The welfare of the school child

Preface

In these pages an attempt has been made to show the importance of healthy environment for the welfare of the school child. Attention is directed in various sections of the book to the need for comprehensive and complete Public Health administration. The School Medical Service in the early stages of its growth was largely occupied in the detection and treatment of defects. The time has now come to attack the beginnings of disease and the causes of illness. Under the direction of the Ministry of Health all the forces of Preventive Medicine must be marshalled for the fray.

In preparing the book, use has been made of the publications of Government Departments, and in particular the Annual Reports of the Registrar- General and of the Medical Officers of the Local Government Board and the Board of Education.

J.C.

Contents

The National Importance of Healthy Childhood — Ante-natal Conditions — Effects of Parental Sickness — Venereal Disease — Maternal Inexperience — Industrial Employment of Mothers — Parental Occupation and Infant Mortality — Domestic Overcrowding — Defective Sanitation — Artificial Feeding — ^Need for the Reorganisation of Health Administration i

CHAPTER I Malnutrition

Nutrition — Causes of Malnutrition : Insufficient or Unsuitahle Food — Insanitary Conditions in and around the Home — ^Want of Sleep — ^Disease — Unsuitable Em^ploytnent. Prevention of Malnutrition ; Educating the Mother — The Healthy Home — Institutional Treatment — A Home Nursing Service — 'Combating Malnutrition in the School 16

CHAPTER II Dental Diseases

Dental Decay — Pyorrhoea — Overcrowding of the Teeth — Causes of Dental Disease — Preventive Measures : Enlightenment of Patents — ^Toothbrush Drill in School — Dental Inspection and Treatment — ^Dental Clinics — Need for a more Comprehensive Scheme • • • 35 viii Contents

PAGB

CHAPTER III Defects of Vision, Hearing, and Speech

Defects of Sight: Prevalence among Children—Causes — Treatment of Minor Eye Ailments — Treatment of Errors of Refraction — Special Classes — Institutions for the Blind. Diseases of the Ear and Defects of Hearing : The Chief Causes — Pievention — Education of the Deaf. Stammering : Probaible Cause — Prevention and Treatment — Special Classes — Following up the Cases — Revision Classes 4*

CHAPTER IV Heart and Lung Disease

Diseases of the Heart : Inflammation of the Cardiac Membranes and Valves — ^Causes — ^Congenital Cases — Functional Disorders — Prevention — Institutional Treatment. Diseases of the Lung : Bronchitis — Pulmonary Tuberculosis — Chronic Broncho-pneumoiia — Prevention of Lung Diseases — Domestic Treatment — Institutional Treatment 56

CHAPTER V Minor Ailments

Ringworm — Scabies — Infestation with Vermin — Injuries — Sclhool Attendance and Illness— The Exclusion of " Contacts " — ^An Alternative System . . . . 66

CHAPTER VI The Cripple-Child

Unsuitability for Cripple-children of Ordinary Schools — Approximate Number of such Children — Inadequacy of the Provision for them — 'Causes of Deformity — Surgical Tuberculosis — Infantile Paralysis — Rickets — Faulty Posture — ^How to treat Crippling iDiseases . 79

Contents ix

PAGE

CHAPTER VII The Mentally Abnormal Child

the Backward Child— The Dull Child— The Feeble-minded Child — Day Schools, Residential Schools, and Permanent Homes for Feeble-minded Children — Epileptics — After-care 91

CHAPTER VIII School Buildings

Influence of School Buildings — Defective Schools — Situation and Site — Self-contained Departments — The Class-room — ^Ventilation and Heating— Water Supply — The Cloak-room — Sanitary Accommodation — ^^Class-room Appliances — Lighting — Accommodation for the Staff . . 104

CHAPTER IX The School Annexe

The Canteen — Advantages of School Meals — The Gymnasium and its Equipment — Indoor Games — Dancing — Pocket-handkerchief Drill — Facilities for Swimming — School Bath.s — Play Centres — Treatment Centres — The Nursing Staff 118

Chapter X

Open-air Schools — Open-air Residential Schools — School Camps — Sanatorium Schools for Pulmonary Tuberculosis — Cripple Schools — Special Schools for the Blind and Deaf 134

LIST OF HALF-TONE PLATES

PLATE FACING PAGE

1. The mid-day rest .......

Frontisfiece.

2. A class-room canteen ...... r8

3. Dentist's room of a school clinic . . . . 40

4. X-ray room of a school clinic . . . .68

5. An infants' class-room 112

6. Operating-room of a school clinic .... 130

THE WELFARE OF THE SCHOOL CHILD

The nation has emerged victorious from the terrible ordeal of a European war. A fouryears' deathly combat has left upon her marks which time alone can efface. Freely she threw into the fight her best of men and her gold, yet there were moments in that long night when it almost seemed that her efforts would be without avail. The day of triumph dawned, and with it came a pestilence more destructive than the ravages of war, taxing mainly, too, the lives of healthy adults. So serious was the epidemic that in many districts the death-rate was more than double the rate at which children were born. In some homes nearly every member of the family died.

Happily, there is no doubt that from both war and disease the country can recover, and can make up the loss in man-power and in wealth.

An earnest, whole-hearted attempt must be made to build up a healthy nation.

Systematic medical inspection has revealed an appalling amount of disease and defect among the children attending the public elementary schools, and examinations carried out for recruiting purposes during the War have brought to light the crippling effects of illness in childhood.

The experience of the School Medical Service goes to show that 80 per cent, of school children need dental treatment, 10 per cent, are suffering from malnutrition, 20 per cent, from eye defects, 3 per cent, from disease or defect of the ears, and the same proportion from enlarged tonsils and adenoids. There are as well a large number with so-called minor ailments, conditions which, untreated, are often the beginning of serious disabling disease.

From an economic standpoint it is an unsound policy to provide a system of education and leave untouched defects which prevent a child obtaining full benefit therefrom. The financial burdens willingly undertaken by the State call for the strenuous exertions of every member of the community to increase the output from factories and workshops and from the land. Highly skilled workers are needed not only for industrial processes long established but for the perfecting of trades in markets yet to be won. The physically sub-normal children unequal to compete with the able-bodied, and as a rule insufficiently educated to obtain any kind of clerical work, furnish the majority of the recruits for the ranks of the unemployed. At a later stage many of them become destitute, and a lifelong charge on the nation. In the narrowest aspect it is surely advisable to secure adequate treatment, and in certain instances, by special methods of training, make those ailing and defective children an asset of the State.

But a broader view must be taken of the national importance of healthy childhood. The weakly boy, the feeble youth, the physically inefficient man, are but stages in the journey along which diseases of infancy pass unchecked.

A C3 population does not acquire its characteristics in a day, nor does it pass away without leaving a legacy.

In considering the welfare of the child of school age some thought should be given to influences which have already begun to mould the plastic frame. The effects of unfavourable ante-natal conditions, and the dangers that beset the infant and the young child, form the themes of other volumes in this Series* ; but the present volume will lack completeness unless those conditions and dangers are glanced at in these introductory pages.

Each infant, then, carries into school the result of five years of home life. For good or for evil this period will be largely responsible for the physical and mental condition of the entrant to school.

Parental ignorance, the illnesses of babyhood, an unhealthy home — these and other factors go to make the ailing, puny child,

* See "The Welfare of the Expectant Mother," by Mary Scharlieb, C.B.E., M.D., M.S., and " Infant and Young Child Welfare," by Harold Scurfield, M.D., iD.P.H.Camb. 1919.

and no scheme to safeguard the health of the school child is likely to show complete success unless there is included the care of the infant under school age.

But the health of the ba5y does not begin at birth. At least nine months before is a vulnerable period, during which, when life is not destroyed, the career of the future infant may be materially crippled.

Of the extent to which ante-natal conditions cause infant mortality, sickness, and a low standard of health in childhood, youth and adult life, it is as yet impossible to speak with any degree of certainty. The laws dealing with the registration of births and deaths expressly exclude any official record of stillbirths. Neither is it known with what frequency miscarriages occur. It has been estimated that two stillbirths and nine miscarriages take place for every hundred live births. In other words, there is a mortality of infants before birth as great as that which occurs among the survivors during the first year of life. A special inquiry in one large city showed that no less than 25 per cent, of pregnancies failed to result in a living full-time child. During the year 1917 over 20,000 deaths of children under one year of age were certified as due to premature birth.

Ante-natal causes, therefore, exact a heavy toll during the nine months of foetal life, and it is only reasonable to expect that they continue to operate after birth.

In 1917, out of 64,483 deaths occurring in children under one year of age, 25,044 took place within a month of birth, and 8,355 of these occurred within a week. No less than 7,377 babies failed to survive the first day of life, and it appears fair to assume that for the cause of the majority of these deaths search must be made among influences acting through the parents.

Reference to the different causes of death in infancy affords striking evidence of the importance of parental health.

Premature birth, congenital defects, and wasting diseases together were responsible, at least so far as certificates of deaths can be accepted as trustworthy evidence,, for 76 out of every loi deaths during 1917 in children under one year of age.

It is safe to conclude that the majority of deaths due to these conditions are attributable to causes acting before birth, and also to lack of care and skilled assistance at the time of confinement.

When it is realised that out of a thousand pregnancies, ante-natal causes bring about within a year and nine months a fatal termination in approximately two hundred instances, some idea will be obtained of the magnitude of the devastation. It may be useful, therefore, to attempt to define some of the unfavourable influences which may act through the parents before the birth of their offspring, and to discover in what measure they may be prevented.

Of the amount of infant sickness and ill-health during childhood and youth attributable to ante-natal causes, there is as yet insufficient evidence to warrant a definite estimate. However, it may be said that a high infant death-rate in a given community implies in general a high death-rate in the next four years of life, while a similar association is found between low death-rates at both age-periods.

It has been shown that children of school age suffering from malnutrition commonly come from families where there has been a relatively high rate of infant deaths, and it may be expected that any condition likely to bring about infant death will certainly entail a large amount of sickness in childhood.

The effect of parental sickness on the health of the children is more important than might at first sight appear. Ill-health of the father, tending to inefficiency as a workman, leads to poverty and domestic privation, and causes the family to drift into insanitary surroundings. Maternal sickness often brings about neglect of infant care, the abandonment of breast-feeding, and lack of attention to general household duties. Venereal disease is a potent agent in infant mortality. Evidence given before the Royal Commission on Venereal Diseases showed that of 102 children examined at a blind school, in 47 instances the blindness was due to venereal disease. A similar investigation at a French institution suggested that 50 per cent, of cases of blindness could be traced to the same cause. Another witness stated that the histories of 34 syphiHtic mothers showed that only 16 per cent, of children born alive were apparently or doubtfully healthy,

A high infant mortality may arise from the inexperience associated with unduly early motherhood. The home surroundings of the child of parents marrying before they are able to maintain a suitable home are likely to affect prejudicially the infant's physical condition. It has been shown that counties with a high proportion of wives under age have a high infant death-rate, and, on the other hand, that those with a low proportion of wives under age have a low rate of infant mortality. In this respect it must be remembered that the counties in which marriage is postponed to a more mature age are chiefly rural in character.

Certain occupations of parents, and particularly the industrial employment of mothers, have an unfavourable ante-natal effect on the health of their children. Bcr yond this, there is the even larger question of the neglect of home life and the lack of motherly care and attention experienced by the children left under the charge of an elder child or a neighbour. Artificial feeding is resorted to at the earliest possible moment, with the attendant evils of unwholesome, contaminated food improperly prepared. At the close of a day of heavy work the employed mother has little inclination or physical capacity to carry out those important domestic duties essential to the cleanliness of the house and the comfort of the family. The occupations of parents are so intimately bound up with social position and home sanitation that it is difficult to eliminate the other considerations involved. It is notorious, however, that deaths from measles, whooping-cough, and similar diseases are relatively rare among the children whose parents belong to the upper and middle classes. Statistics recently compiled show that the death-rate of children 6 to 12 months of age whose fathers were clergymen was 16. 1 per 1,000 births, while the infants of sandwichmen and bill distributors died at the rate of 166. Nor is the reason far to seek. The former have the advantage of well-ventilated rooms and clean, wholesome food, and generally spend their childhood under efficient supervision and sanitary surroundings. The latter, fed on unclean and unsuitable food, housed under conditions of poverty and overcrowding, are left to play about in yards and passages, exposed to all the dangers of defective sanitation.

A relation has been stated to exist between moderately small families and a low infantile mortality, and it is probable that any connection between a high birth-rate and a high rate of infant death arises from the fact that large families are common among the working classes, and that these classes are particularly exposed to influences unfavourably affecting infant and child life. Large families frequently tend towards some degree of poverty, forbidding removal into a house sufficiently roomy for proper accommodation. Domestic overcrowding therefore follows, with its innumerable evils.

Domestic overcrowding is responsible for a large proportion of the minor ailments affecting childhood. Children are anaemic, ill-nourished, and puny because they have

II insufficient room in which to live, impure air to breathe, and unclean, unsuitable, and improper food to eat.

Undoubtedly, the outstanding cause of death and disease among children is defective sanitation, either in the house or in its immediate surroundings. The injurious effect of insufficient accommodation for washing and of the absence of proper storage for food is not likely to be denied. Unpaved yards, middens, pail closets and uncovered ashpits are effective weapons with which to destroy young life. The results of insanitation can be seen in an excessive death-rate from diarrhoeal diseases and in the prevalence of other preventable illnesses of childhood. A high death-rate implies a high rate of damage among survivors. For every infant that succumbs there are many who just manage to survive, and are left as battered wrecks on the ocean of life. The permanent crippling effect of disease is as yet imperfectly appreciated.

It is fair to assume that parental ignorance and poverty are closely related to the prevalence of sickness and death in childhood. Want of knowledge on the part of parents is mainly responsible for two sources of risk to child life, namely, artificial feeding and food contamination.

It is true that artificial feeding is common among the children of the upper and middle classes — sections of the community with a relatively low rate of death. On the other hand, an increasing prevalence of breast-feeding among working-class mothers is coincident with a diminution in infant mortality. The child of a professional man, born into a favourable environment, possessing every advantage afforded by nursing and medical skill, can be placed on a carefully selected artificial food, prepared under hygienic conditions, without risk to health or physical development. The infant of an unskilled labourer, compelled to live in insanitary surroundings, hafndicapped by the disadvantages of impure air and soil, finds the mother's milk a safeguard against the dangers of polluted and suitable food. To such a child, artificial food, unless municipal enterprise intervenes, may be cow's milk of an inferior quality, grossly contaminated before delivery in the home ; or some indigestible substance improperly prepared in a dirty utensil, and exposed to dust and flies.

Lack of facilities for the immediate treatment of small childish ailments, too often neglected owing to their apparent triviality, and the absence of skilled nursing during serious illness, are answerable for much easily preventable suffering and physical damage during the early years of life. The serious after-effects of diseases such as measles and whooping-cough, and the deformities arising from acute poliomyelitis (infant paralysis) and tuberculosis, could be largely prevented were adequate nursing assistance available for the community.

The health of the school child, it must be repeated, depends very largely on the health of the parents and the environment during babyhood. Much of the disease and defect caUing for treatment during school age has a beginning in the first years of life, and could be prevented by appropriate Public Health measures. Further facilities for the education of the prospective mother, the establishment of maternity centres, the provision of an adequate number of trained nurses as health visitors on the staff of each Medical Officer of Health, and sufficient hospital accommodation, are urgently needed in almost every locality. Under the Ministry of Health it is to be hoped that both central and local administration will be reorganised, so that the prevention and treatment of disease may be carried out by one Service under one control and that vested interests will no longer be permitted to obstruct the removal of conditions injurious to life.

CHAPTER I Malnutrition

In the first five chapters of this book we shall consider the case of the physically defective child — the child who is the victim of malnutrition, or who has defects of teeth, of vision, of hearing, or of speech, or who suffers from heart or lung disease or from minor ailments. Of these physical defects, brought to light by systematic medical inspection in schools, malnutrition is probably the most important, both to the nation and to the individual child. Its widespread prevalence, the obscurity of its origin, and the insidiousness of its onset combine to make it a problem that cannot be ignored.

Nutrition is a comprehensive term embracing a complex condition. It may be regarded as one of the most reliable signs of a healthy body, the various systems of which are properly carrying out their physiological functions. In estimating the state of nutrition, there is to be taken into account the relationship between the height and weight of the child, its general demeanour, the

i6 texture of the muscles, and the appearance of the skin. Alert carriage, firm muscles with a covering of fat, and a healthy elastic skin are evidence of good nourishment.

As there are yet no definite and reliable standards by which these various factors can be measured and no index that is generally applicable, the classification of the state of nutrition of a child will largely depend on the personal experience of the observer. It is not surprising, therefore, to find wide variations in the results of the examinations carried out by different School Medical Officers. In some areas a considerable departure from the average may be expected, owing to conditions peculiar to the locality, such as the prevalence of child labour or Bad housing.

But when allowance is made for the difficulties encountered in arriving at a decision in any particular case, and for the influence of local conditions, there remains the fact that about a tenth of the child population attending the public elementary schools of the country is suffering from malnutrition, and that less than a half is well nourished.

In considering the national and industrial aspects of the serious position revealed by the systematic medical inspections carried out since 1908, it may be suggested that a successful stockbreeder would view with dismay the discovery that c 17 less than half his young cattle were thriving and in good condition — in other words, well nourished. He would at once seek the cause, and, having found it, would bring about its removal and prevent a recurrence.

Possibly he might find that the malnutrition was due to in-breeding, or to inherited disease or defect. It is more likely, however, that the feeding would prove to be at fault, the sheds insanitary or overcrowded, and the animals neglected. The stock might be recovering from the effects of some disease, or want of cleanliness might account for the failure to thrive.

A healthy herd cannot be reared from ill-nourished young, nor can a vigorous race be expected from a school population in which a million children are suffering from malnutrition.

In so far as this condition leads to physical unfitness and in many cases to definite disease, it imposes a tax on the community and reduces the earning power of the nation.

The ill-nourished child is prone to minor ailments, susceptible to tuberculosis, listless, apathetic, Incapable of sustained mental effort.

The causes of malnutrition are as yet imperfecdy understood. It is certain, however, that among the more important are the following : —

I. Insufficient or unsuitable food. — The rapidity with which ill-nourished children improve

i8 when in attendance at school canteens or after admission into institutions supports the assumption that either improper feeding or lack of food is a potent factor in the causation of malnutrition. While it is true that poverty may sometimes be ihe reason, it is much more usual to find that want of knowledge on the part of mothers of the value of the various foods, and inability to obtain by simple cooking the full nutriment from foodstuff, are chiefly responsible.

The reports of School Medical Officers clearly show an appalling amount of ignorance in simple home cooking and in the general management of the house, but it must not be thought that mothers refuse to learn when an opportunity is offered. The success achieved by schools for mothers points the way along which future effort must be made.

2. Insanitary conditions in the home* (a) Lack of air and sunlight. — The good results apparent in the health of children in attendance at open-air schools seem to furnish evidence that lack of air leads to ill-nourishment.

Unless sunlight can enter every living-room at some period of the day, dirt and dust are likely to be allowed to accumulate. The destructive effect of the rays of the sun on germ life is an additional reason for the ample natural lighting of rooms.

Staircases, passages and cupboards which are dark and ill-ventilated are difficult to keep clean and dry. Dark recesses are often used as receptacles for various forms of refuse. Although considerable controversy has centred round the question of the effect of back-to-back houses on the health of the inhabitants, there can be no doubt that it is a method of construction which should unreservedly be condemned. In some districts householders are still permitted to erect without restriction buildings in back yards. The effect of this is further to reduce the already insufficient yard area, and to shut off a considerable amount of light and air. Even at the present day insufficient use is made of the windows and other means of ventilation provided.

Unfortunately, in many industrial areas the open window brings dirt and dust and a soot-laden air.

(b) Overcrowding. — On every side there is an appalling dearth of houses. The supply of new houses before the War was not nearly equal to the demand. Since 1914 building has been almost suspended and repair of property has been neglected, with the consequence that overcrowding is rampant in most industrial areas and in many rural districts. One estimate has put the need at a million new houses. Accepting this, it follows that some four to five million persons are living under conditions of overcrowding. Obviously the health of the child is likely to be injured by the unfavourable mental, moral and physical surroundings associated with the overcrowding of persons in a room, particularly when that room is used for sleeping purposes. The vitiation of the atmosphere, the difficulty experienced in washing and cleaning, and the liability to contamination of food through lack of a suitable place of storage diminish vitality and retard nutrition.

(c) Closet and refuse accommodation.— The offensive, insanitary privy midden and that equally disgusting modification of it, the pail closet, have a baneful effect on nutrition. These relics of the Middle Ages are detrimental to decency, they cause noxious effluvia, they encourage the presence of swarms of flies, and they lead to the fouling of yards and passages. Although it is not easy to demonstrate the exact part played by the substitution of water carriage for the conservancy system in reducing infant mortality, since other important sanitary improvements are usually associated with it, such as the paving of back yards and the provision of suitable dustbins, yet its value to health is beyond question. In one district the infant death-rate in houses with the water carriage was 117; in those with pail closets or privy middens, 250. It has been estimated that, other things being equal, by converting privy middens to water-closets a reduction in the infant death-rate of more than one-half may be expected. A high rate of infant mortality, as we have seen, is always associated with a large amount of sickness and ill-health among the survivors.

(d) The storage of house refuse. — Intimately related with the disposal of faecal matter is the storage of domestic refuse. Large, uncovered ashpits, emptied at infrequent intervals, or wooden receptacles deposited in brick ashplaces, are dangerous and totally unsuitable. The accumulation, consisting of ashes and a mass of highly objectionable filth readily liable to decompose, forms a serious menace to health and decent living.

(e) The yard and the street. — Much of the ill-health and consequent malnutrition of children during the summer and early autumn arises from the consumption of contaminated food. Outside school hours the yard and the street are the only playgrounds available to many of the children attending the public elementary schools. An unpaved or defectively paved surface with broken gullies and leaking channels allows waste and slop water to soak into the soil. In wet weather pools of water collecting in the yard are converted into puddles, into which garbage and other debris are thrown. Children playing in surroundings such as these soon become fouled with the dirt, which is carried into the house. In warm weather flies are attracted to the pools and the rotting material ; direct contamination of food in adjacent premises soon follows.

In yards common to several houses similar conditions will be found. A further disadvantage is that a yard which is shared by several houses is rarely kept clean. The influence of an undesirable tenant in one of the houses extends to the other members of the small community. The occupants of the other houses not unnaturally become disheartened on seeing their own efforts at cleanliness frustrated by a slovenly neighbour.

Infectious and contagious diseases are more easily spread where there are ample opportunities for frequent contact in an open yard. With a common yard, too, is frequently found a common water supply. In districts where the sub-letting of houses is prevalent and the only water supply a tap on the ground floor, the use of clean water will be reduced to a minimum.

Much of what has already been said with regard to unpaved yards applies with equal force to unpaved passages. Unless efficient sweeping is carried out daily these passages are little less than a refuse tip for the adjoining houses.

No less important is the state of the paving and cleansing of streets. It would often seem that the health aspect of this question had been entirely overlooked. Dirty streets are the precursors of disease, and children are the first to fall victims to it. Horse-manure and other refuse trodden underfoot in wet weather is splashed over pedestrians and over food displayed in shop windows. During dry seasons a cloud of dust, mainly composed of finely powdered manure and human expectoration, is blown over fruit and other foodstuffs and into the houses. In towns where considerable attention has been paid to the paving and tar dressing of roads, it has been noted that dirt-borne diseases, such as impetigo in children, are rarely seen.*

3. Want of sleep. — The investigations carried out by school nurses show that malnutrition can often be traced to insufficient sleep. Few children obtain the rest that a growing animal requires.