Medical supervision in schools : being an account of the systems at work in Great Britain, Canada, the United States, Germany, and Switzerland

Preface

At the urgent request of a number of members of the medical profession, schoolmasters, and others, to whom the medical inspection of school-children is of special interest, to publish a work dealing with this very important subject, I feel justified in braving the elements of criticism and possible condemnation by presenting a succinct account of the methods adopted in Great Britain, Canada, the United States, Germany, and Switzerland. Having been appointed by the Government of South Australia a commissioner to inquire into this matter in these countries, a great deal of valuable information has necessarily been acquired. Much of this is probably already known to many who are engaged in the work of inspection, but a great deal will be foreign to the majority anxious to gain a knowledge of the subject.

I have adopted a somewhat unusual method of dealing with the question, by treating each town or district separately, and have refrained as far as I considered reasonable from repetition, only resorting to this expedient when an important point seemed worthy of emphasis.

While acknowledging that there may be many discrepancies and points open to criticism in submitting a book on " Medical Supervision in Schools," I do not contend that there are many subjects in this work that have not already received the attention of several very able writers. The whole question being of recent growth and still in its earlier stages of development, my purpose is

281752 vi PREFACE

to contrast the different methods employed in different parts of the world ; to indicate as clearly as I possibly can the forms used in the various countries visited ; to eliminate certain of these forms which appear to me to be unnecessary, and to curtail others which err on the side of elaboration.

I have to thank all the medical officers and others who assisted me during my travels, particularly those mentioned in connection

with the towns and countries enumerated.

Contents

CHArTER PAGE

—I, Thp: Origin and Purport of Medical Inspection - i

II. The English Act and its Provisions ... - 5

Chapter I The Origin And Purport Of Medical Inspection

" Life is merely froth and bubble ; Two things stand like stone — Sympathy in others' trouble, Courage in your, own."

Adam Lindsay Gordon".

Thus graphically expressed in the words of our most famous Australian poet are the sentiments and feelings of every medical man who has the interests of his profession at heart.

He is during the course of his career brought into contact with life in all its phases and stages. He sees and realizes the depredations into the constitutions of the gourmand brought about by injudicious dieting and over-indulgence, and he cannot fail to recognize the sad condition of affairs which may be found among the poor wrecks of humanity who are drifting along life's highway into the great unknown, their bodies one mass of disease, the result of poverty and lust.

" The sins of the fathers shall be visited upon the children, even unto the third and fourth generation." This pathetic prediction, written thousands of years ago, is amply manifested by innumerable occupants of our present-day schoplrooms. It was on account of the increasing mortality amongst our children, the undermining of their constitutions through neglected ailments, the impoverishment of their bodies on account of starvation, that several far-seeing

I

2.V. ':i/l {A {''-"'MEDICAL Supervision in schools

physicians realized the necessity for establishing on a sound basis a system of medical supervision.

Like all forms which have been ultimately recognized as necessary for the well-being of the nation, these proposals were regarded as bordering on faddism, and a direct interference with the liberty of the subject by depriving the family physician of his just rights and privileges.

In precisely the same way important discoveries, even in the medical profession, have been treated with derision.

Origin of Medical Inspection.

It is not so many years ago that Lord Lister had to combat, not only severe opposition, but unqualified prejudice, when he advocated the use of antiseptics in surgery; yet to-day the whole basis of modern treatment is a battle against micro-organisms.

It is obvious that if children are to become useful citizens of the Empire their bodies must be cared for. The trend of civilization from time immemorial has been towards a degeneration in the physical condition of the race, and it behoves every parent — not only on account of his parental obligations, but because of his duty as a citizen — to see that his progeny are protected from the ravages of disease.

The Education Act, which has been compulsory for nearly forty years, has undoubtedly led to an enlightenment of the people, but we cannot expect a profit by this inestimable boon without some compensatory penalties. Previous to the passing of the Act the use of spectacles amongst children was comparatively unknown — whether entirely due to the overstrain which is entailed during a child's school life or to the earlier recognition of the defects, it is difficult to say. Assuming that the former is the cause, it behoves the nation to remedy the defect, and on it must lie the responsibility.

The battle which has been waged for and against medical supervision in our schools for nearly twenty years is practically over. Medical men now realize that such ^system, irrespective of treat-

THE ORIGIN AND PURPORT OF MEDICAL INSPECTION 3

ment, does not in any way interfere with the work of the general practitioner, but, on the contrary, rather tends to facilitate it by the earlier recognition of the presence of disease. The legislator, who is the elect of the people, should no longer talk about the State assuming parental responsibilities.

The snowball has reached enormous proportions, and every nation throughout the civilized world has come to recognize that it is a duty which it owes to the rising generation to see that nothing is left undone whereby they may become useful citizens.

The almost universal adoption of the system is an overwhelming proof that the scheme originally suggested was by no means a visionary one. The rays of hope, due to the awakening of the people, are shining over the horizon, and the silver lining of the black cloud of prejudice and unjust criticism is bursting into the bright sunshine of intellectual enlightenment. Very few are desirous of returning to the primitive condition of our forefathers, and if the penalties of civilization are to be a tax upon the constitutions of our children, such degeneration must at least be retarded. The old ideas of empiricism in treatment have to a great extent been abandoned to the scientific discoveries of recent years.

Objects,

The objects of medical inspection must be recognized as totally distinct from medical treatment, although the one cannot, and must not, be dissociated from the other.

The first important point is the early recognition of the present physical defects. Thousands of children to-day are suffering from undiscovered ailments, which will only become of serious moment when they reach the age of puberty if left untreated. These are to be found in errors of refraction, certain malformations of the body, due to children assuming abnormal positions, certain conditions of the nose and throat, etc.

The second point, of equal importance, is to recognize amongst children certain of these who must be prevented from attending school owing to physical unfitness. Education may be, and is, a necessity, but it is our duty to see that the body is physically fit to absorb it.

As a corollary to this, we must protect the majority from any who may suffer from a physical defect. The imitative faculty handed down from our progenitors, the anthropoid apes, according to Darwin, is very pronounced in children, who are notoriously uninitiative, but facile in imitation. This is instanced in the case of a stuttering child, and may be seen should hysteria occur in any children's ward in a hospital. 0 Then, we have the early recognition of infectious disease and the exclusion from school which is necessary to prevent its spread, to see also that all such cases are traced and every precaution taken. The English Public Health Act has for a number of years required the compulsory notification of infectious disease. To carry this to its logical conclusion such must first of all be recognized, and if not investigated, the probabilities are that many cases will remain undetected, and the Act thus rendered futile.

Further, it is hoped that contagious skin affections will be materially reduced by being brought under proper control, and the great medical bugbear of modern elementary school life (pediculosis) may be at least, if not eradicated, brought to a stage where it may be recognized and its spread prevented.

Before the Act was introduced for the medical inspection of schools in England, Scotland, America, and Germany, investigations were instituted with a view to ascertaining whether or not a systematic system was really necessary. The result was that, on careful inquiry, an enormous number of children were found to be defective, and since the Acts have been enforced the increasing attendance at school has shown a decided improvement. The consensus of opinion is practically a unanimous one, as the benefits which have already accrued are only too patent, and it is merely a matter of further improving the system to make it one of universal adoption amongst civilized races, as will be seen by investigating the various schemes advocated by different nationalities*

CHAPTER II THE ENGLISH ACT AND ITS PROVISIONS History

The first administrative body in England to make provision for a scheme of medical inspection in its schools was the London School Board. This occurred in 1891, but was done in a very perfunctory manner, and carried out in such an unsatisfactory way that the inspection was really of little value.

Then Bradford, in 1893, took the matter up by the appointment of a medical officer, Dr. James Kerr, to organize a system, which, although voluntary, proved to be of such value that, in 1902, he was appointed by the London School Board to thoroughly reorganize the system. This so-called voluntary system meant that any educational authority could appoint a medical officer for the inspection of its children or leave the matter in abeyance, just as it thought fit.

This continued until 1906, when the then Secretary- to the Educational Board, the Right Honourable Augustine Birrell, introduced a Bill into the House of Commons. The Bill, however, proved abortive, and in 1907 the Right Honourable Reginald McKenna introduced another containing some medical inspection clauses. Certain of these were incontrovertible, and were put into an Act called the Education Administrative Provisions x\ct, which was the outcome of a steady movement of public opinion throughout the entire community.

Objects of English Act.

The objects of this Act are fully explained in a memorandum on ** Medical Inspection of Children in Public Elementary Schools," which is dated November 22, 1907, and was issued by the Board of Education. This runs as follows (to quote extracts from it) : " For some years past evidence has been accumulating that there exists in certain classes of English people a somewhat high degree of physical unfitness, which calls for amelioration and, as far as possible, prevention. A consideration of the gravity of the need led to the conclusion that medical inspection of school-children is not only reasonable but necessary, as a first practical step towards remedy. Without such inspection, we not only lack data, but we fail to begin at the beginning in any measure of reform. The reasonableness of such inspection, if it is conducted on sensible lines, leading to an improvement of the surroundings and physical life of the children, must become evident both to the parents and to the nation as a whole.

" The Board desire, therefore, at the outset to emphasize that this new legislation aims, not merely at a physical or anthropometric survey, or at a record of defects disclosed by medical inspection, but at the physical improvement and, as a natural corollary, the mental and moral improvement of coming generations. The broad requirements of a healthy life are comparatively few and elementary, but they are essential, and should not be regarded as applicable only to the case of the rich. In point of fact, if rightly administered, the new enactment is economical in the best sense of the word. Its justification is not to be measured in terms of money, hut in the decrease of sickness and incapacity among children, and in the ultimate decrease of inefficiency and poverty in after-life arising from physical disabilities."

Powers and Duties of Local Educational Authority.

The section of the Education (Administrative Provisions) Act, 1907, which concerns medical inspection of school-children is as follows :

THE ENGLISH ACT AND ITS PROVISIONS 7

"Section 13. — i. The powers and duties of a local educational authority under Part III. of the Education Act, 1902, shall include —

" (a) Power to provide for children attending public elementary schools, vacation schools, vacation classes, play centres, etc. ; "(6) The duty to provide for the medical inspection of children immediately before, or at the time of, or as soon as possible after, their admission to a public elementary school, and on such other occasions as the Board of Education direct, and the power to make such arrangements as may be sanctioned by the Board of Education for attending to the health and physical condition of the children educated in public elementary schools. *' Provided that in any exercise of powers under this section the local education authority may encourage and assist the establishment or continuance of voluntary agencies, and associate with itself representatives of voluntary associations for the purpose.

" 2. This section shall come into operation on the first day of January, nineteen hundred and eight."

Appointment of Dr. George Newman.

At this period — November, 1907 — Dr. George Newman was appointed by the Board of Education to organize the means for carrying out the provisions of the Act, which was put into force and made compulsory on account of the general routine of medical inspection up till this date being as a rule imperfectly followed up, and much of the advice given being ignored. " This Act," according to the memorandum, " is not intended to supersede the powers which have been exercised by sanitary authorities under various Public Health Acts, but is meant to serve rather as an amplification and a natural development of previous legislation."

Responsibilities of the Board of Education.

The Act having been passed, the responsibihty of the Board of Education consisted in advising all local education bodies as to the manner in which they should carry out the provisions of the Act. Seeing that there are in England 328 authorities, consisting of all counties, county burghs, municipal burghs with population over 10,000 and all urban districts over 20,000, the task was by no means a sinecure.

Every part of England is now included and all schools are inspected. Legislation enforces that the provisions of the Act must be carried out. Should authorities neglect to do so, the Government grant is stopped, as medical inspection is deemed to be an integral and organic part of efficient education.

Instructions to Medical Officers.

All medical officers are instructed to co-ordinate with the health officials, as, although the two Acts are separate and distinct, it is recognized that, both working in unison, the provisions will be more effectively and efficientl}' carried out.

Salaries of Medical Officers — how Paid.

The salaries of medical officers are paid out of a local education rate, increased by a Government grant, which is about ^14,000,000, distributed among the educational authorities of England and Wales. This amount is distributed per capita on the average attendance. There are four permanent medical officers in London, appointed by the Board of Education to supervise the working of the system throughout England.

Instructions as to Medical Inspection.

Paragraph XL of the memorandum already referred to is as follows :

"XI. A consideration of these matters has led the Board to the conclusion that, as far as practicable, the statutory medical

THE ENGLISH ACT AND ITS PROVISIONS 9

inspection should, at entrance or at subsequent inspection, take account of the following matters :

" I. Previous disease, including infectious diseases. " 2. General condition and circumstances.

" (a) Height and weight.

"(b) Nutrition (good, medium, bad).

" (c) Cleanliness (including vermin of the head and body). " (d) Clothing (sufficiency, cleanliness, and footgear). " 3. Throat, nose, and articulation (mouth-breathing, snoring, stammering, tonsilar and glandular conditions, adenoids). 4. External eye disease and vision-testing. 5 Ear disease and deafness.

6. Teeth and oral sepsis.

7. Mental capacity (normal, backward, defective).

8. Present disease or defect.

" (a) Deformities or paralysis.

"(6) Rickets.

" (c) Tuberculosis (glandular, pulmonary, osseous, or other

forms).

" (d) Diseases of the skin and lymph glands. " (e) Diseases of the heart or lungs.

" (/) Anaemia.

"(g) Epilepsy.

"(h) Chorea.

" (i) Ruptures.

" (j) Spinal disease.

" (k) Any weakness or defect unfitting the child for ordinary

school life or physical drill, or requiring either

exemption from special branches of instruction or

particular supervision."

Regulations of the Board of Education.

The regulations of the Board provide for not less than three inspections during the school life of the child, and they recommend all local authorities to encourage one or both parents to be present lo MEDICAL SUPERVISION IN SCHOOLS

at the first examination, which takes place when the child enters school, and that a notification be sent as to the time and place at which the examination will be conducted (under Paragraph XII. of the memorandum, which goes on as follows) :

Parents' Attendance at Examination.

" Whilst some trouble may be involved in inviting the parents, the Board believes that substantial gains would thus be secured, for by this means misunderstandings will be avoided and prejudice will be disarmed ; moreover, the parent is able to facilitate examination and provide information, and the medical inspector's opinion could be given clearly and directly to the persons most nearly concerned."

Co-operation with School Authorities.

Certain regulations to medical inspectors are also included in this memorandum. Two of these are of considerable importance, aiming as they do at a co-operation of the school authorities. They are : " (a) The inspection should be conducted in school hours and on school premises, and in such a way as to interfere as little as may be with school work. The examination of each child need not, as a rule, occupy more than a few minutes.

" (6) The convenience of the teaching staff and the circumstances of each school must receive consideration, and in these matters and in the actual examination the medical officer will, no doubt, exercise sympathy and tact, giving due thought to the personal susceptibilities of those concerned."

The other clauses in this recommendation deal mainly with the records, method of filing them, and other matters of a statistical character which need not be detailed.