispensaries impelled the authorities to give attention to those children whose parents were too poor to pav even the necessary car fare to send them to the clinics where the operations could be performed. A number of such children were attending one of the East Side schools, where it was especially important to have the operations performed on account of the presence of a number of mentally defective children in special classes. The parents' consent having been secured in writing, these children, eighty-four in number, were operated on, on June 21, 1906, under the supervision of Dr. Emil Mayer, of Mt. Sinai Hospital.

SOME CHILDREN " BEFORE AND AFTER."

We present herewith the pictures of several of these children taken at the school before the operation. Another set of pictures shows, as well as a camera can show it, the result after the operations. These were taken in September, 1906, after the children had returned from their vacations in the country, where they had been placed in the care of the Association for Improving the Condition of the Poor.

Placed side by side, the pictures strikingly show the marvelous transformation effected by the removal of adenoids in these cases. The dull, listless, apathetic expression, the open mouth, the staring eyes of the children are replaced after the removal of the growths by bright, intelligent countenances, and a general look of health.

The scholarship of these children has improved to such a degree that the principal, Miss Simpson, who has faithfully and enthusiastically devoted time and energy to this special work, has made the following report:

You will doubtless be interested in learning about the little ones who were operated upon last June. Without exception, we have found a marvelous improvement in these children. They all assert that they can breathe better, sleep more soundly, and have better appetites. Several of the boys have been able to give up their habit of cigarette smoking, and all appear to be in far better physical condition; mentally, they exhibit an unusual alertness, interest, and intelligence, the absence of which was the chief and most noticeable feature of their previous condition.

Even our lowest types of mentally defective pupils exhibit a wonderful physical and mental improvement, which can only be appreciated by those who come in daily contact with the children. Much of their abnormal restlessness and nervousness has disappeared, and they show a ready response to directions, which previously was wholly lacking, the latter probably due to their improved hearing.

An added interest from another viewpoint attaches to the particular children pictured here. They were the innocent causes of one of the most appalling riots ever witnessed on the East Side of New York. Some mischievous person had spread the rumor that the Russian Government had hired the teachers and the school doctors to exterminate the children of the East Side Jews and that a wholesale cutting of throats was going on in the schools. A week after the operations had been performed this rumor took effect in a panic in which thousands of frantic mothers stormed the doors of the various schoolhouses of the district, clamoring for their children. The pupils were dismissed in time to avoid serious disaster. The tinder-like quality of the temperament of the foreign population, inflamed by baseless and malicious rumors, precipitated this outburst of passion, and among the clamorous mob there was not a single mother whose child had been actually operated upon. The latter had quietly remained at home, for at great pains they had been informed exactly as to what was likely to happen. Nothing in these riots could therefore be construed as reflecting the indignation of the mothers actually affected by the measures advised by the Department of Health. On the contrary, so pleased were many of the parents at the results of the operations that in the fall of the year a number of them requested the Health Department to have other children in their families operated upon, so as to give these the benefit of this treatment.

BACKWARD CHILDREN AND CRIME.

One of the most interesting phases of this work is its effect upon the education, and therefore, upon the future welfare of the backward child, the mentally deficient child, and the truant.

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It has been shown that 95 per cent, of "backward children" and of mentally deficient children have physical defects which can be remedied, thus improving their mentality as well as their physical health. According to the City Superintendent of Schools, 40 per cent, of the children of the schools of New York are below the grades in which they should be according to their ages. The Department of Health has found that 2 per cent, of all the children thus far examined were mentally deficient, and in nearly all these cases adenoid growths, defects of vision, or other remediable disabilities existed. In the special classes for defectives in Public School 110, 95 per cent, had adenoid growths in the throat.

When the backward child and the mentally deficient child shall receive the special attention which they require at the bands of physicians and teachers, especially when such children shall be taught in special classes or schools by specially trained educators, then only can we say that we have done all that is in our power for these unfortunates. The physical examination of backward or mentally, deficient children, therefore, is but one step in the right direction.

Moral obliquity, of which truancy is the first manifestation in school life, goes hand in hand with physical defects. Thus, among eighty-three truants examined by the Department of Health in the special Truant School in this city, 87 per cent, were found to have physical defects, in most cases of a remediable character. Truancy, and its kindred ills, - the " street habit," and the " gang habit," - lead to crime unless speedily checked. The records of the Children's Court in New York and of the similar court in Chicago showed that nearly all the youthful criminals that were brought to these courts were truants, and, what is more, that 85 per cent, of these children were found physically defective.

The source of truancy, therefore, lies chiefly in defects which prevent children from pursuing their studies. Remove these defects, and the ability to go on with school work will be restored, while the tendency to truancy will be vastly diminished. It is as difficult for a healthy body to do and think wrong as it is for a diseased body to do and think right; as an Italian savant, Mafucci, expresses it, "Man is responsible for the good that he does, - for the evil, the disease that is in him."

DEFECTIVE CHILDREN AND CHILD LABOR.

Deficient physical conditions and consequent inability to cope with their studies are also responsible for the large number of children who leave school early to enter factories and to form a part of the brutal system of "child labor." The physical examination of a large number of children in the upper four grades of a school on the upper East Side of New York showed that the physical condition of these scholars was far more perfect than in the lower grades. The cream of the school rises to the top, while the worthless sediment falls to the bottom and is removed in the process of the survival of the fittest. The children less well endowed physically leave school early, in most cases three or more years before graduation. In nearly all instances these children are far below the grade in which they should be according to their ages, and throughout their school course they have been backward in their studies and troublesome to their teachers on account of their physical defects. Actual poverty is the cause of leaving school early in but a very small proportion of cases, as was found by a principal who has been following the careers of his scholars for twenty-five years.

A moment's reflection will show the great financial loss to the families of these children through the fact that, leaving school in a low grade, they command but a pittance of wages as unskilled laborers, while upon graduation they could enter far more profitable fields of employment, requiring a better education. The earning capacity of the child that leaves school early is actually diminished 50 per cent, as compared to that of the child physically and mentally perfect. Thus every effort should be made by the State to keep every child at school until his elementary education is completed and until he has acquired a good earning capacity.

EXAMINATIONS VITALLY IMPORTANT.

To sum up, we may say that we have shown beyond peradventure that physical defects exist in about 60 per cent, of all school children in New York; that in most cases these defects are remediable by proper treatment, and that the early discovery of these defects is the prime factor in the maintenance of the health of the school children and in enabling them to pursue their studies.

We have shown, furthermore, that backward, mentally deficient, and truant children can be vastly improved by the early recognition of physical infirmities which underlie their mental or moral defects, and that by appropriate treatment, if applied early enough, we can save these children from illiteracy, from drudgery in factories at small wages, or from an almost inevitable criminal career.

In view of these facts what can be more important than a systematic individual physical examination of every school child at stated periods, and what can be of more lasting benefit than the early application of the proper treatment in all cases in which physical defects are found?

In view of these facts what can be more important than a systematic individual physical examination of every school child at stated periods, and what can be of more lasting benefit than the early application of the proper treatment in all cases in which physical defects are found?

The question as to the maintenance of the school child in perfect health is of such overweening importance that the problem of "race suicide," over which so many well-wishers of the race have grown hysterically enthusiastic, is of little consequence in comparison. The "race suicide" idea is based upon the assumption that the average American family should have a larger number of healthy children than the present birthrate shows, - an assumption clearly erroneous. As a matter of fact, physical defects go hand in hand with a large number of children, both in the rich and in the poor. The poor are more prolific than the rich, and the number of children in a family by actual count increases as the poverty of the family becomes more poignant.(footnote 2) A very little study of sociology will convince the advocates of the " race suicide" idea that a few perfect children are far better for the nation and the family than a dozen unkempt degenerates, who add pathos to the struggle for existence, and who sink under the inflexible law of the survival of the fittest.

The health of the school child will determine the very warp and woof of the nation's future, and the lessons taught us by the physically defective child should be heeded by every man and woman who has the future of our Republic at heart.

(footnote 1) In the preparation of this article, and particularly in the securing of photographs, the author acknowledges his indebtedness to Dr. De Santos Saxe, his colleague on the medical inspection staff of the New York City Health Department. It Is proper to state that the department Itself is not in any way responsible for the opinions expressed in the article.

(footnote 2) This is shown, for instance, by the statistics of Bertillon. who found that in Berlin, with an aver age birthrate of 103 children per 1,000 women, the very poor showed a birthrate of 157 children, the comfortable classes showed 96 children, and the very rich only 47 children per 1,000 women In each class.

(Transcriber's footnote: I put the links to the pictures in the transcript along the lines of where they exist in the original article, not as they are referenced in paragraphs written by the original author, Dr. Cronin.)