B 3411 D95 opy 1 MEDICAL INSPECTION OF SCHOOLS. ''"'h'^ y MEDICAL INSPECTION OF SCHOOLS. By SAMUEL H. DURGIN, M.D. Kead at the Annual Meeting of the Massachusetts Medical Society, June 9, 1897. BOSTON: PRESS OF DAVID CLAPP & SON. 1897. \ 73i MEDICAL INSPECTION OF SCHOOLS. The influence of schools upon the spread of infectious diseases, and the need for the exercise of greater public care over the schools, have been much discussed within the last few years, and with nearly unanimous conclusions. I think we should all agree upon the fact that the collection of large numbers of people within small spaces, generally speaking, furnishes the most favorable opportunity for the spread of infectious diseases, but more particularly with school children whose susceptible age and familiar habits render them unusually liable to the incidence and extension of these diseases. We shall also agree that the infective agent is frequently present in our public schools and that it only remains to be shown by what means the infection is conveyed. For the purposes of this brief paper we shall need to consider but two of the most common and dreaded infec- tious diseases — diphtheria and scarlet fever, and perhaps diphtheria alone would be sufficient. It was thought from the beginning of our knowledge of diphtheria until within a few years, that it belonged in the list of what has been termed filth diseases, and with this view in mind Boards of Health followed out different lines of work for the purpose of proving or disproving the theory that this disease might be caused by any unsanitary conditions. 4 MEDICAL INSPECTION OF SCHOOLS. In 1878 the Board of Health, with which I am identified in Boston, called for reports of cases of diphtheria, and for the last nineteen years we have examined every house in which a case of diphtheria was reported, and amongst other reasons to see what connection filth and defective drainage within buildings had with the prevalence of this disease, but with such negative results as to warrant the belief that it is scarcely, if at all, more likely to occur in the poorly constructed and badly kept houses than in the best. The percentage of defects found in connection with cases of diphtheria is found to be but slightly greater than that found when examining from house to house where no dis- ease or complaint has occurred. In 1882 we made an investigation to ascertain what connection there might be between cases or groups of cases of diphtheria and street gullies, perforated sewer covers, sewer outfalls, proximity to tide water flats, low damp ffround and high ground. Here again we found not even a suspicion of relation between cases of diphtheria and any of the suspected causes. On the other hand we are con- tinually reminded of the unmistakable direct or indirect connections between new cases of these diseases and other infected persons or rooms and articles which have become infected. AVe are forced to believe that the means by which children afflicted with diphtheria may and do create foci of infection in our school buildings as well as in their homes, and the facilities by which others may take on the infection from such foci, are both natural and easy. I think we are warranted in this belief by every process of reasoning and upon the facts connected with the disease. Diphtheria is, unquestionably, an infectious disease and may be commu- nicated directly from person to person, or indirectly through some intermediate object upon which the infective matter may have been lodged and where it may remain active for a longer or shorter time. The local manifestation of MEDICAL INSPECTION OF SCHOOLS. diphtheria is nearly always in the throat, Avhere Ave ha^'e the bacilli of the disease in abundance, mixed with the se- cretions of the throat and mouth, and in the most con- venient form to be transferred to any surrounding object. This infective matter is easily scattered and attached to things by coughing, sneezing and spitting, or by the fingers which perform a continual messenger service between the month and whatever may be touclied within the reach of such fingers. We have, for instance, a child suffering from diphtheria in school, not ill enough to attract special attention. He may be there for a day or two before the disease is discovered, with a mild, unrecognized case, or he may be there for a much longer time, in a condition for spreading the disease. During this time he may attach the infective matter to the desk, chair, books, slate, slate- pencil, lead-pencil, pen-holder, sponge, drinking cup, door- knob, door, window sill, banister, wainscotting, or to any- thing else which he may handle or touch after using his fingers about the mouth. The fact that these things may become infected with diphtheria in this way has been con- clusively shown in the laboratory by Professor Ernst. In kindergarten schools the danger of spreading the dis- ease by a single case is much greater, both by direct and indirect infection, because these children by virtue of the different processes of teaching are brought into much closer contact with each other, and they use a large number of ob- jects in common which are very liable to become infected. One unrecognized case under such circumstances may give rise to a dozen more, and without our being able to trace one of them to its particular source. The following account of a kindergarten teacher may be of interest at this point : " Regarding the contact of children Avith each other in kindergarten and the interchangeable use of material, it is 6 MEDICAL INSPECTION OF SCHOOLS. as follows : The chairs for seating the children are small portable ones. These are carried from one place to another as the classes need them ; no one chair is allotted to any particular child, all are used in common. The tables at which the children sit are long enough for four or five children to sit at each. It is impossible to arrange so that each child may have the same chair or the same place at the table regularly. The material used is such that it is almost im- possible to let one child use any portion of it solely as his. We have but two dozen worsted balls with which to teach color, form and direction ; and we have seventy children to use the ball. It is the same with everything else. The blocks used are handled by two or three classes during the same day. The iron rings, wooden sticks, wooden planes, paste-board tablets, wooden beads, w^eaving needles and worsted needles are all used in common. The napkins used at lunch time are washed once a week and taken out before then if really soiled, otherwise tliey are folded and returned to the drawer ready for the next day. The picture books are enjoyed by all and the dolls are used at every recess. In playing the games the children stand holding hands on the ring, and when there is good attendance they are crowded. Many of the games bring them very close together, for instance : In playing the 'Birds Nest' the mother bird chooses six or more children who kneel upon the floor in a semicircle, she twines their arms about each other to imitate weaving the nest. She then chooses three children who are put close together, necessarily, in the nest and then the game proceeds. This is a typical bird game and is very pretty, but in time of epidemic of throat diseases we do not like to play it in our kindergarten as it brings the heads so near each other. There are other games, of course, which do not need such close proximity as the one described, but all the games are for two or more children to take part in and they are generally in contact in some way if only holding hands." Xumerous instances have come under our observation where a child has been found in school suftering from an MEDICAL INSPECTION OF SCHOOLS. 7 infectious disease by the medical inspector of schools, and sent home ; this case has been followed in due time by- other cases in children whose only discoverable exposure was that which occurred in the school room. Fresh evi- dence of such exposure and of its effects has been brought to my attention within a few weeks occurring in the service of Dr. Arnold, one of our school inspectors. An epidemic of diphtheria occurred in a primary school in which there were forty pupils, fourteen of whom were at- tacked with diphtheria within a period of eighteen days, all from one room. Of the fourteen cases seven were discov- ered by the school inspector and three of these only by cul- tures. All suspicious cases were dismissed from school May 5th, and recommended to the care of their family phy- sicians. The next morning every pupil was examined and many cultures were taken. The class was then dismissed from Thursday to the following Monday, the room disin- fected and cleaned up. For ten days after their return the throat of every pupil was examined by the medical inspec- tor when they first assembled in the morning, and no pupil who had been absent with any suspicious symptoms was al- lowed to return until it was proved by a negative culture that there could be no danger. As a result of these meas- ures not a single case of diphtheria resulted beyond those known to have been infected at the time the epidemic was discovered. A similar experience with scarlet fever oc- curred in the service of the same school inspector within two weeks, in which eleven cases resulted from the presence in school of one pupil whose illness had been attributed to German measles. The following tables give the number of cases of diph- theria and scarlet fever reported in Boston, by months for nineteen years and twenty years respectively, and show that when the schools are in session the number of cases is much greater than during vacation time. 8 MEDICAL INSPECTION OF SCHOOLS. Cases of diphtheria reported each month for nineteen years : Years. Jan. Feb. Mar. Apr. May June July Aug. Sep. Oct. Nov. Dec. 1878 241 178 135 102 58 114 65 44 87 106 98 125 1879 155 111 82 108 87 111 53 37 53 100 132 146 1880 167 141 112 101 143 126 100 74 105 150 238 258 1881 179 163 190 140 142 143 108 85 103 162 135 130 1882 136 117 99 92 103 111 56 56 54 119 188 244 1883 170 132 100 98 140 94 64 72 88 126 150 175 1884 130 90 87 81 111 95 50 61 77 130 137 163 1885 164 117 108 109 101 108 85 54 64 123 119 111 1886 122 104 110 66 73 94 75 78 85 130 111 140 1887 128 93 96 101 75 68 53 40 53 112 100 130 1888 112 80 105 107 142 110 97 92 95 143 156 172 1889 179 150 193 205 190 165 93 99 99 137 130 174 1890 203 189 156 164 144 114 73 69 75 96 75 117 1891 80 71 59 71 81 49 31 36 40 78 180 127 1892 102 108 114 135 107 77 76 78 79 144 185 175 1893 152 114 116 70 86 111 88 102 89 194 160 183 1894 195 128 185 139 187 167 138 154 249 450 558 469 1895 343 296 205 185 225 328 268 278 345 415 635 564 1896 381 403 302 304 346 352 300 256 296 461 498 466 Total, 3339 2794 2554 2378 2541 2537 1873 1765 2136 3376 3913 4059 Cases of scarlet fever reported each month for the last twenty years : Tears. Jan. Feb. Mar. Apr. May June July Aug. Sep. Oct. Nov. Dec. 1877 262 227 181 176 117 67 28 25 16 61 70 104 1878 161 99 73 48 35 47 25 36 43 67 94 119 1879 131 108 190 93 82 32 27 47 55 57 65 63 1880 60 36 47 29 32 35 19 10 29 44 89 67 1881 58 28 52 51 41 44 17 11 17 16 19 29 1882 65 41 49 36 70 61 26 41 37 48 102 104 1883 123 82 83 104 101 103 65 89 85 214 168 195 1884 209 186 197 239 215 173 214 209 175 242 224 242 1885 232 131 182 159 160 135 85 56 87 153 148 137 1886 155 126 144 151 115 99 56 52 43 58 82 68 1887 97 76 101 102 98 62 29 51 142 207 320 268 1888 146 119 100 75 70 20 19 11 16 52 29 40 1889 48 29 77 59 53 34 15 15 17 32 36 49 1890 98 103 105 122 118 74 72 30 20 30 40 112 1891 109 95 108 151 159 97 49 40 56 67 136 260 1892 290 291 447 335 370 217 124 86 100 183 226 269 1893 282 190 228 245 203 144 144 140 179 304 283 238 1894 214 169 168 199 266 205 109 135 125 182 192 278 1895 231 174 184 139 137 123 94 82 91 127 120 113 1896 136 99 104 108 77 113 72 42 53 81 157 176 Total, 3107 2409 2820 2621 2519 1885 1289 1208 1386 2228 2600 2931 MEDICAL INSPECTION OF SCHOOLS. 9 It will be seen by an examination of the table for diph- theria that the average number of cases reported for each of the eight school months is 2,772, and for the four months of little or no school it is 2,077. In the table for scarlet fever it will be found that the average number of cases re- ported for each of the eight school months is 2,779, and for the four summer months it is but 1,191. We do not claim that the closing of the schools is the only cause for the largely diminished amount of scarlet fever and diphtheria, but we believe that it is one of the important factors. Owing to the evident spread of scarlet fever and diphtheria in the schools, we recommended, in 1882, that the school-houses be thoroughly disinfected once in two weeks. This proposition was rejected, however, on the grounds that it would cost from $5,000 to $6,000, would be a hardship to the janitors, and that it might not effectually prevent the spread of the disease. From time to time since that date we have recommended to the School Board the need of frequently cleaning and disinfecting such parts of the interior of school buildings as might become infected, and that the use of many objects in common use among the children and Avhich might easily become sources of infection, be discontinued. A few of these recommendations have been adopted. In 1890 the Board of Health proposed to furnish the schools with daily medical inspection with a view to discovering the earliest symptoms of infectious diseases among the children, by examining all cases of children sick or complaining from any cause in the schools, and giving to the teachers such professional advice as is constantly needed for the disposi- tion of such children. After four years of unsuccessful ef- orts the Board succeeded, under the influence of a severe epidemic of diphtheria, and began the work November 1st, 1894. The Board of Health divided the city into fifty districts. 10 MEDICAL INSPECTION OF SCHOOLS. giving an average of about four school-houses and fourteen hundred pupils to each district. No difficulty was experi- enced in finding Avell qualified and discreet physicians who would undertake the duties prescribed ; and the Board se- lected and appointed one physician for each district with a salary of $200 a year. His duty is to make a visit to each master's school daily, soon after the beginning of the morn- ing session. The master receives from each of the teachers in his district early reports as to the appearance of illness in any pupil in his charge. These reports are given to the visiting physician, who at once examines the reported children and makes a record of his diagnosis and action in books furnished by the Board of Health for this purpose and kept in the custody of the master. If the visiting phy- sician finds the child too ill, from any cause, to remain in school, he advises the teacher to send the child home for the observation and care of its parents and family physician. If the illness is from a contagious disease the child is or- dered home and the case reported to the Board of Health. The disposition of the sick child while at home, and the proper isolation in cases where contagious diseases develop in such children, as well as giving them a warrant for re- turning to school, depends principally upon the report of the school inspector. In the examination of the children in school every facility is extended to the doctor by the teachers, and he in turn reaches a satisfactory conclusion with the least possible de- lay or annoyance to any one. There being frequent need for looking into the children's throats, we provided the inspec- tors with something for a tongue depressor which could be used once and destroyed, and thus get rid of the danger of communicating any disease from one pupil to another, and avoid unfavorable criticism on that score. I have some of them here to show you. These little pieces of clean pine ai-e made for us at a cost of one-tenth of a cent each. MEDICAL INSPECTION OF SCHOOLS. H They are without objection in use or appearance, and will burn as easily as a match, which is the intended destiny of each after being used once. The thermometer is rarely a necessity in these examinations, and when used is treated with due care. The school inspectors do not give professional treatment in any case. They merely point out the need of profes- sional treatment where the need exists. The treatment it- self must be received from the family physician, or in the hospitals, or in the dispensaries, and great care is necessary to avoid giving offence to physicians and their families. It should be remembered that the Boards of Health of this State are authorized and required by statute law, to take charge of any case of contagious or infectious disease which may be dangerous to the public health ; and while it is preferred that many cases should remain at home and be cared for by the family and the family physician, their isolation at home must be satisfactory to the Board of Health, and so certified by a medical agent of the Board. So also in the discharge of such patients from isolation, the evidence of their freedom from the disease, and the safety of their return to school or to the public, must be satisfactory to the Board of Health and come from its medical agent. For this duty the same medical inspectors are serving as agents of the Board of Health in the control of infectious diseases which are treated at home. We send to each of the school inspectors every morning a bulletin of the cases of diph- theria and scarlet fever which have been reported during the previous twenty-four hours. Each medical officer selects the cases reported in his district, visits them to see if they are properly isolated, leaves a card for the attending phy- sician informing him of the official visit, and reports his approval or disapproval of the patient's isolation at once to the Board of Health. If the patient is properly isolated the inspector places a card on the door of the room to indi- 12 MEDICAL INSPECTION OF SCHOOLS. cate the official designation of the room for the isolation of the patient. If the case is not properly isolated, and it can- not be commanded at home, he reports the fact to the Board of Health, and such patient is taken to the hospital. He makes another visit to the patient on the question of dis- charge from isolation, and again reports to the Board of Health. If it is a case of diphtheria a negative report from the laboratory to the Board of Health is necessary, and if it is a case of scarlet fever desquamation must have ceased, and the fact certified by the agent before such patient can laAvfully be released from isolation. The agent of the Board is thus held responsible for the proper isolation of the patient at home, for recommending the patient's re- moval to the hospital when necessary, and for the patient's release from isolation. In other words, the Board of Health is provided with trustworthy information upon which it can act for the best protection of the schools and the pub- lic against the spread of infectious diseases. This corps of inspectors has become an organized asso- ciation, which meets once in two months, to discuss the manifold medical questions which arise in the performance of their duties. The whole number of children examined in 1896, and found to be ill, was 8,964. The diseases of which the children were suffering were classified as follows : Specific Infectious Diseases, 267 Oral and Respiratory Diseases, 3,934 Ear Diseases, QQ Eye Diseases, 382 Skin Diseases, 628 Miscellaneous Diseases, 3,687 Those who were found to be suffering from infectious diseases were, as a rule, unaAvare of the fact, owing to the early stage of the disease or to the mildness of the attack. Occasionallv one is found who has been prematurely re- MEDICAL INSPECTION OF SCHOOLS. 13 leased from care. All, however, were in a condition to spread the disease from which they were suffering. There are about 85,000 pupils and over 1,500 teachers in the public schools, and about 13,000 pupils in the paro- chial schools of Boston which furnishes a wide field and the best opportunity for the exercise of professional observation and sanitary precautions against the diseases of childhood incident to school attendance. This work has now been in successful operation in Boston for two years and seven months, has constantly grown in favor in the medical pro- fession, among the school teachers and in the community at large. There is every reason to suppose that under the in- fluence of this daily medical attention every teacher will become more interested and expert in the outlook for and detection of any existing illness amongst the children under his or her care. Every parent may feel that his child is less exposed to disease while in school, and less likely to be ill without immediate attention from teacher or physician than was formerly the case. This is the first work of its kind performed in this country, and, so far as I am able to learn, in the world. The nearest approach to it is done in Brussels where, under the control of the Bureau of Hygiene, school doctors are employed, and to whom the pupils are sent when suspected of being ill with infectious diseases. Our work has been recently copied in many places in this country, including the city of New York, where it has been employed for the last three months with complete satisfaction. I am satisfied that it would be hard to find a field for medical inspection and supervision which presents equal facilities for the early detection of diseases, or which offers more satisfactory results. LIBRARY OF CONGRESS 020 313 748 5 LIBRARY OF CONGRESS 020 313 748 5