The medical inspection of girls in secondary schools

Front matter

THE MEDICAL INSPECTION OF GIRLS

SECONDARY SCHQOJ S

.CAlHERWiJGMlSlOiiM

Preface

The high schools for girls which have come into existence since the Schools Inquiry Commission of the 'Sixties had the advantage of making a fresh start, of establishing a new tradition. Those of us who remember these early days know well that no small part of that tradition was a new respect for health and vigour of body as well as of mind. Indeed, one characteristic feature of the whole movement for the higher education of women has been the stress laid on physical training and hygiene, so far as these have been understood; in some of the pioneer schools medical inspection by a woman doctor was customary a generation ago, and for years in the ''Girls' Public School Year Book" have appeared in many prospectuses the names of medical officers. But, at the present time, a marked impetus has been given to medical inspection in secondary schools by the Act establishing medical inspection in primary schools, and by the general public interest in the maintenance of health, and in the prevention of disease and physical disability. The problems of the school have also become more urgent : we have many delicate children brought to us for education ; the standards of examination have risen, risen dangerously; parents and children viii PREFACE

are less able; certainly less willing, to put up with discomforts and difficulties, they rightly demand more attention to physical well being : while the national, the international, demand for efficiency is greater as the struggle for industrial success, and for the improvement of material conditions, becomes more severe. Under these conditions all who are responsible for the upbringing of young people, parents, teachers, administrators, depend on the medical expert more than did our fathers. School hygiene becomes more and more the foundation of our educational structure ; while it is increasingly obvious that the medical authorities themselves must derive their experience, not only from the hospital and the consulting room, but from the school, the works, and the ordinary life of the citizen.

A large day school for girls, containing a great variety of types, and serving the needs of a busy urban community, presents opportunities for developing a useful system of medical inspection. It is because I have so keen a sense of the value to us in this place, and to education generally, of the work of my colleague Dr. Catherine Chisholm, that I have urged her to place on record some account of her plans and principles. We have found that a good deal more can be done than merely measuring and weighing the pupils, drawing up tables of results, advising parents as to eye defects, or the need of special gymnastics, and the like. We hope to be able to find out something that is really true and certain for us in our conditions as to school

PREFACE ix

customs, methods and equipment, as to the effects of work and play, and even of administrative regulations. Much has of course already been discovered through the medical inspection of primary schools ; the effect of their appalling statistics must be far reaching in promoting social and educational reform. In secondary education we have still much to learn, and if careful medical inspection becomes general, as it is rapidly becoming, the evasive and thorny problems of the secondary school will secure some elements of a solution.

But if the medical officers are to help us teachers to solve our problems — and we need help sorely— we and they, experts both, must work together. The famous Scottish phrase as to the relations of Church and State, "Co-ordinate jurisdiction with mutual subordination " must be the rule for the relations of the school Head and the school Doctor. It is not an easy matter to carry out this rule in practice, and there are of course limits to its application.

A school medical officer cannot continue to advise school authorities who pay no attention to her recommendations ; but a woman of sense knows that financial, personal, and administrative conditions may make it difficult, all but impossible, to carry out particular hygienic ideals in the everyday life of the school. Similarly, a head mistress, on whom the ultimate responsibility for the school must rest, may once in a way regretfully put aside the views of the medical authority as to a time-table, a menu, or x PREFACE

the requirements of a scholarship competition. But it is always a risk to set aside the judgment of the expert : it is often unwise and always dangerous. One may do it occasionally, and risk the consequences for what may prove a greater advantage. Such occasions are, however, rare, and should become rarer, as the scientific basis of education is better understood.

In actual fact it is found that by good sense and sympathy, and give and take on both sides, the two authorities, teacher and physician, can work together, as they do in many schools, for the common purpose that urges each — the right development of the future citizen.

SARA A. BURSTALL.

Manchester High School for Girls, October, 19 13.

Author's Preface

This book was written in response to a request for one which would explain the methods and aims of Medical Inspection and be useful to the Head Mistresses, and authorities of secondary schools for girls where medical inspection does not yet obtain. The present volume does not aim at anything more than giving the lines on which the writer's practise is based. It is hoped that it fulfils in some measure the terms of the request, but the writer is conscious of its many deficiencies.

November 8, 19 13,

Contents

CHAPTER PAGE

Introduction i

I. Medical Officer 14

Introduction

The conviction that without the full physical development of the body neither mental ability nor moral force can exert its fullest influence or attain to its highest state of efficiency, is the source from which the system of medical inspection of school children has sprung.

Though the Greeks aimed at producing the man fully developed, physically, mentally, and aesthetically, providing as the basis of their education, music, rhetoric and gymnastics, the moderns have but recently dropped their cherished idea that a scholar normally appears with bowed head, narrow chest, and pallid brow.

But at last, two facts are clearly recognized, and on them is based our present attitude to physical culture. The first is, that to enhance mental ability the body must be trained and not

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2 SCHOOL MEtflCAL INSPECTION

exhausted. The second, resulting from this, is the recognition that it is important to start as early as possible, and that if the best is to be obtained from the man, every care must be taken that he shall develop from childhood, nay, from birth, and even earlier, under the best conditions, and that adverse physical tendencies shall be checked at the earliest moment.

The Education Act of 1870 compelled every child to enter the schools. Many of them were ill-fed. Often through ignorance, occasionally through the carelessness of their parents, children suffering from various pathological but remediable conditions were attending school, though unable to profit properly from the instruction given. It became evident that the money spent in Education was to a large extent wasted. Various authorities began to take the matter up, and in 1891 the London School Board appointed a medical officer. In 1893, Dr. James Kerr, whose name stands out most prominently in the history of medical inspection of school children, was appointed to be the school doctor of the Bradford School authority.

Nine years later the Government, in passing the Education Act of 1902, made further appointments. In 1905, a report was issued on the Medical Inspection and Feeding of Children attending the Elementary Schools. The number of bodies having medical officers for educational purposes was by this time largely increased. In 1907, the Education (Administrative Provisions) Act was passed, providing for the systematic medical examination of all school children in the Public Elementary Schools.

We are already reaping the benefits of this Act. The reports of the medical inspectors are showing statistically that improvement in general physique, as evinced by the average heights and weights of the children, is clearly evident. The prompt notification to parents of defects found in their children has in many cases led to immediate treatment of those defects, and the consequent improvement of the children. The parent has now no longer the excuse of ignorance when he allows a child suffering from ill-health or physical defect to attend school. And the parents have been found very ready to respond to the calls for treatment made by the school authorities.

The result has been that benefit has accrued through the early notification to parents of defects present in their children.

Unfortunately, in many cases, the means of the parents preclude the possibility of the child's obtaining adequate attention except through the already overworked out-patient department of the hospitals, or by the help of the Poor Law. In many towns, therefore, clinics have been provided for the treatment of certain of the diseases often found among school children.

Although medical inspection is now enforced by law in the Elementary Schools of England and Scotland, as yet medical inspection in the High Schools or Grammar Schools for boys and girls is by no means common. In these latter schools the introduction of medical inspection was originally commenced from different motives than in the Public Elementary Schools.

In the Elementary Schools, as has been shown, medical inspection was commenced in order to attempt to improve the obviously poor physique of some of the children, and to remove the evident disabilities from which they were suffering.

In the Secondary Schools most of the children appear to be well looked after and cared for, and the necessity for inspection on this score was not so evident. When, however, the education of girls was being reorganized and developed as a result of the movement for the higher education of women, the place of gymnastics and drill in the school curriculum had to be carefully considered.

Frances Mary Buss recognized the fact that physical training was important in order that her girls might develop all that was best in them to the highest degree. She felt, however, that the girls must be carefully treated, or more harm than good would result. Therefore, more than thirty years ago she insisted on a medical examination taking place before physical exercise was undertaken.

It was only so lately as 1899 that Dr. Clement Dukes (whose work is so well known) commenced to examine every boy who entered Rugby. This was the first Boys' Public School to adopt the system of routine medical examination.

That Secondary School Teachers welcome and desire medical inspection is shown by the resolutions that their associations have passed. The Head Mistresses' Association declare that in their opinion such inspection is advisable.

The National Union of Teachers also thinks it advisable to have inspection in the Municipal and County Secondary Schools.

There are, however, yet comparatively few schools admitting children to secondary education where there is established systematic medical inspection.

In 1910, only 42 out of the 132 High Schools mentioned in the High School Year Book had a medical officer mentioned in the prospectus, and on inquiry it was often found that this officer was merely a medical referee in case of infectious or unexpected illness.

The figures collected by Dr. Alice Corthorn show that in 1910, out of 276 Secondary Schools, including Public, Private, and Convent, 92 had medical examination, 11 had partial examination, and 19 had an examination by the drill mistress ; further, 65 principals wished to have examinations but had none, and there were in addition 89 schools with no examination.

It is frequently urged, even by those who admit the advisability or even the necessity for medical inspection in the Public Elementary Schools, that such inspection in the Secondary Schools is totally unnecessary.

They declare that the parents of these children are able and willing to pay for advice and treatment for their children.

That it is the parents' duty to do this is true.

But the number of defects discovered on making a routine examination in a Secondary School of a good type shows, that through either ignorance or carelessness, many pathological cases, and many cases of abnormality are untreated. The parents are generally found ready and anxious to remedy these defects and abnormalities, when they are discovered. Thus the previous omission appears to be due to ignorance.

The Secondary Schools are of two main classes. There is the Grammar School or High School, which derives its funds, apart from the pupils' fees, either from an old foundation, or from a company founded to provide the education given in the schools. Some of these schools receive grants from the local education authority, and take a certain proportion of free scholars.

The other class is financed by the local authority to provide secondary education for the children of the town.

Many of the parents of the pupils in both classes are professional men with incomes none too large, or they are struggling tradesmen and business men. Many of the children are enabled to enter the schools by the means of scholarships and bursaries.

But though the parents will make great sacrifices to remedy a known defect, they cannot afford, nor do they yet appreciate the economy of, a periodical visit to the medical attendant to learn if all is going well with their children.

Thus it would appear to be advisable in the Secondary Schools, as in the Elementary Schools, to appoint medical officers to detect defects at an early stage.

Nowhere is there greater opportunity for a medical officer to do work of permanent social value than in these High Schools and Secondary Schools.

We are in this book more particularly concerned with the girls' schools. In these schools, the ages of the pupils vary from six years in the Preparatory forms, to nineteen among the senior students. Thus, though few children pass all their school life in the same school, the development of the large majority may be watched for many years at the most crucial period, through childhood and adolescence to full maturity. Often, indeed, the process may be observed in member after member of a large family.

It is important that the girls from these schools shall be turned out into the world mentally and physically as fit as their circumstances will allow. The work that they will have to do will be responsible and need all their capacity if it is to be done in the best possible way. Many will have to depend for their livelihood on their own exertions. The preparations for their life-work will in many cases, particularly for those going through a university course or a nursing training, be long and exacting. The tendency of eager, ambitious students is often by early over-pressure to spoil their later efforts. Perhaps this tendency is to be found more especially in girls' schools. The ambition of the girls is quickly stirred, their sense of duty and responsibility to those who are giving them opportunities is often keenly felt. They have fewer opportunities for distraction than their brothers. Their training and surroundings make them, even when keen on games and out-door sport, less likely to be carried away into indulging in them to the detriment of their studies. Moreover, every girl has some home duty or occupation, which helps to fill in her time and gives her, on the whole, less time for recreation than her brother. That this tendency to over-work exists in ambitious girls, or girls of ambitious parents, is shown by the numbers of those who in the earlier days broke down at the university or failed to bring to fruition the promise they had shown. These failures on inquiry will almost inevitably .be found to result from an unwise system of work resulting from over-anxiety to excel. It is no good to win a good place at io SCHOOL MEDICAL INSPECTION

school or in the university if it is done at the expense of the body, and if success so impairs the health that justice cannot be done to the profession for which the scholastic work was merely the preparation.

The possibility of over-working at games and in the gymnasium must also be avoided. It is generally, though not always, a different group of girls who are likely to suffer in this way. One of the problems in a school having a gymnasium is to strike the right balance between encouraging physical development and checking that enthusiasm and interest in gymnastic work which makes excellence here an end in itself and a source of danger by overconcentration on this one branch of work.

Thus the care of the bodily development during the years when the girls are discovering and testing their capacity, when they are subject to great strain of growth and effort, and have not yet learned their limitations, is of the highest importance and full of interest.

But the medical officer in a school does not find the opportunities for valuable work limited to the inspection of individual girls. Details in the daily life of the school, advice on infection, school buildings, ventilation, heating, problems arising from the curriculum and discipline, all

INTRODUCTION u

will, from time to time, come under his or her notice. There will be many opportunities, some formal, some informal, for giving hygienic teaching.

The social position of the girls in Secondary Schools is such that they will exert an important influence on the community in which they live. They are the teachers, the educators of the future, the civil service inspectors, the social workers, the nurses and women doctors, the wives of the professional, business, and legislating classes of their generation.

The attitude of such women to the question of public and private hygiene is of very great importance to the community. The presence and influence of the medical officer in the school where they are educated should and will accentuate the importance of a healthy sound body, and its dependance, not on fussy futile drugging, but on following broad hygienic principles, such as the provision of a sufficiency of air and food, the formation of habits of regularity and moderation in indulgence. Indeed, the formal instruction of the girls in sound wholesome teaching of physiology and hygiene should be a necessary part of the curriculum, and such instruction is best given by one having the authority of a medical training.

It is probable that the children of the next generation, brought forth and cared for by former pupils of a school whose life is based on the co-ordination of pedagogical and medical experience, will start life under better auspices than the generations which have preceded it.

And it is just this conjunction of the experience of the pedagogue and the physician that is valuable and necessary to good education. More and more the teacher recognizes the necessity for training in psychology before he can understand how best to treat his subject and introduce into the receptive minds of his students the material he himself has assimilated. The senior wrangler may need much training in education before he is qualified to instruct the young in mathematics, and will always instruct the better after a study of psychology. Once we recognize the importance of the physical condition of the brain cell, its growth and development, the recognition of the physiological basis of education follows.

A medical officer in a girls' secondary school should be interested not only in general medicine, but in psychology, in education, in sociology. The work is more intimate, more concentrated than the work of the medical inspectors of elementary schools. If time can be given to it, the opportunities and research are many. The work is full of interest and value. Such an officer ought to aim at being more than a mere inspector, and have an influence which is felt in the atmosphere of the school as a whole, in the arrangement of the curriculum, in the health of the individual girl and in the homes from which the girls come.

Chapter I Duties— Room— Notices— Secretary

If, then, it is advisable for the proper full equipment of the school that medical inspection should be undertaken, and undertaken with the objects spoken of in the previous chapter, the methods of carrying out the work must be considered.

It is taken for granted that in a girls' school the most suitable officer will be a woman. To one considering the matter without prejudice, it is evident that if the examiner is a woman the girls will find it easier to submit to the searching examination which is essential if the inspection is to be of any value.

On many occasions difficulties and problems arise in such schools which a woman is naturally more able to understand and with which she can more readily deal.

It frequently happens, for instance, that a case in which discipline is involved is reported to the medical officer for advice. It will be easier in many instances for a woman to get to the bottom of what may be causing the unsatisfactory conduct. The large majority of cases of really bad conduct are found to be due to some physical cause. This may be ill-health, unsatisfactory home conditions, unsuitable recreations. It is often possible for the medical officer who approaches the question without any bias caused by previous troublesome encounters with the girl, and who inquires into the whole matter from a health point of view, to find the cause of the trouble even after a sympathetic teacher may have failed. It is only a woman who could really set about investigating such questions. A great deal which is helpful to the mistress may be learned from a girl by a medical woman interested in psychology in a private interview with the girl involved. This is of course particularly true in the case of girls inclined to be hysterical. Such an interview would be impossible with a man doctor under the same circumstances.

Moreover, the medical inspector whose interest is in the school, and who works for the benefit of the school work, must be a member of the staff who can drop into the common room i6 SCHOOL MEDICAL INSPECTION

and discuss school problems with any of the mistresses without reserve. This, again, only appears possible with the woman officer. There must always be a certain amount of reticence and difficulty in discussing some school problems with a man. In medicine it is quite true that sex should not be regarded, but many things which the present-day lay-woman can talk freely about under necessity and in case of severe illness she finds difficult to mention when there is no urgency nor vital necessity.

The duties which a medical officer has to perform may be divided into —

i. The routine examination and re-examination of the girls.

2. The keeping of records and the collection of statistics and information about the normal child and variations from the normal type.

3. The supervision of remedial work in the gymnasium.

4. The giving advice to the Head Mistress on questions arising out of infectious diseases or other matters of school hygiene.

5. The instruction of (a) the pupils and {b) the parents and guardians, in the hygiene of school life.

In arranging for the first of these duties, and the one which probably will take most of the time, different school authorities have adopted different plans, probably according to their conception of the scope of medical inspection.

Some authorities, chiefly concerned with the dangers of girls doing gymnastics and games when in a physically unfit condition, have adopted a voluntary system of inspection. In these schools the parents are notified that the proposed examination is to take place unless the parent or guardian signifies his or her objection. If permission to undergo the examination is refused the Head Mistress either asks for a medical certificate from the child's private medical attendant or refuses to allow the child in the gymnasium. Other schools, however, offer the examination, and if the parents refuse to allow the child to submit to it, no further action is taken in respect to that pupil. It is, in such cases, assumed that the parents accept all responsibility.

But in a school where medical inspection is instituted because health is known to be an essential for that development of mind and body which education superintends, and where the inspection is not simply a safeguard over A's or B's individual health, but a necessity to the school as a whole, the system must be a compulsory one.

c

For this reason the expenses of the medical inspection ought to come out of the inclusive fees— that is; a special fee ought not to be charged for the medical examination. The compulsory entrance fee might be raised to supply the money. Many of the parents of children at the Secondary Schools have to consider every expense. They will often consider unnecessary an examination which is very important to the school. The examination is needed for the efficiency of the school work. Re-examination may often be even more useful to the mistress in helping her to decide on the proper treatment than directly beneficial to the girl's health. Especially is this the case where difficulties of discipline may have arisen. Therefore the fee ought not to be an extra. This inclusion of the medical expense in the general fee will make it less likely that requests for exemption will arise. Experience shows that parents are generally very glad to have their children examined. But it is often just the cases whom the Head Mistress is most anxious to have examined for the sake of the school and curriculum; who are inclined, under a voluntary system, to ask for excuse. To help her in such cases, and to keep the statistics of the school as a whole accurate, it is necessary that all the girls in the school should be examined.

In the prospectus of the school, therefore, it is well to state that there is in the school a system of medical inspection, and that each child is inspected at the wish of the Head Mistress. Due regard ought, however, to be paid to people such as Christian Scientists who have conscientious objections to medical treatment or examination.

The Examination Room in which the medical examination takes place ought to have special characteristics for the convenience of the work.

It ought to be a bright, cheerful, well ventilated room with good windows, if possible facing south, and capable of being opened. It is necessary that the room should be bright and attractive as the children are often nervous and a dark room is depressing.

Further, the room ought to be a model of what a hygienic room should be. Even if the girls and their mothers are in it only a short time, it is a pity that they should be in circumstances which one is explaining to them as unsuitable.

The size of the room is not of much importance, except, that for testing distant vision, one diameter of the room should measure six metres.

2o SCHOOL MEDICAL INSPECTION

the walls in convenient places. The windows should be supplied with well-fitting dark blinds i~ zrier :in: ::;.: i_ri. i:.:::.::r.ri:~::.:::::.s — ay re —lie

The furniture of the room should be as simple as possible, fresh, attractive, and easily cleaned It ought also to be as little official as possible, for we must remember the nervousness of the young people The floor should be polished or covered with cork linoleum, and be frequently cleaned The r::~ s.-.:_'.: :e r.er.e: v..;- -.;-.e hei: ir.^ =-zziratus of the school buildings, but there should i'.s: :e i f.rtz.iif is i f.:t my ::':::. : t r.t :z~:-:y when examining children only partly clothed, ever. .:" :r.e v.- either : = ir~ er. : ugh :: i: vr;;h:u: :he iri.r.iry r.eiur.g ::" :he sir.::'.

A table or desk fitted with drawers with lock and key is needed A couch for abdominal examinations is required The high plinth used as apparatus in Swedish gymnasia is very suitable These can be made by a local joiner i: r :: ~ _ ;.. ei: :: = :

Cases to contain record cards, and two or three chairs, complete the necessary furniture of the r::~ ::S.i:5 :ue :_:r. .:_:e ;r:;er ::: r.eeis ir.e s'.ir.iiri ::: v;;^;..:.^ ir.i rr.eisurir.i'

Quite simple and useful ones can be provided on a stand for about £1 175. 6d.

A convenient dressing-room near will be an advantage to the speed with which examinations are conducted, as a great amount of time is wasted if each child has to dress and undress in the examination room. No child but the one who is being examined ought, as a general rule, to be in the room with the examiner. The room ought to be kept quite private, and the intrusion of even the clerk who is assisting ought to be deprecated. Every child has the right to perfect privacy, and any delicate feelings ought to be very carefully considered and respected. Screens ought to be provided in case it is advisable on occasion to have a child detained in the room while another is being examined or some interview arranged.

Method of conducting the Examination. — When the girl has entered the school a notice is sent to the parents appointing a day and hour, as near the beginning of the term as may be, for the medical examination. It is advisable that the mother be urged to attend at the time stated. The presence of the mother lengthens the interview considerably, and when many girls have to be seen it appears to take up much valuable time, but that time is generally well spent. The mother can often explain the routine of her daughter's life, tell of her previous medical history and describe her present state of health. Girls, especially of fourteen and fifteen, often try to persuade their mothers not to attend in order that they may have no restrictions laid on their bad habits of late hours and injudicious feeding which they may hope to conceal. But the interview with the mother is most valuable. One often learns much of the girl's home surroundings from the type of mother and the relations existing between mother and daughter. Moreover it is easier to speak of slight deformities, tendencies to weakness and actual defects without causing the unnecessary anxiety and alarm which a written communication, even when composed with care, may cause.