A^ A = n = u = =^^ -^ = ^^^ ■ / = __^ Lj 1 — — j> 4 — "■ y = 4 = j> b = S^^ I — ^^ ^^_ ^ 7 ctiital OiDffitcrs of $^cboals Association The Need, Objects, and Method of the ^ Medical Inspection of Primary Schools 15Y RALPH H. CROWLEY, M.D., M.R.C.P., Hoiiovayv Physician, Bradjovd Royal Jufiniinry ; Mcdicul Supcviukvdiut, Bntdfovd Education Committee. i 1 A PAPER READ BEFORE THE MEDICAL OFFICERS OF SCHOOLS ASSOCIATION, DECEMBER 13th, I'JOG. ISMIllJ liV THE MEDICAL OFFICERS OF SCHOOLS ASSOCIATION LONDON J. & A. CHURCHILL 7, GREAT MARLBOROrOH STRRF.T 1907 Entetid .;/] [5/,!//' .■< U ^ 1 rus DooK IS UUE, on the last aate stampea Deiow MAR 5 ^^^^ APR 9 19^^ Southern Branch of the University of California Los Angeles Form L I LB 5413 Mrticil (^'Ifficf r«- on The Need, Objects, and Method of the Medical Inspection of Primary Schools BY RALPH H. CROWLEY, M.D., M.R.C.P., Honorary Plnsiciaii. Bnidford Royal liifii inary ; Medical Siifrriidciniciil, Bradford Ediiiatioii Coiiniiittcc. A PAPER READ BEFORE THE MEDICAL OFFICERS OF SCHOOLS ASSOCIATION, DECEMBER 13th, IHOG. issric n BY THE MEDICAL OFFICERS OF SCHOOLS ASSOCIATION LONDON J. & A. CHURCHILL 7, GKliAT MARLBOROUGH i^TREET 11)07 EiUertd «/] [Sialwncrs' Hull AR m 3U th sib Lo! 'o r^ THE NEED. OBJECTS, AND METHOD OE THE MEDICAL INSPECTION OF PRIMAKY SCHOOLS. /S76/ Sir Thomas Barlow, Ladies, and Gentlemen, ^ "i I feel it a considerable honour to have been asked to open a discussion on this subject at a meeting of our Society. It seems to me peculiarly fitting tliat a Society which has done so mucli in tlie pa^t in tlie matter of school hygiene in so many of our great residential schools should, ripe with so much exj)ericnce, turn its attention to the same question as it affects our elementary schools. This twentieth centviry has opened with vistas of pos- sibilities in very many directions ; some of us wonder whether there is any direction along wliich the future will show that these possibilities were more pregnant with meaning than in that direction which is indicated in the phrase " the medical inspection of schools." To many who may not perhaps have had occasion to give ])articular attention to the subject, it may not seem to involve very much — it may be a drain put light here, a child examined for defective vision there, or perhaps an epidemic of some infectious disease incpiired into and action taken. To those of us, on the other hand, who are actively engaged in the work, the possibilities, direct and indirect, arising as necessary corollaries of medical inspection, seem almost endless. It v\ ill be found that, apart from imme- diate benefit in a variety of ways to individual cliildren, it v,i\\ form the foundation of new thought with regard to our ideas of education, proving an important factor in leading to the abolition of the A\atertight-compartment theory at present so general, and that it will ]ioint vvith irresistible force to the conditions under which our cliildren live, and will in this way unquestionably have an important bearing on the solution of some of our urgent social problems. But I find that I have pre-supposed that the need is admitted, and, indeed, I cannot think it possible that there can be anv in an audience of this kind who are not convinced 4 THE NF,i;n, oi'.jects, and method of ttte that such is the case. It is curious, tliougli. how slow we, even medical men, liave been to reahsc it. P]videncc on the matter has, however, rume as an avalanche during the past few years, and anyone who is not already convinced from jiractical experience of the condition of our schools and of our children has a mass of facts now at hand frojn Mhich there is no getting a\\ay. Whether the question be considered fiom the point of view of the school buildings, including the problems of ven- tilation, lighting, and all the otliei' factors making up the child's environment dui'ing school hours, oi- fi-om that of the child itself, its ])hysical (•ai)ability of ])rotiting from the ediica- tion it is forced to submit to, or from that of the dangers from infectious disease to which it is ex])osed, oi' from that of the school (uu'iiculum and the necessity of ensuring that a sense of proportion is kept and that educati(»ii should pi-oceed on sound physiological lines — from any and all of these jioints of view it must be granted that there* is a need, and a great and pressing need, for medical inspection. But if this admits of no question, the same cannot be said of that of how to carry it into effect. Around this ques- tion, alike abioad as in Great Britain, has waged, and is waging, a good deal of controversy. Much of this arises from the fact, common to so many other controversies, that we may all be presumably talking about the same thing — in this ( as.\ medical inspection — yet as a mattei- of fact what that implies varies very greatly in ditferent ])eoj)le\s minds, and it would therefore seem very necessary to endeavour to come to some common agreement in considerable detail as to wliat are the objects to keep in view, foi' in no other way can we hope to arrive at the be-st methods to adopt for obtaining these objects. It is, for instance, obvious that if by medical insp(>ction we mean, say, reports on the buildings, witti, perhaps, an aimual report on the eyesight thrown in, the method adopted w ill be a very different one from that necessary if we take it to include a daily visiting of the schools with th(> avowed object of preventing the spread of infectious disease. And, further, if we succeed in agreeing on what objects we think should be aimed at, it will l)e found that the method will necessarily vary according to whether we are dealing with a county area, a big city, or a smaller borough. What, then, are the duties which may b(* considei-ed as advisable, ignoring for the time the (piestion of expense, for the education medical officer to carry out '! They may bo MEDICAL INSPECTION OF PEIMAKY SCHOOLS. O classified under the following ten headinos, proeec^ding, s|)eak- ing generally, from those involving le-;s to tluise involving more detail. (1) To act as general adviser to the Kdueation Com- mittee in all matters relating to the hygiene of the school and scholar. (2) To carry out a sanitary inspection of the school building, including in this the important problems of ven- tilation, heating, lighting, seating, cloak-room accommoda- tion, and other details. (3) To pay attention to the spread of infectious disease, and to advise re the exclusion of particular scholars or school closure. (4) To separate out special classes of children, e.g.. the blind, deaf, cripple, mentally defective, and epileptic. (5) To make aperiodic — say, quarterly — inspection cf the school and scholars, the latter to be examined from the point of viev\^ of any defects v\-hich may prevent the child from bene- fiting from the instruction given, and also in order to ascertain any condition of ill-health or malnutrition v/hich may obtain. (6) To examine certain children alleged to be absent from school on the score of illness. (7) To medically examine members of the teaching staff as occasion may arise, and to give instruction to the teachers on school hygiene. (8) To make any special investigations and inquiries v.'hich may suggest themselves. (9) To examine each child on its first admission to school and to record certain data, such examination to be repeated at an interval of, at most, three years, and as often as may seem expedient should any defect have been found. (10) To pay a visit to each school daily v.ith the avowed object in viev,* of keeping a sufiiciently close eye on the children in order to prevent the spreading of infectious disease. Given these as desirable objects (omitting the last for the time being) to be aimed at in medical inspection, hov\- can they! best be carried out ? The first obvious condition, necessitating, I think, no discussion, is that there should be a medical adviser to the Board of Education, v.ho should direct, co-ordinate and stimu- late. Next, we may clear the ground by stating one important principle which should be univei-sally applied, viz., that every education authority, be it a county, city, or borough authority, A 2t 6 THE NEED, OBJECTS, AND METHOD OF THE should have a medical adviser. This appears to me a sine qua non,\\\\&,te\ev further arrangements such authority may make for carrying out the more detailed duties. This proposition affirms the very important principle that all ANork done in connection with school inspection, he it of the schools themselves or of the children, should be at the instigation of and under the control of the Educa- tion Committee. Perhaps there is nothing of more impor- tance as regards our educational system at the present time than that the Education Committee should take an all- round view of its work and should come clearly to recognise that these matters are as closely connected A\ith the educa- tion of the children as is the intellectual work which is looked upon as its special province. Coming nov,' to the question as to upon v.hom this duty should fail, 1 believe we may deduce an obvious corollary from Avhat I have already said, viz., that the education authority of each of the larger county areas and of each of the larger cities and boroughs should retain its own Education Medical Officer exclusively for school purposes. In these areas, at any rate, it would not be possible for the v.'ork to be adequately done by any existing Health Officer. In v.liat one feels to be unansv\crable confirmation of the opinion stated above, I would refer you, so far as the counties are concerned, to the most interesting report of Dr. T. Heurv Jones to the Surrey Education Committee, published in full in the B.M.J, for February 17, 1906. The experience of Manchester, NcAvcastle, Bradford, and elsewhere confirms the opinion expressed in regard to the larger cities and boroughs. In the smaller county areas, or in towns of a less popu- lation than, say, 100,000 or 150,000, two courses are open, the work being undertaken either by the Medical Officer of Health or by a specially appointed medical officer, not necessarily, of course, a v\hole-time one. The one arrange- ment which is not permissible is that the work should be doiie by a man who merely ranks as an assistant to the Medical Officer of Health. I do not think that any law need necessar- ily be laid down on the question as to which of the above alternatives should be adopted. Probably one locality will favour one plan, and another another. Local considerations must inevitably play an important part ; the existing Medical Officer of Health, for instance, may have his hands as full as he wishes, or he may not be cut out for work of this kind. One thing, however, is obvious — that, whoever does the work, there w'xW have to be a harmonious \^'orking between the Public MEDICAL INSPECTION OF PEIMARY SCHOOLS. 7 Healtli Officer and the Education Medical Officer. Wliere the work is undertaken by the Medical Officer of Health, k^t me,lio\v- ever, reiterate the principle already laid down, viz., tliat it should be in all its branches under the jBgis of the Education Committee. The system above sketched is, I submit, the minimum possible. It arranges for the carrying out of, at any rate, the first eight out of the ten duties already enumerated, and this by responsible officers, none of the work being rele- gated to assistants exceptiag in the case of large county areas and of a fevr of the largest cities, where assistants would be required to enable even tliese first eight duties to be carried out. It is a minimum v\hich involves no great expense — an expense, indeed, almost negligible, even allowing for adequate payment for the Avork done, v\'hen compared with the huge sums already spent on compulsory education. I pass nov\' to the question of greater detail in medical inspection — hov/ far it seems advisable, and if advisable, in v>-liat vv^ay it can best be carried out. The chief question around whicli this centres is, ' ' Is there to be a daily medical inspection of the schools ? " This procedure is warmly advocated by some, and the case for it is fully put in a leading article in the B.M.J, for February 17, 1906. It is advocated almost solely on the strength of its being the only possible v\-ay in which the spread of infectious disease through a school can be prevented, and it is claimed that not only would this be of great benefit to the children, but that, so far as the local authority is concerned, any expense entailed would be largely, if not entirely, met by increased grant due to better attendance. I am not myself clear that it is proven that by this daily medical inspection a great difference would be made qua the incidence of infectious disease. All that is required can be done as regards, for example, scarlet fever and diph- theria, by paying special attention to the school as occasion arises, the influence of the school in spreading the disease, by the bye, being as generally over-estimated in the case of the first disease mentioned as it is under-estimated in the case of the second. The question really largely resolves itself into that of whether measles — which is, of course, the disease which plays the greatest havoc in school attendance — could be controlled. Considering hou extremely infectious the complaint is even during its very earliest stages, how easy it would be even for a medical man to ])ass over a case at the earliest stage among a large number of poor and snuffling hifants, 8 THE NKED, OBJECTS, AND METHOD OF THE especially wlien there is nothing to warn one when tlie first,, the most important, case is abcut to occur, and how insuper- able vvould be the ditiiculties of preventing such an infectious cliild from actually mixing and sitting in class before being singled out, it seems very open to doubt whether a great deal could be accomplished in this direction as a result of daily inspection. Still, it may be conceded that, at any rate, some advantage might be gamed and that, associated with, as a necessary corollary, the closing of the class, for the requisite time immediately on discovery of this first case, the age at which measles would be contracted could be possibly advanced. Daily inspection on this score vvould anyliow only be necessary in the Infants' departments, and routine daily inspection on any other ground than this does not seem to me either necessary or commendable. Were, however, such a method adopted the duty would obviously fall on a general practitioner in the neighbourhood. We now come to the suggested duty involving .the examination of every child on its first admission into school, together with arrangements for periodic re-examination at intervals of, at the most, three years. I feel that such a I'ecord made v.ith the parent present, stating the usual clerical particulars, the infectious diseases from which the child had suffered, the physical condition of the child, the weight and the height ancl the result of a physical examination, would be of the greatest value. Such a record would follow the child through its school life, and would be sent oji, on application, to any other school to which the child might remove. Such recording would, of course, involve a large amount of labour. Take, for instance, a county area or a city with say 50,000 school children. This would mean, as a rough estimate, tliat there would be some 6,000 fresh admissions each year, and were the exaininations spread over the whole year, it would mean approximately the examination of some 30 chil- dren daily. Work of this kind would be very monotonous if a large number of examinations had to be made by one man continually day after daj^, and it would I believe best be done by men in general practice, the number appointed de- pending largely on how scattered were the schools. It should not be more than necessary; probably in a city each man might well have an average of half a dozen a day, though no doubt in practice the examinations would be done in batches. Thus in the case supposed, where the population of the city was from 250,000 to 300,000, some half-dozen practitioners might well be appointed to carry out the work. MEDICAL INSPECTION OF PRIMAllY SCHOOLS. 9 Finally, as regards methods, there is tlie question of the appointment of specialists to do certain work. To this ques- tion I shall briefly refer later, suffice here to say that the appointment of specialists, e.g., ocuHsts, aurists and dentists, is not necessary qua inspection ; any medical man can detect the cases needing attention ; it is only when the question of treatment comes in that the question of specialists arises. Having now perhaps sufficiently covered the ground as to what should be done, it would be as w^ell to briefly point out what is actual^ being done in this country. Abroad, speaking generally, the importance of school hygiene in all its branches is much more fully recognised than here. It is really surprising how little we have done. Taking the Rej^ort of the Inter-departmental Committee on Medical Inspection and Feeding of Children attending PubUc Elemen- tary Schools, it will be seen that tliere were, at the time that that report was drawn up, viz., during 1905, only two Count}^ Councils out of 48 which had approved of any kind of organ- ised scheme of medical inspection. In the county boroughs, arrangements of a more or less sj^stematic kind had been made in 27 out of 71, while in the boroughs and urban districts there were only respectively 14 out of 136 and 12 out of 56 authorities where action had been taken. I now i^ass on to allude briefly to an important but difficult aspect of the subject, one which to most people has not presented itself, since it only comes home in places where systematic medical inspection has been for some time in force. Medical inspection is obviously but a means to an end. It is something, undoubtedly, to know facts ; but still, if the responsibility of the community were to stop at the fact of mere inspection, it would seem doubtful whether the pro- cess would be worth the carrjang out. It is not enough to know that such and such a percentage of children have defective eyesight or hearing, or other physical defect, or are dirty or are too underfed or physically unfit to benefit from tlie instruction given ; but the question will arise at once, " Howcan these condi- tions be remedied ? " And the same question will arise in regard to the hopelessly unsatisfactory conditions so often surround- ing the child during the time it spends at school, the over- , crowding, bad ventilation, fighting and seating. Tiiese latter, •' however, are a question of expense only, and do not involve, as the former considerations do, that of the relative respon- sibifity of the parent and the Education Authority. I know from experience how much of the work entailed in medical inspection is wasted, either through the indift'er- ence of the parent or through financial inabifity to do what is 10 THE NEED, OBJECTS, AND METHOD OF THE required, e.g., \n tlie case of getting the cliild spectacles. Tlieii, too, in the case of the undcifed, there are few more pitiable sights than the ill-nutritioned children in our schools, and the picking of these out has so far been of little avail, though it seems that more definite action is likely to be taken with regard to such children in the near future. This is not the occasion upon which to discuss the responsibility of the parent for seeing that these defects, which hamper a child through school life, are remedied ; the point however upon whi(^h one feels clear is that it will not pay the State, to put it on no other ground, to allow parental neglect to stand in the way of the child's education, using the word in its fullest meaning. The opening up of all these difficult questions makes one realise, as I suggested at the commencement of this paper, how many-sided and deep-rooted is this question of medical inspection. It is not merely an individual child here and an- other there which is concerned, for the children are the nation of to-morrow ; and it is the utmost folly, and I would even say wickedness, for the nation of to-day to neglect them, and even to injure them, as it has done and is doing. Medical inspec- tion will usher in the dawn of a brighter day ; it will aid in giving us a more true idea of what education means for these children of our elementary schools ; that it is not to be looked upon as, in the main, a mere commercial asset, but as the means of the development of a complete life. In conclusion, I cannot leave the subject of medical inspection without reference to the important part which the teacher will have to play. Indeed, our hope is in him and in her. The success and the advantages to be gained will be in proportion to the harmonious working together of doctor and teacher. The former, to be really helpful, will have much to learn at the hands of the latter, while the teacher must, from his earliest days onwards, be carefully trained in all matters relating to the hygiene of the school and of the scholar. There is no happier augury for this coming century than this close association betvveen the doctor and the teacher. The Peesident said that no politics were known in this Association, but that he Avas sure everyone v.as anxious, in connection vvitli the Education Bill noAv before the tv/o Houses of Parliament, that the religious difficulty should be got out of the way, cs])ecially for the sake of one addition which had been made to the Bill, namely, the introduction of official medical inspection of primary schools. He did not MEDICAL INSPECTION OF PBIMABY SCHOOLS. 11 think he v.ould be going beyond the mark in saying that that was one of the most momentous changes, in its bearing on the health of this country and the physical development of our children, that liad been decided upon for many generations. It was a most difficult subject, and politicians were very much at sea as to the extent to ^vhich this medical inspection should be carried. Members of the County Councils of the country were very anxious indeed on the subject of the expense. The funds at their disposal for educational purposes were limited, and they maintained that the needs of the country districts in regard to medical inspection v\'ere not so great as those of the urban districts, and they Avere very anxious that they should not be committed to a very large ex]3enditure. The Council of the Association thought that this was a subject on vrhich, v.ithout prejudice, and in a perfectly open-minded Avay, this Society could express its vievvs. And it v\as unani- mously agreed that Dr. Crov/ley, who had had considerable practical experience in one of the largest Nortliern manufac- turing tov.ns, should introduce the subject this afternoon. Dr. Kerb said that someone else who had acc^uaintance v.ith some other branch of the subject might have extended Dr. Crowley's remarks a little further, so tliat the v.hole question could have been set out before discussion. Hov.ever, when the State made compulsory education a requirement, as far as the elementary schools v.ere concerned, then, of course, medical inspection almost followed as a necessity ; because, especially in England, v.here there vvere such very different social grades, w^here some grades vvere almost threatening danger to others, if children v.ere to be comjielled to go to school, the authority which compelled the school attendance should also guarantee that the school attendance should not be harmful. For that reason it vvas necessary to make the schools safe, both in the buildings, in the sanitation, in the children attending, and in the work which was done there. In the elementary scliools one of the first things that was required was to ensure that the children should be clean, free from disease. That elementary idea tlie teachers ought to be able to carry out themselves. Still, experience had shown that neither teachers nor Government inspectors paid much attention to cleanliness until the doctor and nurse began to go into the school. And in very many schools, even to-day. prolaably 50 per cent, of the children Avere verminous. The question of infectious diseases only forces itself into notice through the action of the MedicarOflficer of Health. That question is important in this way : tliat people seem to tliink the chief 12 THE NEED, OBJECTS, AND METHOD OF THE l)art of the work of the school doetof .sliould be the deahng with those infectious diseases. But this forms a very minor part of such work. The v.hole of that particular work might be taken away from him and put somewhere else, without tlie slightest trouble or detriment either to the school or the lesults. Some of these diseases can be controlled, others seem to be beyond control. Daily visits of the doctor would be of very little use in preventing infectious diseases. In one disease, diphtheria, so prevalent in London, a daily visit of the doctor would do something to prevent. But as much can be done without daily visits by simply visiting at tlie point where the disease is threaten- ing, and taking ])recautions. Fortunately, bacteriological means give almost complete control over that disease. Then there was scarlatina, which cropped up from time to time. Much could be done to control it. But it was extraordinary how little was known about that disease and its dissemination. They had been trying in London to do something with it lately, but it was difficult to devote the time and attention necessary to follow up the scattered facts Avhicli make up its history. Probably about 80 per cent, of the population always escapes scarlatina, and may be said to be immune to it. So any effects which exist are very diluted, and it cannot be said that schools have very much to do with its dissemina- tion. Measles v.as quite a different matter, and the daily visit of a doctor or of half a dozen doctors would not make much difference where a child with measles gets into a school where the majority of the children have not had it. The prevention of infectious disease becomes a matter of impor- tance, especially Adhere a large section of the population is neglectful of its children. Most extraordinarily neglectful some of them are. Some of them could not tell when their children were born. Only that day a mother had not been able to tell him the ages of her three children, nor the month the last was born ; she could only tell him that she expected another in March. People subject to disease and dirt, who neglect their children, are an ever-present danger to other people, ' and the State or authority should step in and do something, both for the sake of the children and for other people. For th(^ sake of the children, because every child born has the right during its helpless time to be protected and looked after by somebody. It was Avell to take the history of the child as soon as possible after it came into school. That would have to be done by making out a personal health card, as is done in some German States, and following up the child. It is doubtful whether we have at present the MEDICAL INSPECTION' OF PIUMAKY SCHOOLS. 13 means of doing that as fully as it ought to be done, but no doubt it VN'ould come in time. Tlie examinations of the chil- dren took a great deal of time, though many things could be found out about them and many things remedied v.hich are not remedied. Unless somebody apart from the parents follov.s up these children nothing is likely to be done. When the defects are found and nothing is done by the parents, is the State to step in and do something ? They are sometimes, by the aid of managers, teachers, and people interested, got to hospitals. They are seen there once or oftener, and perhaps the doctor spends some time over them, and still the parents refuse to have anything done. There is this great difficulty, Avhich will have to come up for solution, that a large number of children are now being detected requiring treatment in some form, and this treatment, if it is to be done, will have to be undertaken by the authorities before long. It is all quite beyond Acts of Parliament at present, but these would have to be modified also. It meant a great deal more than appears at first sight, because all the hospitals in London together could not do the amount of satisfactory treatment which is wanted for the children of London schools. Hospitals, even large hospitals, say they can only treat so many children, half a dozen or so per day, v.hereas they would have to treat hundreds to deal vvith the subject as is required. Coming nov.- to the children who are comparatively healthy, the whole curriculum wanted looking into from the medical or the child's developmental point of view, and the tasks required to be suited to the capacity of the pupils. The child at one age can learn to do well and delightedly one thing, but cannot learn to do something else ; and the small boy who is set to do Latin grammar Avhen he wants to be using his hands, suffers. He had no doubt the classical learn- ing imparted in most of our secondary schools had a deterio- rating and cramping effect on the brains of the children sub- mitted to it. Fortunately, he personally v.as not submitted to it, because he could not learn and so escaped. But he daily saw its evil effects upon others. Not to dv>ell too long on the primary schools, v.e had, as far as the national interests were concerned, to consider that period also betv.een the age of leaving school and the age of responsible employment. Something there ought to be done. Nothing, or very httle, is being done at present ; and for v\ant of more attention children are getting into habits of life v.hich are detrimental afterwards. js--^ In the higher and secondary schools tov.-ards v.'hich education is tending, medical inspection will be required, 14 THE NEED, OBJECTS, AND METHOD OF THE of a very particular and exact nature. So far as we liave gone at present tliei'e is no doubt that in the secondary schools over-pressure begins to come in. The child forces itself to work inefficiently, and drives itself when its brain can neither think nor take in A^hat it is deahng v\ith, v.hen it is making impiessions which do not last. In the case of girls especially tiiis is very harmful to their general health. It is found constantly in secondary schools v^hich are being insjiected, and also among pupil teachers. In that way medical inspection will play a great part in the future, in the detailed control of the individuals v.ho are undergoing higher education from fourteen upwards. Another aspect in which medical inspection would do much good is in rela- tion Viith the teachers themselves. Hitherto, in many cases, especially in elementary schools, teachers have had to get up a certain amount of knov.ledge in a short time. They have been kept at it hour after hour, so that there has been no time to think and properly digest the mental ]iabulum put before them ; and on the day they get their certificate many of them seem to have finished Avith mental vvork as students for the rest of their lives. And these people afterv/ards go through the routine, almost senseless, uninteresting routine, v.hich becomes mere constant repetition ; and many of them break dov.n often in comparatively early middle life. The most common cause of this is the neurasthenic condition, v.hich is most troublesome and lasting. He thought if interest in their v. ork v.as developed, as it v.ould be by medical inspec- tion of the children and schools, and they v/ere to use their brains in a more general v.ay, and v^'ere to examine the chil- dren and treat them as individuals instead of en bloc, the v.hoie interest of the teaching life A-.ould be increased, and the enormous amount of nervous ill-health v.ould be dimin- ished. This medical inspection v.ould result, both to teachers and children, in the diminution of pressure all through school dsiya, and v.ould be exceedingly useful in enabling the chil- dren to attain their natural possibilities. Dk. Richards v.ished to thank Dr. Crowley for his inter- esting paper, but v\as obliged to dissent from some of his con- clusions. He did so because for many years past he had been of opinion that the work of the Medical Officer of the Educa- tion Authority should be co-ordinated with that of the Medical Officer of Health. Tlie organisation of medical inspe(>tion should be considered apart from the ]iractice of medical inspection. All those who. like himself, had held the dual position of Medical Officer of Health and Adviser to the MEDICAL INSPECTION OF PRIMARY SCHOOLS. 15 Educational Authority, would agree that the organisation of school work must be in tlie hands of the Medieval Officer of Health. As to v.ho should carry out medical inspection he had an open mind, and he thought, v.ith Dr. Growley, the practice must differ in different districts. Dr. CVowley referred to the paper of Dr. Henry Jones, of the Surrey County Council. A fev\' v.eeks ago Dr. Richards had some conversation vvith Dr. Henry Jones, vvlio generally agreed with him on this point, and confessed that the absence of co-ordination added to the difficulties of the Education Committee's Medical Adviser. Most of the members of this Society had to do vrith second- ary schools, and they might need reminding that the problems in elementaiy schools are entirely different. If the Medical Officer to a secondary school finds that a child is suffering from illness, it simply needs a note to the parent to have it put right. But in elementary schools the ill-liealth of the children depends largelj- on the insanitary conditions vuider which they live. He vvould mention a case in point that occurred cluring the last fev,- days. A child found to be ver- minous vv'as excluded from school, and an inspector was sent to inspect the house. He found that the bedding and the whole clothing of the famity required disinfection. If there were a separate School Medical Department sending their Officer to the house, and a separate Health Department send- ing their Officer to disinfect the premises, thei'c vrould be much v.aste of time, possible friction between tlie departments, and resentment by the public of the intrusion of so many officials. It frequently happened that the cases urgently needing attention in elementary schools could not be put right on account of poverty. Only yesterday he had had the case of a child v.ith incontinence of urine, who had been sent to school day after day in an offensive condition. On visiting the house it v.as found this partly arose from the fact that the mother v.as a widov.', out at work from six in the morning to six in the evening, and she did not know in what condition the child v.ent to school. In case after case it is found that school inspection necessitated domiciliary visits ; and if we are going to have another set of inspectors doing this work, v.e shall be unnecessarily duplicating the staff and arousing pubhc resentnu^it. Dr. Crowley had found, even in Braclford, v.here he had nothing to do vrith the Health Department, he would need medical assistance if the v.ork v.ere to be done as thoroughly as he v.ould like. Why should not that assistance be organised as part of a common Public 16 THE NEED, OBJECTS, AND METHOD OF THE Health service, in which the Avork of the Education Medical Officer and nf tlie ^Medical Officer of Health v>culd be fused ? A\'itli regard to daily visits he was in general agreement with Avhat Dr. Crowley and Dr. Kerr had said. He A\ished to emphasise the fact that there is a large amount of gross A\'ork to be done in schools. Dr. Kerr said that about half the children are verminous, and that applied all over the country. Rather more than half v\-ere verminous in Croydon, and until these grosser conditions had been remedied lie thought a lot of tlie more special work to Avhich reference had been made could be postponed. With regard to treatment he was in agreement Avith the statement that Avhen medical inspection is once undertaken on a largo scale we are bound to go in for treatment. They had found it so in Croydon already. At the beginning of this 3'ear they found nearly 200 children excluded from school because they Avere suffering from ringAvorm, and the local autliority liad authorised liim to organise the treatment of this disease, and had alread}^ secured most encouraging results. It had been stated by Dr. Kerr that there are no legal poAA'ers to undertake treatment ; he rather differed, because provincial sanitary authorities already had Statu- tory poA^crs to build hospitals and treat diseases, and this Avas a further argument why the AA^ork of the Education Com- mittee and of the Sanitary Committee should be fused in as far as the health of the children are concerned. Dr. Willoughba' (Eastbourne) said he came specially to learn, but he Avould like to em})hasise all that Dr. Richards had said. For some years he had been Medical Officer of Health and Medical Officer to an Educational Authority in the same place ; and the A'vay in a\ hich the AAork of the tAAO departments doA'ctailed Avas Avonderful, especially in infec- tious disease Avork. Dr. CroAAley had spoken of Medical Officers of Schools attending to this A\'ork, but as Medical Officer of Health one is bound to knoAA' all the conditions affecting the infectious diseases Avhich arc going on ; and therefore the Medical Officer of Health must liaA^e to do AAith school children all the time, Avhether he is Medical Officer to the Education Authority or not. To haA^e tAvo se])arate organ- isations Avorking at the same infectious disease would be an unnecessary exjjense and lead to unnecessary friction, even among medical men. As to the point raised about the Medical OfHcer of Health having anything to do Avitli oph- thalmic w oik, personally he had been able to effect much good, and finding by a rough test that 10 per cent, of the children MEDICAL INSPECTION OP PRIMAKY SCHOOLS. 17 have defective eyesight, his practice had been to send a circular to the parents of tliese cliildren saying they must have the eyesight seen to. This had been done by only about one in eight or ten of the parents written to. There v.ere some so iiopelessly poor that the work must be done for them. These children were suffering daily in school from headaches and otherv.ise, and so occasionally an ophthalmic speciahst and himself did the necessary refractions for those vvhom they found could not pay ; and what was necessary was being done gratis in the most severe and necessitous cases. Treatment is bound to follow inspection ; one could not see chilcken going on in that way without doing something for them. As Dr. Richards had said, the Sanitary Authority has, in many cases, power to spend money in this direction, in- directly if not directly, though possibly the expense of some of the things done, if detected by the auditor, might be disallowed. The Sanitary Authority can do, and does, so much work for school children that the longer he was con- nected with education v\ork the more he was sure that in districts the size of Eastbourne, at all events, the work of the Medical Officer of Health and the School Medical Officer must be co-ordinated, even if the same man does not carry out the work ; otherwise there would be everlasting friction and umiecessary exjDenge. In large cities hke London and Brad- ford, of course, it would be impossible for one man to do the work. As it would be imp( ssible for the Medical Officer of Health of the County Council to do all the Avork himself, so it must be impossible for the School Medical Officer — say, for instance, Dr. Kerr — to do the v\ork himself. Just as the Medical Officer of Health cannot be a specialist in eyes, ears and throats, but is a specialist in health work, so Dr. Kerr, he took it, was a specialist in education work ; but was equally not also capable of doing the ophthalmic woik or all the various abstruse s jrts of medical work that v/as neces- sary for school children. There must be co-ordination of the two offices, at all events in all places but large cities ; and the man at the helm to arrange and co-ordinate the wcrk should be. in his opinion, the Medical Officer of Health. Dr. Butler (M.O.H., Willesden) said he also held a dual appointment, similar to that of Dr. Willoughby, and in the district where he was Medical Officer they had 20,000 to 25,0(M) children in elementary schools in a ]iopulation of 140,000. He held that dual position because when the question first arose as to the medical inspection and hygienic control of schools generally, it was obvious that to have in a district such 18 THE NEED, Oli.TECTS, AND METHOD OF THE as his two indepencU'iit health authorities would inevitably lead to frietion and to eonsiderable v.aste of time and administra- tive energy. It v\'as more especially v\ith a view to avoid that that he developed in his district, v.ith the aid of his Council and Education Committee, a scheme for the hygienic control of schools, and partial, at all events, medical inspection of children. After tv.o or three years' experience of that he was convinced that only when the Public Health Authority and the School Health Authority are co-ordinated in one responsible medical officer can such v\ork be done joroperly. It had been said that infectious diseases form a comparatively insignificant ]3art of the work of the Medical Officer for Schools. It may be an insignificant part cf all the v\ork that should be done, but at the present time it is so important a part, and is so large in the amount of work vvhich it entails, and is so pre-eminently the work of the Medical Officer of Health, that he v\as sure that it, at all events, could only be done by him. He had had himself over 4,000 cases of communicable disease, exclusive of those notified under the Statute, intimated to him during the year, all of which A\ere dealt v\ith by the officers of his department, acting under supervision. 4,000 cases represent an enormous amount of work, and these cases which come to the knowledge of the Medical Officer of Health can be dealt with only by domiciliary visits as well as by school inspection ; and these visits can only be made where there is an organisation that already has statutory powers of entry and power to deal with the conditions %vhich are found. The Medical Officer of Schools v.ould not, if he were made an independent authority, have those powers of entry. There exists at the present time large administrative machinery and legislation which has permitted organisation which fits in with tiie medical inspection of schools. That is all to the good and favourable to the vievv' that the Medical Officer of Health should either himself (or with someone acting under him) be Medical Officer of Schools. Wheie there are 20,000 children it is not possible for the Medical Officer of Schools to deal personally with each case ; it must be done by organisation. There are over 10,000 children in his district whose eyesight is examined every year, and that could not be done by any Medical Officer who is appointed even solely and exclusively for school \\ork. Such inspection as that can only be done through the co-operation of the teachers, and it is a simple matter to issue precise instructions to them v\hich they can follow, which will enable the child's acuity of vision to be measured. And medical inspection at present goes only so far as to discover the cause of the ill-health MEDICAL INSPECTION OF PKIMAKY SCHOOLS. 19 or defect ; it does not, for most part, involve treatment. AYhat is required to be known is, Does the child require medical treatment 'i If it is a case of vision, is it of such a character that it should come under an ophthalmic surgeon ? A teacher is capable of measuring a child's visual acuity, and v>'hen he finds it is below normal, he should intimate it to the Medical Officer of Health or the Medical Officer of Schools, v.ho in turn vvill intimate the fact to the parents, who send the child te an ophthalmic surgeon or ophthalmic hospital. The same system would apply to adenoids, and to discharges of all kinds. The teacher must be instructed vdiat to look for, and what cases to bring under the notice of the Health Officer, and that officer can direct the parents as to the necessity for treatment. That is the most that can be hoped for in the first instance. In some degree treatment is already undertaken. The Medical Officers of the Isolation Hospital in his district already deal vrith cases of ringworm, v.here parents cannot or v.ill not get other medical attendance. Ringworm is a case in point. The teacher is capable of recognising or at least suspecting it after a httle instruction ; he can exclude such cases from the school, and intimate the fact to the Medical Officer. Cases in Dr. Butler's district are visited by the Lady Health Visitors, and ' medical attendance is urged upon the parents ; and v.herever it is found that the parents cannot afford it, or even to take the child to the hospital — v.hich means a journey to to^Ti — ih.ey arrange for such cases being treated. It vrould be ex- tremely inhuman to let these cases, v.ith httle or no tendency to natural cure, go on from year to year and do nothing to check the spread of the disease. They had been able to arrange in his district — and he thought Dr. Richards had been able to do so in Croydon — to take such cases and treat them under the powers vvhicli are given by the Public Health Act. These are the broad facts relating to this question. Those v.ho had had experience of the dual v\ork Avere emphatically of opinion that it v^ould be the greatest possible mistake if there were tv\-o Health Authorities, v.orking often at cross purposes, in one district. It is a branch of Pubhc Health w ork, and the Medical Officer should be trained in the future to cover this work. There are practically no medical officers of public elementary schools at present ; v\-e are at the commencement of organisation in regard to medical inspection of schools, and in very fevr districts is there any special pro- vision for this A^ork. Dr. Thomas said there [vras nothing which impressed him more in Mork in schools than the fact that the doctor is by that brought into relation with every branch of social 20 THE NEED, OBJECTS, AND METHOD OF THE Avork, everything that goes to make up the social work of the State. It is the pivot and it will he the point from A\Iiieli all organisation vvill sjithig. One is constantly brought into relation with the Medical Officer of Health and his work, with isolation hospitals, Avith Poor Law Authorities — for starving children must be fed — with children considered to be imbecile, for A\hom Boards of Guardians refuse to do anything, witli charitable organisations, such as the Cliarity Organisation Society, Avith the Prevention of Cruelty to Children Society, Avith hospitals and Avith private practitioners in a much more intimate Avay than the Medical Officer of Health (in his old definition). He thought the Medical Officer of Health should control CA^crything that goes to make up the health of the population. But he Avould ask those Avho Avere both Medical Officers of Health and Medical Officers to the Education Authority Avhicli part of their A.ork they considered the more im]3ortant. He thought those Avho have acted as both Avould unhesitatingly say the education side is the most impor- tant. What is going to happen if the Medical Officers of Health are asked all over the country to take up education Avork ? There are a few of them who throAv themselves Avith zeal into the school work, but there are many unv.illing to do that ; some do not even wisli to take it over. It is forced upon them ; and Ave see in the medical papers adver- tisements for medical assistants to the Medical Officer of Health to give their AA'hole time to examinations in schools at £120 or .£i50 per annum in very large boroughs ; this is hai>pening almost Aveekly at present. Medical Officers of Schools feel that medical inspection is far too important to be paid for at that rate. A lot of this conflict betAveen the tA\ o aspects is due to the fact that four years ago there Avere two different authorities in every toAvnship and council area, one looking after education and the other after pubhc health. That has been altered by the Education Act of 1902. It is noAV the same authority, and he did not see any difficulty in bringing about co-ordination when there was the same authority responsible for education and public health. Even if there are tAVO officers, one the Medical Officer of Education and the other the Medical Officer of Public Health, tliere is only the question of conferring together on the part of colleagues. If these are to be combined, he felt it AAOuld be very disastrous if medical inspection of schools should be pushed on one side as a subordinate branch of AAork, and done by a very ill-paid assistant to the Medical Officer. Dr. Lauder (Southampton), after thanking the Associa- tion for liaA'ing extended to him an invitation, and Dr. AfEOrCArj INSPECTION OF PT^TMATiY SCHOOLS. 21 Crowley for his excellent paper, said that he \\as quite in accord with the expressions of Dr. Thomas — particularly A\lien he said ' ' The child of to-day is the nation of to- morrow." It was impossible to disassociate school work from public health A\ork without A\eakening both. Dr. Crowley had advocated decentralisation. It would seem that the main object of putting elementary education under the Sani- tary Authority was for the purpose of centralisation. Were Medical Officers to continue as licads of each department, authority and usefulness would continue divided. Dr. Crowley may have been correct \vhen he said Medical Oflficers of Health are not tit to do school work (Dr. Crowley said he did not say so). Dr. Lauder : JJut if tliey are not fit let them have officers ^\■ho are fit. Di'. Tliomas liad said he came in contact with Medical Officers of Health and Poor liaw Officer :<, but lie (Di'. Lauder) v\'ould go so far as to suggest that the Poor Law should be under the Sanitary Authority in the same \\'ay as the Education Committee, when they would probably obtain what they had not heard much of that afternoon — thatv\'as, treatment. ]Most of the remarks had been confined to the examination of children, but the treatment had been a matter practically untouched. He believed that v.hat was required v\'as proper organisation, under one head, of the Health Department. Whether the present Health Officers v.ere fit or not v.as not the point, but there should be one medical head of a proper organisation. They v.ere told that many of the cases which v.ere examined required treatment, and in such cases the parents were financially unable or hope- lessly incapable of taking care of the children. At present, the Sanitary Authority and the Education Authority, as one, v.ere incapable of dealing with such ceases ; consequently it v, ould appear that the examinations so much spoken of were not of so much practical advantage to the individual pupil as they would probably be, from a statistical point of view, in demonstrating the advantages that would accrue by bring- ing the Poor Law administration luider the same authority as the Education Committee, when the children of persons financially unable or socially incapable to assist their children could receive a further benefit of the careful examination of V. liicli they had been pleased to hear so much. He had the advantage of being JNIedical Officer of a Borough, Port, Schools and Fever Hospitals, with a staft" availalDle in each, and he could easily realise that if each authority had an independent medical head how the interests common to all might be impaired, without the advantages 22 THTI NEED, OH.TF.f'TS, AND METHOO OV TIIK \vl»iol\ the present position gives of concentratinb'dical Ollicers of Education Authorities for the pos .sessi«)n of the .schools. This was not the main ])urpose of these jneetiniis, the chief object of which should be the welfare of the children and the best means of attaining that end by which- ever department the insp(>ctionwas organised. He was in entire agreement with the reader of the paper, that daily inspection of classes (hirinir ;ip. epidemic by the Medical lu'-pector wa-- impracti -able and unnccesfary ; it would involve a serious in- terruption of school work, and in a large district could not be carried out satisfactorily by one Medical Officer, even if he devoted his whole time to the work; the exjM'Mse \, oukl alsf) be very great. At Wimbledon, during an epidemic, the teacher of each class w hen a case had occurred carried out a daily inspection, and excluded from school any children who showed susj)ici()us sym])toms ; it Avas (piite possible to train teachers to perform this duty satisfactoril\ . Again, a full medical examination (►f each child on entry and the keeping of a lecord of jmigicss during school MEDICAL INSI'KCTIOX OF J'KIMAUV SCHOOLS. 23 life was no doubt desirable as an ideal, but. apart from statisti- cal purposes, it v\ as difficult to see liov\' the ultimate benefit to the child would justify the expense, the large amount of time and A\ ork involved, and the interruption of school work by such detailed examinations. Medical inspection of schools v\ as in its infancy, and it a\ as necessary to move cautiously, and be on cur guard not to convert schools which existed for educational purposes into institutions for collecting statistics or nito ante- rooms for hospitals. It was quite clear tliat inspection could only be a means to an end, and that end must consist in an attempt to remedy the evils brought to light. In a large number of cases the parents were unable or unwilling to carry out the recommenda- tions of the Medical Officer, and he deprecated the view that treatment should be carried out by rate aid as tending towards socialism, the pauperisation of the j)arent, and the lessening of parental responsibility ; it was preferable that help should be afforded by the organisation of voluntary agencies in each district, and allusion was made to the excel- lent work done in Wimbledon by the local branch of the Invalid Children's Aid Association : in suitable cases, he made recommendations to this Association, and parents were thereby helped to obtain spectacles or children were taken to hospital, or to local medical men, for treatment, or were sent away to convalescent homes. Reference was made to the method at Wimbledon of employing school nurses who worked under the direction of the Medical Officer. A weekly visit was made by them to each school, in addition to home visits for the purpose of interviewing and instructing parents. The value of this work could not be over-estimated ; a personal interview 1 )y a tactful nurse was often far more efficacious than an official notification from the School Doctor ; the standard of cleanli- ness and the effective treatment of verminous conditions had been vastly improved by their aid, and they were welcomed both at the schools and in the homes. Without the assistance of these nurses, and the Association he had mentioned, the mere inspections and recommendations he made would too often have proved barren in their results. Dr. Louis Paekes (Medical Officer of Health, Chelsea) said that, in his opinion, if iiermanently good results were to follow the medical examination of children in elementary schools, gratuitous treatment by the State must be a supple- mentary procedure in the case of those cliildren whose parents were in such necessitous circumstances as to render them 24 iMi;iiI( A I. INSrECTlOX OF 1 IIIMAUV SCHOOLS. unable to pay for medical advice and treatment. In many of the districts of London and of the lartfc |H(>\ incial cities this would mean a majority of the children attendina underlying each sei'vice should be "prevention," and not merely the ivlicf of the indi\idual. This was the basis of all Public Health woik : but the same l)rinciijle should underly the administration of the other State medical dci)artments. namely, that the rehef of individual sutfering should lead to measures for the control and ameliora- tion of the conditions which originated the illness. If this jninciplc w^ere once accepted. State relief for all cases of sickness would soon justify the e.xpendituiv of State funds that it would involve, not only by a reduction in the cost of maintenance of the sick poor, and by the relief it would afford to the medical charities, but also by reason of the im])ti)ved standard of health of the rising gcnci'ation. this, in its tiuii. meaning an increased national eiticiency and a laiger output of capable Morkers. Cnwiii LioUicis, I.IH., Piiiilcis, .•?, IMijiii" bliecl, Loi.ilon. t.t. p & r JAN UC SOUTHERN REGIONAL LlB'''\f;\' '.^^/'L'' / AA 000 714 948 7 \