MEDIG 
 
 NSPECTION 
 
 OF SCHOOLS 
 
 A.H.HOGARTH 
 
LIBRARY 
 
 OF THE 
 
 University of California. 
 
 Class 
 
OXFORD MEDICAL PUBLICATIONS 
 
 MEDICAL INSPECTION 
 OF SCHOOLS 
 
OXFORD : HOEACB HAKT 
 PEINTER TO THE UNIVERSITY 
 
OXFORD MEDICAL PUBLICATIONS 
 
 MEDICAL INSPECTION 
 OF SCHOOLS 
 
 BY 
 
 A. H. HOGARTH 
 
 M.B., B.Ch., Oxon., D.P.H. 
 
 COUXTY MEDICAL OFFICER OF HEALTH FOR BUCKINGHAMSHIRE 
 
 ASSISTANT MEDICAL OFFICER (EDUCATION) LONDON COUNTY COUNCIL 
 
 MEDICAL OFFICER MANSION HOUSE COMMITTEE ON THE DWELLINGS OF THE POOK 
 
 UNIVER^.a 
 
 OF 
 
 LONDON 
 
 HENRY FROWDE HODDER 8c STOUGHTON 
 
 Oxford University Press Warwick Square, E.G. 
 
 1909 
 

 OvKOVP Koi laTpLKt], €(j)rjV, iTnaTT] (JLT) IdTlV 
 
 Tov vyuivov ; 
 
 Plato, Charmides, 165 C. 
 
 We are taught to live when our life is well-nigh spent. 
 
 Montaigne. 
 
TO 
 
 DR JAMES KERR 
 
 THE FIRST ' SCHOOL DOCTOR 
 
 196436 
 
PREFACE 
 
 The scope of this textbook is necessarily confined 
 to the needs of elementary schools. The value of 
 medical inspection for secondary schools, to which 
 incidental reference is made in Chapter VI, is equally 
 obvious. In course of time its necessity will be 
 generally admitted. 
 
 The chapter on school diseases is intended partly 
 for teachers and educationalists and partly for school 
 doctors, and has consequently been written less from 
 the clinical and medical than from the school point 
 of view. Any attempt to deal more fully with the 
 diseases specified would have exceeded the limits of 
 the present volume. 
 
 Acknowledgments are due to many friends for 
 invaluable criticisms and suggestions, but especially 
 to my sister, to Dr. E. M. Niall, and to Mr. L. Cope- 
 Cornford. 
 
 ToYNBEE Hall, Whitechapel. 
 February, 1909. 
 
CONTENTS 
 
 OHAP. PAGE 
 
 I. Introduction I 
 
 II. History and Legislation : 
 
 Endand and other countries ... 9 
 
 1. History 9 
 
 2. Legislation 25 
 
 III. The Case for Medical Inspection . . 35 
 
 IV. The State's Responsibility .... 42 
 V. Schools and the Public Health . . 57 
 
 VI. The Claim of the Individual Child . . 70 
 
 Recapitulation 78 
 
 VII. The General Principles and Aims of 
 
 Medical Inspection 79 
 
 VIII. School Hygiene as a Factor in State 
 
 Medicine 92 
 
 The Organization of a Central Department 
 
 IX. Local Organization of School Hygiene . Ill 
 
 X. The School Doctor : his Duties and Quali- 
 fications 138 
 
 XI. The School Doctor : his Methods . . 156 
 
 XII. The School Nurse 172 
 
 XIII. Administrative Routine . . . .187 
 
 XIV. Medical Treatment at School . . . 209 
 XV. The School Clinic 237 
 
 XVI. Common Diseases affecting School Life ; 
 
 1. General Diseases 260 
 
 2. Symptomatic or Local Diseases . . . 278 
 
 3. Chronic Contagious Diseases . . . 293 
 APPENDIX 
 
 I. Bibliography : 
 
 L Medical Inspection of Schools . . . 298 
 
 2. School Hygiene 299 
 
 II. Extracts from Official Documents and 
 
 Memoranda 303 
 
 III. Forms and Schedules . 330 
 iNDEX 339 
 
OF THE 
 
 UNIVERSITY 
 
 CF 
 
 CHAPTER I 
 INTRODUCTION 
 
 Medicine the Science of Health.— Importance of Preventive Medicine 
 not generally Recognized.— Evil Results of Industrial System of Nine- 
 teenth Century. — Policy of Laissez-Faire.— Educational Progress more 
 Apparent than Real— National Bill of Undischarged Obligations.— 
 Mental Deterioration. — Backwardness of England as a Nation. — Is 
 Education the Panacea ?— Medical Inspection of Schools the First 
 Step.— Two Courses: (1) Suicidal Policy of Laissez-Faure ; (2) Adminis- 
 trative Activity. — Both Courses involve Equal Expenditure. 
 
 The proverbs of every race and country are a 
 national possession, the heritage of succeeding genera- 
 tions. The more fallacious are quoted on all sides 
 with apparent reverence. Others containing germs of 
 truth are neglected. Of such a kind is the maxim 
 that ' Prevention is better than cure '. It is on every 
 one's lips almost from childhood, but its principle — 
 remarkably true — is ignored by all sorts and conditions, 
 the rich and the poor, the educated and the ignorant. 
 * Medicine', wrote Plato more than two thousand years 
 ago, * is the science of health '. To-day it is popularly 
 regarded as the science of disease. But had the truth 
 of Plato's dictum been recognized, some Government 
 department of preventive medicine would long ago 
 have been established in our midst ; and we should 
 be in the habit of paying for medical attendance only 
 while we were actually maintained in good health, 
 
 HOGARTH -D 
 
2 MEDICAL INSPECTION OF SCHOOLS 
 
 The truth of the principle that prevention is better 
 than cure is appreciated only in the face of actual 
 and imminent danger, such as the outbreak of cholera 
 or small-pox. In such an emergency nothing is left 
 undone, no expedient is left untried. The preventive 
 measures adopted may even savour of extravagance. 
 But the crisis weathered, our national lethargy resumes 
 its sway. It is thought unnecessary and contrary to 
 precedent to make costly provision for possible, or 
 even for probable, contingencies. And under a form of 
 government theoretically democratic, legislative en- 
 thusiasm is not to be anticipated in regard to any 
 principle which is still awaiting general acceptance. 
 Public opinion must first be impressed by solid argu- 
 ment based on vsubstantial facts and common sense. 
 Then progress may be expected. 
 
 Here, consequently, is found one reason why public 
 opinion in England, and even the medical profession 
 itself, has for so many years withheld judgment upon 
 the necessity for the medical inspection of school 
 children. 
 
 Had the importance of preventive measures been 
 more thoroughly realized, there would have been less 
 delay both in the recognition of the necessity for, and 
 in the institution of, medical inspection. The most 
 superficial physical examination at school undoubtedly 
 tends to prevent much actual ill health, owing to the 
 resultant discovery of disease in its early stages as well 
 as of many simple ailments which might ultimately 
 hooomc serious. 
 
INTRODUCTION 3 
 
 But the general neglect of an essential principle, 
 continued from generation to generation, must involve 
 the inevitable penalty of procrastination. The history 
 of the last hundred years serves to show that the 
 nation is now confronted with a sum of accumulated 
 evils, which are the direct consequences of the in- 
 dustrial system estabHshed in the early years of the 
 last century. 
 
 Almost a hundred years ago England, released from 
 the strain of perpetual warfare, turned to the develop- 
 ment of her rich and virgin resources, and became the 
 workshop of the world. She supplied to other nations 
 the materials wherewith to build afresh the shattered 
 fabric of their civilization. Wherever coal and iron 
 were discovered, huge towns sprang into ugly being, 
 and grew and spread, and there was an immense and 
 sudden increase of population. 
 
 The spirit that was born of the Industrial Age was 
 characterized by the greed of gain. It dominated the 
 whole community, alike in politics and in private life. 
 The doctrine of the economists of the Manchester 
 School, known as laissez-faire, was accepted as a law 
 of nature ; and there was little attempt to check 
 the evils of the industrial system. 
 
 It was during the industrial age that children spent 
 the greater part of their days as slave apprentices, 
 that the wrongs of the sweating system were developed 
 to their fullest extent, and that houses and factories 
 were built with the minimum outlay that could secure 
 a quick return for money invested, without any regard 
 
 b2 
 
4 MEDICAL INSPECTION OF SCHOOLS 
 
 to such immediate requirements of health as were 
 understood at the time. 
 
 Among the more obvious results were the continued 
 growth of towns, great aggravation of the original 
 inequality in the distribution of wealth, consequent 
 accentuation of the extremes of luxury and poverty, 
 overcrowding in cities, and all the attendant evils of 
 town life. Above all, there was an enormous increase 
 of population. 
 
 England was asleep, asleep to all national needs, 
 except the accumulation of material wealth. No 
 preventive measures were seriously considered. No 
 provision for the future was made, no care or attention 
 was given to the problems of the immediate present, 
 except with a view to the extension of the industrial 
 system. This attitude of the Legislature and of the 
 Government was but a reflection of the apathy and 
 the improvidence of the country at large. In a word, 
 the ideal was individual aggrandizement, involving 
 the loss of individual peace and contentment, and im- 
 plying the neglect of all other interests. Education 
 was neglected. Medicine was still in its days of dark- 
 ness. The notable exceptions that can be quoted 
 from the history both of individuals and of legislative 
 effort were by no means in harmony with the spirit 
 of the age. 
 
 The Education Act of 1870 marked a beginning of 
 progress. But the influences of the past were still 
 powerful. The newer ideal was overshadowed by the 
 industrial system, by the continual growth of cities, 
 
INTRODUCTION 6 
 
 by apathy and neglect, as well as by ignorance and 
 poverty. The result was that for many years progress 
 was more apparent than real, and was often most 
 marked when tending in a wrong direction. 
 
 Towards the close of the nineteenth century, Eng- 
 land was brought face to face with the serious problem 
 of a vast aggregate of unfulfilled responsibilities. The 
 sins of the fathers were being visited on the third and 
 fourth generations. The nation realized for the first 
 time not only the misery, the degradation, the poverty, 
 the vice of its people, but the increase of crime and 
 of lunacy, and above all, the neglected health and the 
 neglected education of its children. More advanced 
 opinion was impressed by the urgency of the problem, 
 but the general tendency was to ignore or to under- 
 rate its urgency, to seek to gain time — in fact, to 
 put off the day of reckoning as long as possible. 
 
 At the beginning of the twentieth century, the same 
 problem confronts us. Are the evils to be allowed to 
 continue and to bequeath an ever-increasing debt to 
 posterity ? Or is there to be some attempt to cancel 
 the debt and to save the wreckage ? 
 
 Even apart from the heavy national bill of undis- 
 charged obligations, the prospect affords Httle ground 
 for complacency. Our industrial supremacy may or 
 may not be declining, our race may or may not be 
 degenerating in character and in physique. But, at 
 all events, evidence of serious mental and intellectual 
 deterioration is not wanting. It is a far from encourag- 
 ing reflection that, at the very time when the nation 
 
6 MEDICAL INSPECTION OF SCHOOLS 
 
 is beginning to appreciate its real position, it should 
 apparently have lost the power of vigorous, dis- 
 interested, and intelligent action. 
 
 To say nothing, for the moment, of mental deteriora- 
 tion, there is little doubt that the general level of 
 education among the people of England is set on 
 a lower plane than that which is observable in Con- 
 tinental countries, though these may be smaller and 
 less prosperous than our own. Evidence of mental 
 and intellectual deterioration is to be found in the 
 national attitude of mind towards the more vital 
 problems of life, towards education, and towards our 
 plain duty to posterity. The English public school 
 ideal is characteristic. It aims at turning out gentle- 
 men and ' good fellows ' — who, as Herodotus tells us 
 of the Persian youth, are taught ' to ride and speak 
 
 the truth'. 
 
 To-day, England is living on her reputation. Her 
 people exist for appearances. ' Education is doing 
 its work. To take everything for granted, to grasp 
 fringes and avoid fundamentals, to think only of the 
 obvious',^ — these are the ideals with which the present 
 generation is inspired. 
 
 Another symptom of mental and intellectual de- 
 terioration lies in the fact that England as a nation 
 now tends to lag many years behind the development 
 of other countries in most spheres of activity — always 
 excepting those of sport, of pleasure-seeking, and of 
 money-making. 
 
 ' The (Jrty World, by Evelyn Ladeihill. Heinemaim. 
 
INTRODUCTION 7 
 
 What, then, is to be done ? Is education the 
 remedy ? If so, our educational system must be 
 revised and placed on a scientific basis. Now is the 
 time to lay the foundation of a science of education. 
 Medical inspection of schools and of scholars is the 
 beginning, a long-deferred step in the right direction. 
 
 The institution of medical inspection by the Educa- 
 tion Act of 1907 must be regarded primarily as an 
 attempt to save wreckage, and only secondarily as 
 a foreshadowing of better things to come. The legis- 
 lature has at any rate done its part and prepared the 
 way. It rests with our administrators to realize their 
 responsibilities, to rouse public opinion from its lethargy 
 and, by following the spirit rather than the letter of 
 the law, to develop the scheme into a system of pre- 
 vention. In their efforts both to deal with the legacy 
 of evil accumulated from the past, and to dissipate 
 popular ignorance and apathy, the choice must lie 
 between two possible courses. Both of these, if rightly 
 considered, involve equal expenditure. They are : — 
 
 1. A policy of laissez-faire. 
 
 2. The fulfilment by prudent activity -of the maxims : 
 Prevention is better than cure; and Medicine is the 
 science of health. 
 
 The first course implies that the sick, ailing, and 
 defective children of the present day and the adults 
 of the next generation will continue to be treated in 
 hospitals, asylums, prisons. Poor Law infirmaries, and 
 convalescent homes. The maintenance of these insti- 
 tutions involves heavy expenditure in rates and in 
 
8 MEDICAL INSPECTION OF SCHOOLS 
 
 charities, with little to show for it. For, there has 
 been no attempt to prevent the onset of ill-health, 
 while the ravages of neglected disease continue almost 
 unchecked. Such a policy defeats its own ends. 
 
 The second course, which also involves the expendi- 
 ture of money, is one of reasoned and far-seeing ad- 
 ministrative design. It implies the fearless recognition 
 of facts as they are and courageous action. Steps must 
 be taken to prevent the occurrence of disease, not only 
 recognized forms of infectious and contagious disease, 
 but the chronic insidious diseases of childhood. When 
 it is discovered that no remedial treatment is being 
 applied, whether on account of incapacity, poverty, 
 ignorance, or vice on the part of parents, the necessity 
 for some form of municipal treatment must also be 
 considered. In return for this careful administration 
 and for the inconsiderable outlay which is involved — 
 certainly not the cost per annum of one battleship — 
 there will, without shadow of doubt, be secured 
 a higher standard both of physical development and 
 of educational results. 
 
 In a word, administrative expenditure of this kind 
 is the soundest economy. Such is the justification 
 of the plea for adequate and efficient medical inspec- 
 tion of schools and scholars as interpreted in the 
 following pages. 
 
CHAPTER II 
 HISTORY AND LEGISLATION 
 
 (1) Historical Review of School H3'^giene in its Relation to Educa- 
 tion. — Schools of Hellas. — Rabelais. — Montaigne. — Ascham. — Mulcaster. 
 — Comenius. — Locke. — Rousseau. — Basedow. — Gutsmuths. — Festal oz zi, 
 Herbart, and Froebel. — Backwardness of England. — Progress in Sweden, 
 Germany, France, and other Countries. — Scientific Investigations by 
 Medical Men abroad and in England. — Health Inspection and School 
 Hygiene Confused. — Inactivity of Education Department. 
 
 (2) Review of Legislative Eflforts in different Countries. — Austria. — 
 France. — Argentina. — Norway. — Sweden. — Japan. — Switzerland. — Ger- 
 many. — United States. — Russia and Bulgaria. — Municipal Enterprise. — 
 Summary. — International Congress of School Hygiene. — Legislation in 
 England. — Education (Administrative Pro%'isions) Act, 1907. — No Pre- 
 paration by Central Authority. — Present Organization the Outcome of 
 Sporadic Impulse. 
 
 (1) History 
 
 In the schools of Hellas, at least one aspect of 
 school hygiene, namely, physical education, was recog- 
 nized as a means of developing the ideal citizen — the 
 true function of education. The training of the body 
 was regarded as of equal importance with the training 
 of the mind. But in the Greek world physical educa- 
 tion was a reality. It did not consist of a systematized 
 code of physical exercises, nor of a course of physical 
 training imposed at set times. It was a natural educa- 
 tion of the child's body, directed partly to securing 
 healthy growth and development of good physique, 
 and partly to creating a favourable reaction upon the 
 
10 MEDICAL INSPECTION OF SCHOOLS 
 
 child's mental and moral activities. ' Man,' to quote 
 Mr. Freeman, ' was a Avhole to the Hellenes, and one 
 part of him could not be sound if the other parts were 
 not. A national school which trained the minds only 
 and neglected the bodies of the pupils would have 
 been inconceivable to a Hellene '.^ 
 
 Since early Grecian times, there has been no ade- 
 quate system of national education. Study of school 
 hygiene has been confined to a few advanced thinkers 
 and educationalists. Of these, Roger Ascham, 
 Richard Mulcaster, and John Locke were the 
 first in England. But earlier in the sixteenth 
 century Montaigne, following closely in the steps of 
 Rabelais, had discovered the necessity for teaching 
 temperance and hygiene, and had recognized how 
 seldom, owing to their unsatisfactory upbringing, the 
 young men of France fulfilled the promise of their 
 childhood. 
 
 A generation or so later, Comenius — the father of 
 modern education — evolved an educational system, in 
 which school hygiene certainly found a place. He 
 constantly urged the necessity for physical training, 
 and emphasized the importance of providing * airy 
 schoolrooms and pleasant playgrounds '. He insisted 
 that educational methods should be in accordance 
 with Nature, and was the first to establish a practical 
 system of objective instruction. Moreover, he was 
 fully aware of the importance of adapting the school 
 
 ' Schools of Ildlui : OUO-300 B.C.. by Kenneth T. Freeman. Mac- 
 uiillaii & Co., i'JU7. 
 
HISTORY AND LEGISLATION 11 
 
 routine and curriculum to the physical and mental 
 needs of the children. Comenius won a far-reaching 
 reputation, and visited England, Sweden, and many 
 parts of Central Europe for the purpose either of 
 reforming the systems of education which were in 
 vogue at the time, or of introducing his own. 
 
 Towards the end of the seventeenth century John 
 Locke published his Thoughts concerning Education, 
 which was the first attempt in England to treat the 
 subject in a broad and comprehensive manner. 
 Owing to his study of pohtics and philosophy 
 as well as of medicine, the author was able to view 
 education in its right perspective, to consider the 
 subject as a whole, and to lay down rules not only for 
 mental and moral but also for physical training. 
 Locke was the founder of school hygiene in the true 
 sense of the term. For he had combined the duties 
 of physician and pedagogue in a practical way ; 
 he was also a psychologist endowed with some 
 knowledge of the growth and development of a 
 child's mind and with practical insight into a child's 
 mental processes. 
 
 Among the educationalists of the eighteenth century 
 Rousseau is pre-eminent as a theorist. His influence 
 was due to his accurate observation of child life, 
 which enabled him to teach his lesson and to lay the 
 foundation of one branch of school hygiene. Basedow, 
 about the same time, originated an educational 
 system which contained some germs of truth, but he 
 experienced great difficulty in the practical application 
 
12 MEDICAL INSPECTION OF SCHOOLS 
 
 of his scheme. However, it was due to his influence 
 that a little originality was introduced into the dreary 
 methods of physical training which prevailed at that 
 time in Germany. His insight into children's physical 
 and educational needs was probably a consequence of 
 his early training as a doctor. Gutsmuths was the 
 first of modern educationalists to pay any special 
 attention to physical training. His work Gymnastik 
 filr die Jugendwas published in 1793 and long remained 
 the basis of all systems of physical education. 
 
 These ideas and suggestions stimulated educa- 
 tional activity on the Continent, and probably in- 
 fluenced the methods and teachings of Pestalozzi, 
 Herbart, and Froebel. In England, they fell on 
 barren soil. 
 
 There was certainly no room for school hygiene at 
 a time when the children of the poor spent the greater 
 part of their days as slave apprentices. Public feeling 
 at the beginning of the nineteenth century may be 
 gauged from the fact that, in 1803, both manufacturers 
 and parents successfully petitioned against the enforce- 
 ment of the Factory Act of the previous year — an Act 
 which merely proposed a primitive scheme for safe- 
 guarding the health and morals of apprentices in mills 
 and factories, and for instructing them during their 
 first four years of apprenticeship (generally speaking 
 from 7 to 1 1 years) in reading, writing, and arithmetic.^ 
 The provisions of the Act were never enforced, and 
 an evil state of affairs continued for many years. 
 
 ' The Progress of Educalion in England. Montmorency, 1904. 
 
HISTORY AND LEGISLATION 13 
 
 There is indeed no record ^ of interest in educational 
 hygiene till the close of the nineteenth century, and 
 even then advanced educationalists had lost sight of 
 its importance, owing to their absorption in theoretical 
 discussions upon the various methods and comparative 
 merits of Pestalozzi, Herbart, and Froebel. 
 
 Abroad, however, school hygiene claimed a few 
 isolated apostles, — not among educationalists, but 
 among those more enlightened members of the 
 medical profession who interested themselves in the 
 schools. 
 
 First was Peter Frank of Austria, who studied the 
 subject of school fittings and sanitation and suggested 
 a complete scheme of medical police. Then came 
 Peter Henrik Ling, the founder of physical education 
 in Sweden. He was born a poet, but applied himself 
 to the study of anatomy, physiology, and hygiene, 
 with the idea of organizing a scientific system of physical 
 training. In 1813, the Government formally adopted 
 his system and established a Central Gymnastic Institu- 
 tion at Stockholm under his direction. Here Ling 
 devoted his life to ' training a generation of teachers 
 through whom he hoped knowledge of his system 
 might gradually be spread throughout Sweden '.^ As 
 a result of these new ideas of hygienic training, medical 
 men were attached to the staff of some of the secondary 
 
 * It is interesting to note that at this very time (1803-12) John 
 Ware, of Chelsea, called attention to the relation between eyesight 
 and educational pursuits. 
 
 ^ The Organization of Physical Training in Sweden. Board of Educa- 
 tion Pamphlet. No. 11. 
 
14 :\rEDICAL INSPECTION OF SCHOOLS 
 
 schools as early as 1830, and were responsible for 
 a reduction in the amount of school lessons. But 
 there is little record of their work until their duties 
 were prescribed by statute in 1868. 
 
 Apart from physical training, Dr. Karl Lorinser was 
 the first medical man to make a thorough study of 
 school hygiene. In 1836, he published a pamphlet, 
 Zum Schutze der Gesundheit auf Schulen, in which 
 he attacked the educational system and pointed out 
 that the long school hours, the subjects taught, and 
 the school management generally, were largely respon- 
 sible for deterioration of the children's health. This 
 created a great stir in Germany, and led to the general 
 admission that school hygiene was a subject for special 
 and thorough study. In 1842, Dr. Seguin published 
 a book, Le Traitement moral, hygiene et education des 
 idiots, which marked a great educational advance in 
 the field of school hygiene. It is the first practical 
 differentiation of educational methods for idiots ; and it 
 was soon followed, even in England, by the establish- 
 ment of a number of institutions for the education of 
 the feeble-minded. 
 
 In England, for the most part, the health of the 
 school child and the hygiene of educational methods 
 received no attention. The children, coming as they 
 did from well-to-do homes, were not considered to be 
 in any need of health inspection. Cleanliness was 
 essential. For instance, in 1823-30 at the Borough 
 Road School, ' a dirty arrival would be washed by 
 a girl sent from the other (girls' school), to our amuse- 
 
HISTORY AND LEGISLATION 15 
 
 ment '.^ Gradually the habit of school attendance 
 became more general among the poorer classes. In 
 1803 only 1 in 21 of the population attended school, in 
 1820 the proportion was raised to 1 in 16, while in 1833 
 Parliament voted £20,000 for the erection of schools 
 for the poorer classes. In 1857, however, only 27 per 
 cent, of children in attendance were over eleven years 
 of age and only 36 per cent, earned a capitation grant.^ 
 
 The Education Act of 1870 changed all this. Every 
 child was brought under the cognizance of the State. 
 But so imbued were educationalists and legislators at 
 that time with the one idea that every child should be 
 taught reading, ^vriting, and arithmetic, that little 
 consideration was given to physical training, and the 
 bodily needs of the community were neglected. For 
 twenty years after the institution of compulsory school 
 attendance, no need for any medical advice was recog- 
 nized officially either by central or local authorities. 
 During this time, however, many observations which 
 have since proved the basis of further inquiry were 
 made by medical men both in England and on the 
 Continent. 
 
 Of these Cohn of Breslau was the first. He had 
 been an army surgeon during the Prussian War of 1866, 
 and had observed defective vision among the soldiers. 
 About the same time he turned his attention to the 
 schools of Breslau and published his famous report upon 
 the eyesight of 10,000 school children. His investiga- 
 
 ^ An Octogenarian's Reminiscences, by Mr. James Bon wick, 1902. 
 ^ The Progress of Education in England, 1904. Montmorency. 
 
16 MEDICAL INSPECTION OF SCHOOLS 
 
 tions gave rise to much speculation in Germany and 
 elsewhere, and as a result medical inspection of schools 
 was advocated in 1869 by Virchow, and discussed in 
 that year at the Scientific Congress at Innsbruck. 
 Later Cohn himself drew up a scheme of duties for 
 school physicians which was first considered at the 
 International Congress of Hygiene at Geneva in 1883. 
 Meanwhile other investigations were pursued. In 
 1875 Professor Bowditch recorded the measurements of 
 height and weight of 25,000 school children in Boston. 
 In 1881 Hertel of Copenhagen began an extensive 
 inquiry into the conditions of school life. A year later, 
 as a member of a Danish Commission, he reported 
 that, of 16,000 children examined in both primary and 
 secondary schools, 29 per cent, were unhealthy. He also 
 investigated the subject of over-pressure in the High 
 Schools. In 1884 a Royal Swedish Commission was 
 appointed to investigate health conditions in school. 
 On their behalf, Professor Axel Key examined 18,000 
 children in several countries and published a report 
 upon the growth and development of boys and girls at 
 different age periods. He also, like Hertel, discovered 
 that a large proportion — approximately 35 per cent. — 
 of children were suffering from chronic physical defects 
 such as anaemia, headache, and short sight. 
 
 Table showing Percentage, according to Age and Grade, op 
 Physically Defective Children in Swedish Schools. 
 
 QeneraL Schools. 
 
 Grade. I II III 
 
 Average age . 11.3 12-3 13-4 
 
 Short sight . 3-2 2-4 5-2 
 
 Other defects . 34-4 37-6 38.0 
 
 Lai in Schools. 
 
 IV V VIi VI, VIIi VII2 
 
 14.3 15.4 I6.5 17-4 18-3 19-4 
 
 6-5 8-9 15-0 14-1 17-6 21-6 
 
 37-4 3G-G 34.7 38-6 40-5 36-9 
 
vi^ 
 
 VII, 
 
 VIIo 
 
 17-6 
 
 18-7 
 
 19-5 
 
 8-1 
 
 14-8 
 
 11-4 
 
 31-7 
 
 33-6 
 
 38-6 
 
 HISTORY AND LEGISLATION 17 
 
 Modern High Schools. 
 Grade. IV V VI^ 
 
 Average age . 14-6 15-7 16-6 
 
 Short sight . 5-2 8-3 12.2 
 
 Other defects . 32-9 26-7 25-8 
 
 Note. — This table is adapted from Axel Key's report, translated by 
 Dr. Leo Burgerstein. 
 
 England 
 
 In many parts of Europe the respective govern- 
 ments followed a natural tendency towards progress. 
 In England, on the contrary, there has been no 
 reasoned plan of development. The new system of 
 medical inspection of State schools, dating from 
 1908, is the result of special Parliamentary legislation,^ 
 which inspired sudden action on the part of the Board 
 of Education. In a few scattered localities various 
 steps had previously been taken by the responsible 
 educational authorities to secure some degree of 
 health inspection. But their efforts were all equally 
 devoid of cohesion and comprehensiveness, and ex- 
 tended over a period of nearly twenty years without 
 marked development in any direction. 
 
 Scientific investigations on the part of individuals, 
 however, were not without their parallel in England. 
 About 1860 the need for some system of physical 
 training in the public schools and in the army began 
 to attract attention. As a result a gymnasium was 
 established in Oxford, which, under the direction of 
 Mr. Archibald Maclaren, for many years served as a 
 great centre for spreading knowledge as to the impor- 
 
 ^ See part (2) of this chapter, p. 33. 
 
 HOGARTH Q 
 
18 MEDICAL INSPECTION OF SCHOOLS 
 
 tance of physical education. Throughout the middle 
 of the last century Mr. Edwin Chadwick was doing 
 a great work on behalf of national education.^ With 
 him originated many modern ideas as to the physiology 
 and psychology of school methods. In 1882 he pub- 
 lished an essay upon ' The School Children of the 
 Metropolis ', in which he gave a brief summary of his 
 observations and research in the schools. 
 
 In connexion with the London Health Exhibition of 
 1884, some interest was displayed in the subject of 
 school hygiene, but no definite advance was made. In 
 1885 there was considerable agitation about the subject 
 of overpressure in school, which was probably an out- 
 come of the inquiries of the Prussian Commission on the 
 same subject a few years earlier. 
 
 About this time. Dr. Francis Warner first directed 
 his attention to the examination of school children, 
 with special reference to their mental status. His 
 pioneer work led to the appointment, in 1888, of a 
 Committee of the British Medical Association for the 
 scientific study of the mental and physical conditions of 
 child life. In 1892 Warner published a full report of 
 the examination of 50,000 school children in 106 
 schools ; 2 and later issued a further report upon another 
 50,000 children in conjunction with Dr. Shuttleworth 
 
 * Edwin Chadwick, C.B., was one of the Poor Law Commissioners in 
 1832-4. He was author of the 'half-time system of education', which 
 in those days marked a tremendous advance towards compulsory educa- 
 tion. He was also the promoter of many sanitary reforms. 
 
 * These investigations were conducted in a variety of schools — Poor 
 Law, indiistrial, residential and day schools. 
 
HISTORY AND LEGISLATION 19 
 
 and Dr. Fletcher Beach. The result of these investi- 
 gations was to arouse general interest in the whole 
 subject of educational hygiene. The need for the 
 scientific classification of school children according to 
 their mental and physical capacities was evident and, 
 as a result, mental deficiency was officially recognized, 
 in 1889, by the Royal Commission on the BUnd, Dumb, 
 and Feeble-minded. Dr. Warner also drew public 
 attention to many conditions adversely affecting the 
 health of the school child. In fact, he laid the founda- 
 tion of the science of child study and stimulated the 
 interest of many medical men in the larger field of 
 school hygiene. 
 
 In contrast to this enthusiasm on the part of indivi- 
 dual workers, official sympathy was but slowly aroused. 
 Few of the Local School Boards concerned with the 
 administration of the Elementary Education Act, 1870, 
 appreciated the importance of Dr. Warner's investi- 
 gations, though, even at this period, agitation for 
 systematic medical inspection had become universal 
 in Germany. The first official step in England was the 
 appointment of medical officers to act as advisers on 
 general medical matters in connexion with Elementary 
 Education, and especially for the examination of 
 children suffering from gross disease necessitating 
 absence from school. No statutory provision for these 
 appointments or for the conduct of any medical inspec- 
 tion existed ; but progressive School Boards, taking 
 a wide view of their general powers, appointed medical 
 advisers as ' necessary officers ' under the general 
 
 c2 
 
20 MEDICAL INSPECTION OF SCHOOLS 
 
 powers conferred by Section 35 of the Elementary 
 Education Act, 1870. 
 
 Thus, in 1891, a medical officer was appointed by 
 the School Board for London : and two years later 
 Dr. James Kerr was appointed at Bradford, ostensibly 
 for the purpose of examining absentees from school, who 
 were alleged to be suffering from disease, but who did not 
 furnish a doctor's certificate. The appointment of these 
 officers was a matter of expediency for the authorities 
 concerned. It was expedient to hold a medical examina- 
 tion of teachers and other employees, to have expert 
 opinion about outbreaks of epidemic disease and to 
 prevent unnecessary absence on the part of children 
 suffering from slight diseases. But these early steps 
 were taken in the interests neither of education nor of 
 the children. And yet much has grown out of little. 
 Dr. Kerr was the pioneer of all official routine in con- 
 nexion with medical inspection in the elementary schools 
 of England. He appears to have been the first medical 
 man to enter the schools daily in the role of a school 
 doctor, and to study all problems of school hygiene, 
 working in conjunction with the teachers in the interests 
 of the children. In Leipzig, local school doctors had 
 been appointed two years previously, but apparently 
 they acted in the capacity of specialists for the eyes 
 or ears, rather than for general purposes. 
 
 The first authoritative advance was made by the 
 statutory provision for the appointment of medical 
 officers for the purposes of the Elementary Education 
 (Blind and Deaf) Act, 1893, and of the Elementary 
 
I UNIVERSITY I 
 
 HISTORY AND LEGISLATION 21 
 
 Education (Defective and Epileptic Children) Act, 1899. 
 About this time — but more especially since the con- 
 stitution of the new Education Authorities under the 
 Education Act, 1902 — medical officers were appointed 
 in many places, but for various purposes — some to give 
 lectures to the teachers in hygiene, some to examine 
 children with defective vision, others to examine 
 mentally defective children and children alleged to be 
 physically unfit to attend school, and others to report 
 upon the sanitary condition of school premises. But 
 nearly all of these appointments were held in conjunc- 
 tion with other offices, and were insufficiently paid. 
 The effect was, that very little useful or satisfactory 
 work resulted from such spasmodic efforts, and the 
 doctors devoted scant attention to the broader problems 
 of school hygiene. As late as May, 1903, the medical 
 officer to the School Board for London reported that 
 ' the chief matters coming under notice hitherto had 
 been : — 
 
 ' 1 . Notification by teachers and control by individual 
 exclusion, class, or school closure in cases of infectious 
 diseases. 
 
 * 2. Examination of teachers, candidates, or em- 
 ployees in regard to health. 
 
 'The examination of defective children was also 
 carried on by the medical officer and his staff, but not 
 under the supervision of the Department. As regards 
 (a) school work and methods in their hygienic bearing ; 
 (6) physical conditions of children — measurements, 
 nutrition, vision, hearing ; (c) condition of schools — 
 
22 MEDICAL INSPECTION OF SCHOOLS 
 
 ventilation, heating, lighting, furniture, very little has 
 been attempted.' 
 
 The remainder of that report, however, is pregnant 
 with possibilities, and is the earliest literature in Eng- 
 lish dealing with the practical results of systematic 
 school inspection by medical men. 
 
 Dr. Leslie Mackenzie, writing in 1904, says, ' In 
 England the system has so far spread, that already 
 there is a Society of Medical Officers for Schools ; the 
 larger School Boards provide for medical attendance 
 on their teachers and pupil-teachers, for the regular 
 visiting of their schools, for the dovetailing of medical 
 school inspections with the regular work of the public 
 health organizations, and, generally, for the discovery 
 of infection among school children and the prevention 
 of infection by detailed periodic examinations of school 
 premises.' The fact that this progress was more 
 apparent than real may be gathered from the attitude 
 of the central authority, which, in 1903, decided to 
 abolish the epidemic grant ^ — a retrograde decision, still 
 unrevoked ; as well as from the report of the Inter- 
 departmental Committee on Medical Inspection and 
 Feeding of Children attending Public Elementary 
 Schools, 1905. This report states that, ' in addition 
 
 * The epidemic grant was the national insurance against the spread 
 of infectious disease in school. Its abolition is prejudicial in two ways. 
 In the first place it has the practical effect of mulcting local authorities 
 who exclude children suffering from epidemic disease. Secondly, the 
 teachers themselves are penalized ; for their grading and salary depend 
 on the percentage of attendance. In doubtful cases, therefore, the 
 toachor may be inclined to act contrary to the public interest. 
 
HISTORY AND LEGISLATION 23 
 
 to London, 48 local authorities, comprising 2 counties, 
 25 county boroughs and 11 urban districts have 
 established a definite system of medical inspection'. 
 But, on further investigation, it appears that not more 
 than 10 of these authorities considered the matter at 
 all seriously in its systematic and educational aspects, 
 while the actual work done was inconsiderable owing 
 to the general lack of system and organization. 
 
 The reason for this slow progress is sufficiently 
 obvious. All local efforts were voluntary, and occa- 
 sionally were marked by misdirected zeal. There was, 
 indeed, no accurate or certain knowledge as to the 
 meaning of school hygiene or as to the requirements 
 of medical inspection. School doctors were educating 
 themselves, and none had made a statement of what 
 was necessary or of what was practicable. No authori- 
 tative body or directing head was to be found, and, 
 above all, the Board of Education, to whom the local 
 authorities naturally looked for guidance, was slow to 
 take any action. There was a consequent lack of 
 system, together with confusion of ideas and absence 
 of clear thinking. Practical results were hardly to be 
 expected. 
 
 Owing to this imperfect understanding of the sub- 
 ject, the inseparable problems of health inspection and 
 school hygiene became confused in the mind of the 
 medical profession as well as of the public. Health 
 inspection caught the popular fancy ; school hygiene 
 was lost to sight. 
 
 As a result of the South African war, 1899-1902, 
 
24 MEDICAL INSPECTION OF SCHOOLS 
 
 public interest in the problem of the national physique 
 had been aroused. A War Office Memorandum con- 
 cerning the progressive deterioration of the classes 
 from which recruits for the army were drawn, gave 
 rise to various alarmist rumours. An Interdepart- 
 mental Committee was appointed in 1903, and after ex- 
 tensive inquiries recommended, among other measures, 
 the introduction of systematic medical inspection of 
 school children. This recommendation resulted in the 
 appointment of another Interdepartmental Committee 
 in 1905, whose terms of reference required them ' to 
 ascertain and report on what is now being done, and 
 with what result, in respect of medical inspection of 
 children in public elementary schools'. Their report, 
 to which allusion has already been made, showed the 
 nakedness of the land, but the Committee were limited 
 by their reference to the recording of results. They 
 were not required to make any recommendations for 
 improvements. 
 
 As an outcome of these official inquiries and in- 
 vestigations, the need for health inspection of the 
 children, for improved sanitation and for the preven- 
 tion of infectious diseases in the schools was recog- 
 nized ; but no attention was given to the general 
 requirements of school hygiene. It was in this spirit 
 that legislation was proposed in the Education Bill 
 of 190G, the consideration of which is postponed until 
 the legislative efforts of other countries have been 
 summarized. 
 
 I 
 
HISTORY AND LEGISLATION 25 
 
 (2) Legislation 
 
 Meanwhile, great progress was taking place on the 
 Continent of Europe and elsewhere. It is impossible 
 to give more than a brief sketch of the movement ; 
 and reference, for the most part, will be confined to 
 legislation and to the general attitude of the various 
 States, rather than to the activities of individual 
 municipalities.^ 
 
 Austria and Hungary 
 
 In France special regulations for medical inspection 
 of schools were issued in 1833, but were not enforced.^ 
 The Swedish Government prescribed duties for school 
 physicians in secondary schools in 1863. But, as far 
 as primary schools are concerned, Austria was the 
 first country to publish effective legislation. A minis- 
 terial decree of 1873 ordered the establishment of per- 
 manent health committees, with physicians as regular 
 members. Detailed regulations concerning the sanitary 
 arrangements of schools were also issued. A number 
 of State physicians have been appointed to inspect 
 schools, to make suggestions for the amelioration of 
 evil conditions, and to submit annual reports. In 
 addition, certain localities have undertaken to supple- 
 
 ^ The following notes have been collected for the most part from 
 Dr. Leo Burgerstein's Handbuch der Schvlhygiene. 
 
 ■^ These regulations were probably the outcome of inquiries into the 
 educational needs of feeble-minded cliildren. Dr. Belhomme and Dr. 
 Voisin had already organized special schools for idiots at the Bicetre 
 and Salpetriere asylums in Paris, thus anticipating by a few years the 
 work of the more famous Dr. Seguin. Cf. p. 14. 
 
26 MEDICAL INSPECTION OF SCHOOLS 
 
 merit this inspectorial system by appointing local 
 physicians for special work. Vienna has a special law 
 dating from 1895. 
 
 In Hungary, the office of school physician was created 
 in 1885, and two years later a number of physicians 
 with specified duties were appointed for secondary 
 schools. 
 
 France 
 
 In France, though regulations date from 1833, few 
 steps were taken until 1884, when health inspectors 
 were appointed in Paris. In 1886, medical inspection 
 of schools was decreed for the departments. With 
 a view to the enforcement of these regulations, the 
 communal physicians of the poor were required by 
 the law of 1892 to inspect all children in the provincial 
 schools. The system of medical inspection was com- 
 pletely reorganized in Paris in 1896. In each district 
 schools are now divided into groups and a local school 
 doctor is appointed to visit each fortnightly, and is 
 expected to make a careful examination of each child 
 once a month. Some of the school doctors undertake 
 special investigations in the problems of school hygiene. 
 
 Argentina 
 
 In 1888, the Argentine Republic entrusted the 
 medical supervision of primary schools to a School 
 Medical Board, consisting of sixteen members. At a 
 later date the secondary schools were placed under the 
 medical supervision of a special School Section of the 
 National Board of Health. In addition to carrying 
 
HISTORY AND LEGISLATION 27 
 
 out routine health inspection, these specialists under- 
 take the scientific observation and study of school 
 diseases and their prevention. 
 
 ISTorway 
 
 The history of medical inspection in Norway presents 
 a model of orderly and progressive legislation. In 
 1885, some localities had appointed school physicians. 
 In 1889, permissive regulations were passed, empower- 
 ing local authorities to appoint health inspectors. Two 
 years later these regulations were made obligatory. 
 The duties of medical inspection were entrusted to 
 salaried local physicians, who were required to investi- 
 gate the health conditions of the children in their 
 schools three times a year. In 1898, a further law 
 was passed, instructing school physicians to attend to 
 the fuller requirements of school hygiene and to furnish 
 an annual report. 
 
 Sweden 
 
 Sweden, which has already been mentioned as one 
 of the pioneer countries in the matter of physical 
 education, has adopted a similar method of progress 
 for secondary schools. As far back as 1868, a local 
 medical officer was attached to the staff of each school. 
 His duties were gradually increased by statute and 
 his sphere of activity has been slowly extended. At 
 first a school physician was required only to examine 
 children as to exemption from physical exercises. In 
 1878, an examination as to general health was held 
 
28 MEDICAL INSPECTION OF SCHOOLS 
 
 at the beginning of each term and a health committee 
 was appointed to each school. The medical supervision 
 of primary schools was not begun till 1895, and has 
 been left entirely to municipal enterprise. Thus the 
 city of Stockholm, in addition to establishing a system 
 of health inspection in 1899, has devoted itself more 
 especially to the experimental study and investigation 
 of many problems of school hygiene. 
 
 Japan 
 
 In 1898, in Japan, the Minister of Education ordered 
 the appointment of school doctors at every public 
 school. Only places with less than 5000 inhabitants 
 were exempted. The school doctors are nominated 
 by the local governors, and their duties are defined 
 by law. The schools are visited once a month. 
 
 Switzerland 
 
 In 1898, the Swiss Federal Government recommended 
 the medical examination of all children upon their 
 first admission to school. Thirteen cantons carry out 
 the recommendation, and many of these had previously 
 made additional provision for systematic health inspec- 
 tion and for general school hygiene. The Education 
 Department of each canton exercises its own judg- 
 ment, in accordance with local needs. But in almost 
 every case a doctor is to be found as an active member 
 of every local school board (Schiilkommission) through- 
 out the country ; in this way total neglect of school 
 hygiene is avoided, even in outlying districts where 
 no provision is made for systematic inspection. 
 
 I 
 
HISTORY AND LEGISLATION 29 
 
 Germany 
 
 In Germany different regulations have been adopted 
 in the various provinces and towns. In 1891, Leipzig 
 made a beginning, and was soon followed by Wies- 
 baden, which was the first municipality in the world 
 to establish a model system of medical inspection — 
 a system which took account not only of the health, 
 but also of the educational requirements of the children 
 on admission, and at the same time made provision 
 for the re-examination and supervision of all children. 
 In 1898, the Prussian Ministry urged the adoption of 
 the Wiesbaden plan by all municipalities and towns 
 in the kingdom. In consequence, the movement 
 spread rapidly throughout Germany. One of the aims 
 of German methods of administration is to reduce as 
 far as possible the number of children allotted to each 
 school physician, with the object of securing more 
 personal work. 
 
 United States of America 
 
 In the United States of America the chief aim of 
 the medical inspection, so far, has been directed 
 towards the prevention of infectious and contagious 
 disease. Much useful work has been done in this 
 direction by various municipalities, but very little has 
 been attempted with regard to the real problems of 
 school hygiene, except in Boston, where a director of 
 school hygiene was appointed as early as 1891. In the 
 following year, medical inspectors were first appointed 
 
30 MEDICAL INSPECTION OF SCHOOLS 
 
 for the prevention of contagious disease ; next the 
 problem of school sanitation was considered ; then 
 came the physical condition of all school children, 
 followed by the scientific study of child life and of 
 problems of school hygiene. This evolution extended 
 over a period of sixteen years, and now a fully staffed 
 special department of school hygiene has been estab- 
 lished, with a director, three assistants, special instruc- 
 tors in military drill and in physical training and 
 athletics, playground teachers, nurses, and a medical 
 inspector of special classes. In New York and other 
 cities a great deal of work has been done for the 
 prevention of infectious and contagious diseases. 
 Legislation as to medical inspection exists only in four 
 States. In 1906 a mandatory law was passed in 
 Massachusets which made provision (1) for the detec- 
 tion of contagious disease at school ; and (2) for the 
 annual examination of children (a) by physicians for 
 non-contagious physical defects, and (b) by teachers 
 for defects of eyesight and of hearing. 
 
 Russia, Bulgaria, and Koumania 
 
 With regard to secondary schools, Russia and Bul- 
 garia, in addition to the countries already indicated, 
 have made special provision for medical inspection — 
 dating from 1871 and 1904 respectively. In Russia, 
 the Minister of Education has a medical department 
 at his service. In 1895 six school physicians were 
 appointed to supervise the seventy-two elementary 
 schools in Moscow. In Roumania adequate legislation 
 
HISTORY AND LEGISLATION 31 
 
 for the main purposes of school hygiene has been in 
 force since 1899. 
 
 Apart from State legislation, various municipalities 
 have adopted systems of medical inspection. Two are 
 especially worthy of mention. Brussels is credited 
 with being the first municipality to establish a system 
 of school inspection by medical men. Ever since 1874 
 physicians have been appointed for the purpose of 
 visiting schools two or three times a month. In 1896 
 fifty-two school physicians were at work. Oculists and 
 dentists are also employed for special duties. At Cairo, 
 in Egjrpt, a school physician was first appointed in 
 1882. He has the services of two assistants, each of 
 whom has charge of 5,000 school children. 
 
 This brief outline of legislative tendencies abroad 
 shows that many nations have arrived at nearly the 
 same stage of activity and progress. No State has 
 a completely organized scheme, but there is evidence 
 of a considerable amount of dissatisfaction and agita- 
 tion amongst educationalists in several countries. 
 Some Governments have favoured progressive methods 
 of educational advance combined with sympathetic 
 interest in school hygiene. Others for many years 
 past have been content to impose or to recommend 
 some system of health inspection. But, for the most 
 part, activity in both these directions has been the 
 result of municipal enterprise. 
 
 At the beginning of the present century the agita- 
 tion as to the far reaching importance of school hygiene, 
 
32 MEDICAL INSPECTION OF SCHOOLS 
 
 quite apart from systematic health inspection, had 
 become so universal that an International Congress 
 was inaugurated at Nuremburg in 1904. The second 
 meeting, which was held in London in 1907, served to 
 arouse public interest in this country. The effect of 
 these Congresses has been to focus attention upon 
 what is being done in all parts of the world. 
 
 England 
 
 Though the Congress of School Hygiene in 1907 
 showed that England was still far behind many nations 
 as regards public interest in school hygiene, yet it 
 was evident that the compulsory measure — at that 
 time under the consideration of Parliament — could be 
 utilized for the introduction of a scheme far ahead of 
 any that obtained in other countries. For already 
 London had prepared the way, and had made the first 
 real advance in England towards a definite system 
 of inspection as a factor in the larger problem of school 
 hygiene. 
 
 In 1904 the Education Committee of the London 
 County Council first increased the permanent staff 
 of its medical officers' department with a view to the 
 more careful supervision and control of special branches 
 of the work. In 1905 twenty ' part-time ' medical 
 inspectors were appointed, and to each was assigned 
 one of the metropolitan school areas. The greater 
 portion of their time was occupied in routine work, 
 such as the inspection of physically and mentally 
 defective children in the schools and the examination 
 
HISTORY AND LEGISLATION 53 
 
 of children with defective vision ; and at the same 
 time advice was given to the teachers concerning the 
 general hygiene of the schools and of the children. 
 In addition, a staff of thirty-two nurses, under a lady 
 superintendent, was employed for the routine examina- 
 tion of all children as to verminous and parasitic 
 conditions and as to contagious skin disease. This 
 scheme only purported to be an outline of better 
 things. But each medical inspector was encouraged 
 to make original investigation under the guidance and 
 supervision of the medical officer ; and in this way 
 a clear insight into the work and its possible develop- 
 ments was obtained. Each inspector, following his 
 own individual line of thought, has, so to speak, 
 educated himself in school hygiene and added some- 
 thing to the store of knowledge on the subject. 
 
 Though the scheme was only tentative, and though 
 no absolute and definite status was given to the medical 
 inspectors, yet the results clearly justified the experi- 
 ment ; and the reports of the medical officer were the 
 basis on which the details of the first official memoran- 
 dum issued by the Board of Education to local authori- 
 ties were prepared. 
 
 In 1906 legislation was first introduced into Parlia- 
 ment, and a permissive clause, empowering local 
 authorities to make provision for health inspection, 
 was included in the Education Bill of that year. All 
 parties, however, were unanimous in their desire to 
 make the provision obligatory. The clause was accord- 
 ingly amended, but, during the ensuing twelve months, 
 
 HOGARTH 
 
34 MEDICAL INSPECTION OF SCHOOLS 
 
 it went through many vicissitudes in Parliament until 
 it was finally embodied in the Education (Administra- 
 tive Provisions) Act of 1907 in the following terms : — 
 
 ' The powers and duties of a local education authority 
 under Part III of the Education Act, 1902, shall 
 include : — 
 
 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 
 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.' 
 
 In the meantime, no preparations were made by the 
 central authority in view of these impending obliga- 
 tions. It was not until the Act was actually placed 
 on the statute book that a medical officer was ap- 
 pointed to advise the Board of Education, and the 
 first official memorandum was issued only five weeks 
 before local authorities were required to institute 
 a system of medical inspection. 
 
 Hence it is that the present organization throughout 
 the greater part of England is rather the outcome of 
 sporadic impulse than of any orderly process of reasoned 
 development. Moreover, it is only now, in the twentieth 
 century, that modern civilization is again beginning 
 to approximate to the system which obtained in ancient 
 Greece, when a national school which trained the mind 
 only and neglected the body of the pupil was an 
 inconceivable institution. 
 
CHAPTER III 
 THE CASE FOR MEDICAL INSPECTION 
 
 State Control of Health Inspection. — Irrelevant Arguments : (a) An- 
 thropometry ; (6) Underfeeding ; (c) Overpressure ; {d) Infectious 
 Disease. — Medical Inspection not necessarily the Corollary of Compulsory 
 Education. — Essential Argument for Medical Inspection. — Large Amount 
 of Unrecognized Defects among School Children. — Medical Inspection 
 a Means to an End. — Education of Parents and Children. 
 
 Medical inspection of schools forms an integral 
 factor in every modern system of education, and its 
 expediency may be assumed from its successful ad- 
 ministration in other countries. But hitherto, despite 
 their essential claim to universal consideration, the 
 general principles have never been clearly defined. 
 Fundamentally, the State control of health inspection 
 depends upon the fact that a large proportion of children 
 attending State schools are suffering from preventible 
 and remediable diseases. It matters not for the 
 moment to what extent the home is responsible, nor 
 how far the diseases are aggravated by school life. 
 It is sufficient that the defects are unrecognized either 
 by teachers or parents, who alone are in contact with 
 the children. 
 
 Hence it is clearly a national duty to discover 
 a system by which these preventible and remediable 
 defects may be brought to light. It is unessential to 
 
 d2 
 
36 MEDICAL INSPECTION OF SCHOOLS 
 
 the State whether the health inspection of its children 
 take place in the school, at the home, or elsewhere, 
 so long as a physical census is taken and all defects 
 are investigated. But, seeing that the children are 
 collected together during nine or ten years of their 
 life in State schools for the purpose of education, it 
 becomes a matter of convenience to delegate the 
 nation's responsibility to the Education Department. 
 
 This appears to be a simple and a logical stand- 
 point which scarcely requires further justification : 
 but on all sides arguments, in many respects irrelevant 
 or non-essential, have been brought forward to justify 
 the interference of the State. Thus, those who believe 
 in the general progressive physical deterioration of the 
 race have escaped the trouble of further thought by 
 arguing that the very existence of this physical de- 
 terioration shows the necessity for systematic medical 
 inspection of school children. It is, however, more 
 than probable that no such general deterioration is to 
 be found — and this probability accords with the con- 
 clusions of the Interdepartmental Committee on 
 Physical Deterioration, 1904.^ Some also — perhaps as 
 
 ^ ' It has now been seen that there are no sufficient data at present 
 obtainable for a comparative estimate of the health and physique of 
 the people, and the Committee have indicated the measures that, in 
 their opinion, should be adopted in order to supply the want, but, 
 before concluding their task, they deemed it their duty to consider the 
 causes and conditions of such physical degeneration as is no doubt 
 present in considerable classes of the community, and to point out the 
 means by which, in their opinion, it can be most effectually diminished, 
 and more especially to discuss this aspect of the question as it affects 
 the young during tlie three periods of infancy, school age, and adolescence. 
 
 It may be well to state, at once, that the impressions gathered from 
 
THE CASE FOR MEDICAL INSPECTION 37 
 
 a result of the Committee's recommendations — have 
 inclined to an enticing scheme for an anthropometric 
 survey of the cliildren as a sound basis for the intro- 
 duction of routine medical inspection. But the pro- 
 posal, though of a certain scientific value, will not bear 
 too close an investigation at present, and may even 
 be less valuable than appears at first sight. 
 
 Many others, in seeking to establish a superficial 
 case for health inspection, have been led to emphasize 
 certain points which are beside the main issue. This 
 attempt to enlist popular sympathy takes many forms. 
 Alarmist press articles headed : ' Under-feeding,' 
 ' Brain-fag at School,' ' Defective Vision,' ' Infectious 
 Disease at School,' meet us on all sides. Many a 
 champion of the cause bases his position upon some 
 such appeal to sensationalism. Yet not one of these 
 reasons alone, not even the sum total, could justify 
 routine medical inspection of schools by the State, or 
 by the local education authorities. Such superficial 
 statements must be thoroughly sifted and analysed 
 before they can be reasonably claimed as logical argu- 
 ments in favour of the scheme. And while it cannot 
 be denied that on all these points there is need for 
 progress or amelioration, as also in the planning, 
 building, and sanitation of the schools, it is clear that 
 particular remedies can be discovered for one and all 
 without having recourse to wholesale medical inspec- 
 tion. 
 
 the great majority of the witnesses examined do not support the belief 
 that there is any general piogressive physical deterioration.' 
 
38 MEDICAL INSPECTION OF SCHOOLS 
 
 For instance, the want of harmony and co-opera- 
 tion between architect, doctor, educational expert, 
 and sanitary engineer, cannot be satisfactorily amended 
 by the periodical inspection of school premises — a duty 
 often given as the raison d^etre for medical inspection, 
 and often in the past one of the chief functions 
 assigned to the educational medical officer. This lack 
 of co-operation is due to a fundamental error of ad- 
 ministration, which will gradually disappear with 
 growth of insight into the requirements of schools and 
 scholars. Moreover, too little at present is known on 
 the vexed question of ventilation for any one, except 
 an expert, to dogmatize, and only the medical inspector 
 who has time for research will help to solve this ' most 
 pressing question of school hygiene. 
 
 Routine medical inspection of the children will 
 neither prevent nor materially alter the course of 
 outbreaks of epidemic disease. The theory that infec- 
 tious diseases may be prevented by a system of 
 routine inspection has been urged in America, and 
 was at one time recommended in the medical press, 
 one leading authority asserting : ' I regard prevention 
 of infection as the prime, if not the main, function of 
 physical inspection '. These outbreaks must still be 
 dealt with, as they occur, by the co-operation of the 
 sanitary authority with the school doctor. Their 
 prevention can only result from careful research and 
 observation — quite apart from routine inspection — 
 towards which many school doctors will contribute 
 their share of work. Further, it must be remembered 
 
THE CASE FOR MEDICAL INSPECTION 39 
 
 that the school may not be so important a factor in 
 the spread of epidemic disease as is commonly sup- 
 posed.^ 
 
 Similarly, the existence of under-feeding has been 
 thought a sufficient reason for the institution of 
 systematic medical inspection ; but this matter is 
 rather a problem for social than for medical investiga- 
 tion. At the same time those school doctors who 
 have time for research will be in a position to give 
 invaluable assistance in solving the problem. 
 
 Finally, it is a plausible but scarcely a convincing 
 argument to assert that medical inspection of school 
 children by the State is the natural corollary of com- 
 pulsory attendance at school. Such an argument 
 presupposes that a number of healthy children are 
 injured in health by bad buildings, by unsatisfactory 
 discipline and faulty curricula, or by exposure to 
 infection. But, even if the assumption were well 
 founded, the remedy for such injury would consist 
 rather in improving the schools and the routine — an 
 improvement at once secured by the merest stroke of 
 the pen — a memorandum issued from head quarters. In 
 other words, the State can discharge its responsibility 
 for safeguarding the child's health at school without 
 instituting systematic inspection of the children. 
 
 All these arguments, which are commonly advanced, 
 fail to touch the root of the matter. The majority of 
 schools are not hotbeds of infection, nor do the majority 
 of schools show a proportion of degenerates or under- 
 
 ^ Cf. chap. V, p. GO. 
 
40 MEDICAL INSPECTION OF SCHOOLS 
 
 fed children, or of children suffering from infectious 
 disease. But every school does contain a percentage 
 of children suffering from unrecognized defects. 
 
 Here, in a word, is the essential point for the intro- 
 duction of systematic inspection of all children at 
 some time or other during their school career. 
 
 In fact, as was indicated at the beginning of the 
 chapter, the only justifiable a priori argument for the 
 State control of a system of health inspection rests 
 upon the fact — which cannot be denied — that there 
 are present in the schools (town and country alike) 
 children suffering from preventible and remediable 
 diseases, of which both the teachers and the parents 
 are ignorant ; besides others suffering from diseases the 
 serious nature and consequences of which no one but 
 a medical man can recognize. This assertion scarcely 
 needs the support of figures and statistics, but in 
 passing let us recall the fact that more than 80 per 
 cent, of the children are suffering from defective teeth, 
 that 50 per cent, are affected with vermin or other 
 parasitic conditions, 20 per cent, with defective vision, 
 and that 10 per cent, are retarded in their educational 
 progress by physical defects such as anaemia, general 
 debility, and deafness resulting from adenoid growths, 
 or discharging ears. These figures may not be exact. 
 Some are probably underestimated, and some are 
 probably exaggerated, according to the inspector's 
 opinion of what constitutes a defect. But the general 
 inference is sufficiently sound. 
 
THE CASE FOR MEDICAL INSPECTION 41 
 
 All other a priori arguments for systematic inspec- 
 tion can be modified upon further inquiry into the 
 subject. But as long as there are in the schools such 
 children as those which have been described, so long 
 the necessity for systematic health inspection is obvious 
 from all points of view. In other words, medical 
 inspection in the elementary schools is necessary 
 because the parents are ignorant. It is only a means 
 to an end, and at present the end is the education 
 of the people. Indeed it has been argued that it de- 
 volves upon the State at the present day to make good 
 its defective training and education of the parents 
 during the last twenty or thirty years, by directing 
 a system of health inspection towards the education 
 of parents and children alike. For, if all parents had 
 been taught the elements of healthy living, and were 
 able to recognize the presence and to realize the 
 importance of physical disabilities and defects in their 
 children, systematic health inspection would, theoreti- 
 cally, be out of the question. Medical advisers to 
 local education authorities would still be necessary, 
 and little more. 
 
 But, as matters stand to-day, the interference of 
 the State is essentially justified by the large amount 
 of preventible and remediable defects among school 
 children. These defects are unrecognized either by 
 teachers or parents, and can only be discovered by 
 systematic medical inspection. 
 
CHAPTER IV 
 THE STATE'S RESPONSIBILITY 
 
 Children the Nation s best Asset. — Development of this Asset. — Pre- 
 venting a Bad Debt. — Physical Census of Children. — State requires 
 exact Knowledge of Health Conditions. — Eutrophics. — Digestion and 
 Utilization of Facts and Statistics by the State. — Increased Attendance 
 at School. — A Lesson from New York. — Educational Wastage Prevented. 
 — Preparation of Children for Education. — Physical Defects and Back- 
 wardness. — Adaptation of Educational System to Needs of Children. — 
 The Dull and Backward. — Lower Grade Schools. — Summary. 
 
 In the last chapter an a priori case for the health 
 inspection of school children was established — namely, 
 that medical inspection is necessary because a large 
 percentage of children are suffering from unrecognized 
 defects. But the subject must be analysed still further 
 and considered from three different points of view : — 
 
 (i) of the State, 
 
 (ii) of the public health, 
 
 (iii) of the individual ; 
 each of which will be treated in a separate chapter. 
 
 First of all, in what way and to what extent docs 
 medical inspection of schools concern the State ? If, 
 as it is constantly asserted, * the children are the 
 State's best asset', and the education of children is 
 ' grand Imperial work ', ought noj the State to develop 
 its asset to the fullest possible advantage, always pre- 
 venting waste and unnecessary expenditure, without 
 
THE STATE'S RESPONSIBILITY 43 
 
 at the same time turning a deaf ear to what is obviously 
 necessary ? Such truisms necessarily imply that it is 
 desirable in the national interest, if not to protect 
 and nourish the children with care and attention, at 
 least to keep the balance on the right side, to prevent 
 the asset from becoming a debt. Although it may 
 not be to the advantage of the State to educate the 
 feeble-minded, or to maintain the life of a consumptive 
 child, it is a matter of expediency to educate the 
 educable and to keep the healthy in good health ; 
 and in both cases expert medical advice is essential, 
 unless the efforts of the State are to be misdirected. 
 
 Thus both from the physical and the educational 
 standpoint medical inspection becomes a national duty. 
 
 Owing to the prevailing ignorance of health condi- 
 tions, a physical census of the children — not necessarily 
 an anthropometric survey — is periodically required. 
 Ever since the beginning of the South African war 
 in 1899, the standard of our national physique has 
 claimed public attention. In 1 903, on the responsibility 
 of the Director-General of the Army Medical Service 
 and the Inspector-General of Recruiting, the War Office 
 issued a memorandum, in which attention was drawn 
 to the increasing number of recruits who were rejected 
 as useless for military service through want of physical 
 development, defective vision, disease of the heart, 
 and through bad dentition. As a result an Interdepart- 
 mental Committee was appointed, and, though they 
 were of opinion that no general progressive physical 
 degeneration was to be feared, yet they observed many 
 
44 MEDICAL INSPECTION OF SCHOOI-S 
 
 serious factors affecting the health of the nation. In- 
 cidentally, the Committee indicated particular remedies 
 and emphasized the importance of collecting definite 
 data bearing upon the physical condition of the people ; 
 and with this object in view they recommended that 
 ' a systematized medical inspection of children at school 
 should be imposed as a public duty on every school 
 authority,^ and that a contribution towards the cost 
 should be made out of the Parliamentary Vote '. 
 
 What practical purpose will a physical census serve i 
 The annual wastage of life from epidemic disease, from 
 infantile mortality, or from any particular condition, 
 is known ; but, except in very general terms, the 
 factors which are the cause of this wastage are not 
 known. 
 
 Thus we know that, according to official returns, 
 out of every five applicants who present them- 
 selves for military service, only two remain in the 
 army as effective soldiers at the end of two years' 
 service. The remainder are either rejected because 
 they do not attain the low standard of health re- 
 quired, or they are subsequently invalided as unfit for 
 military service. But the State has taken no cogni- 
 zance of the life history of these degenerates ; few of 
 us know how they have survived the perils of infancy 
 
 ' This duty does not necessarily fall to the school authority. It 
 merely devolves upon the State to devise some scheme for taking 
 a physical census of its people. This might be undertaken at any time 
 or place. But, because all children are collected together at school 
 during a period of life when most advantage can be derived from health 
 inspection, it seems natural to impose the task upon the education 
 authority, rather than upon any other body. 
 
THE STATE'S RESPONSIBILITY 45 
 
 and of school days ; how they have been neglected 
 and abused ; how they have been deprived of air- 
 space and sunshine. Yet the very factors which 
 prevent would-be army recruits from attaining a low 
 standard of physique are at the same time under- 
 mining the health of the numberless children, whose 
 records are not to be found in life-tables, in army 
 recruiting lists, or in the annals of the criminal court, 
 of the lunatic asylum, or of the Poor Law infirmary. 
 
 The State requires absolute and definite knowledge 
 concerning the health of its children, together with an 
 analysis of the health conditions of town schools as 
 compared with the health conditions of country schools. 
 
 The first step towards this knowledge is investigation, 
 and by investigation is meant a physical census of 
 the children. What is needed is not so much statistics 
 of height, weight, and chest measurements — desirable 
 as these are from the scientific point of view, — but 
 exact knowledge of the conditions which lead to general 
 physical degeneration, defective teeth and eyesight, 
 epidemic disease and consumption. This knowledge is 
 to be obtained from the general impressions of com- 
 petent observers embodied in accurate reports upon 
 special subjects, rather than from the accumulation 
 of unwieldy statistics and ill-digested information. 
 
 Once in possession of this knowledge, the State will 
 be in a better position to understand the problem of 
 the national health ; and will be able to recommend 
 and to enforce reasonable measures for the prevention 
 of the tendency to physical degeneration which exists 
 
46 MEDICAL INSPECTION OF SCHOOLS 
 
 in certain classes of the community as well as for the 
 amelioration of evil conditions revealed by medical 
 inspection. Then also it will be possible to decide 
 upon the desirability of instituting a permanent 
 anthropometric survey for practical purposes. 
 
 In the meantime, a general improvement in the 
 health and physique of the nation should be the result. 
 It is obviously a national duty to spare no effort to 
 improve the general standard of health and physique 
 of the children now at school, and so, as a result, 
 of the next generation. This is one of the first prin- 
 ciples of the science of Eutrophics which, for the 
 moment, wins more general approval than the more 
 drastic methods of Eugenics. 
 
 The State may safely delegate the burden of collect- 
 ing information and of carrjdng out ordinary routine 
 work to the local authority. But far more remains 
 to be done. Facts and statistics, which, if left to 
 accumulate in pigeon-holes, become valueless, must be 
 digested, assimilated, and utilized as material for 
 inference and research work. It is with this task 
 that any central authority should be primarily con- 
 cerned. Instead of complacent acquiescence in con- 
 vention, instead of wilful blindness, obstinate deafness 
 to the teaching of experience, there should at least 
 be some attempt at head quarters to keep abreast of 
 the advancing tide of increasing knowledge, to welcome 
 obvious reforms, to abandon the traditional attitude 
 of indifferent hostility towards any and every innova- 
 tion. Where else can the inquirer look for guidance ? 
 
THE STATE'S RESPONSIBILITY 47 
 
 Valuable work has been done on all sides : the con- 
 clusions arrived at are not too readily accessible, and 
 can only be extracted with difficulty from the unwieldy 
 mass of information to be found in the reports of school 
 medical officers. Hence it would seem advisable, under 
 the new regime, for the Board of Education itself to 
 institute special medical investigations in conjunction 
 with the local school doctors. For instance, statistics 
 as to eyesight in various districts of England were 
 collected ten years ago and duly placed on record. 
 A report was published, but no practical steps were 
 taken either to digest the facts, or to ameliorate the 
 conditions. But unless such statistics are employed 
 as a basis for inquiry into the exact conditions which 
 make for defective eyesight in towns and populous 
 centres, their precise value is to seek. What is 
 essential is to arrive at and follow up conclusions such 
 as those actually obtained by many observers, and 
 more recently by Mr. Wright Thompson ^ in Glasgow, 
 viz. : — 
 
 1. That defective eyesight is largely preventible. 
 
 2. That town children (over and above those actually 
 suffering from optical defects) have less acute vision 
 than country children. 
 
 3. That children from the poorest quarters of popu- 
 lous centres are more seriously affected than other 
 town children. 
 
 4. That visual exercises may be undertaken at school 
 
 ^ Second International Congress on School Hygiene : Transactions, 
 ypl. ii, p. 530. ^^ 
 
 ' Of ■rv^t ...., 
 
 OF ^ 
 ALlFOg^ 
 
48 MEDICAL INSPECTION OF SCHOOLS 
 
 with the object of increasing the sharpness of distant 
 vision. 
 
 Similarly with regard to adenoid growths, defective 
 teeth, the spread of tuberculosis, and other problems, 
 the bare facts have been before us for years past. But 
 they are still waiting for official cognizance and further 
 scientific investigation. 
 
 From the educational standpoint, how is the State 
 to be benefited ? Systematic medical inspection will 
 eventually lead to an increased attendance of children 
 at school. The report of the Interdepartmental Com- 
 mittee on Medical Inspection shows that the various 
 medical officers, who have already acted on behalf of 
 the local education authorities, have done much 
 towards improving the attendance of the children at 
 school, and have frequently prevented unnecessary 
 school closure, in cases of outbreaks of epidemic disease. 
 
 The State has imposed compulsory education on all 
 children, and to a certain extent estimates efficiency 
 by the school attendance figures. The system is not 
 altogether satisfactory ; but obviously, the higher the 
 percentage of attendance, the more chance there is 
 that the education given will prove beneficial to a 
 greater number of children. So that efficiency in- 
 directly depends upon attendance, and most measures 
 that increase attendance make for increased efficiency 
 in education. We say ' most measures ', advisedly ; for 
 it is common knowledge that the present system of 
 prize and medal distribution, depending as it does on 
 attendance, is pernicious ; for the reason that it induces 
 
THE STATE'S RESPONSIBILITY 49 
 
 parents to send children to school when they ought, 
 for health's sake, to be at home. But any system 
 which increases the attendance of healthy children, 
 or which justifies the presence of less healthy children 
 in school under observation, should certainly be en- 
 couraged. 
 
 For instance, the transference of physically defective 
 and crippled children to the special schools, which have 
 come into being mainly as the result of the suggestions 
 and advice of medical officers, must necessarily add 
 to the efficiency of any system of education, by in- 
 creasing the attendance of the children and by bringing 
 education within the reach of those who would not 
 otherwise attend. Accordingly, if systematic medical 
 inspection is conducted on right lines, there is every 
 prospect that it will lead to improved attendance at 
 school. New York offers one necessary word of warn- 
 ing. As a result of imperfect organization and the 
 lack of appreciation of the principles of medical inspec- 
 tion during its initial stages of evolution, the local 
 medical inspectors, acting ostensibly in the interests 
 of the public health, were responsible for the wholesale 
 exclusion of children from school. Thus Dr. J. J. 
 Cronin has said ^ — 
 
 * Under the old system of inspection, which was 
 organized by the Department of Health, and which 
 obtained from March, 1897, to September, 1901, all 
 contagious conditions were recorded on a class index- 
 card, and on subsequent inspection were allowed forty- 
 
 ^ Second International Congress on School Hygiene : Transactions, 
 vol. ii, p. 551. 
 
 HOGARTH JJ 
 
50 MEDICAL INSPECTION OF SCHOOLS 
 
 eight hours' grace, and, if not within that time under 
 treatment, were at once excluded. The number of 
 exclusions were enormous ; some of the schools were 
 depopulated by half. This created the most bitter 
 and strenuous opposition from the Board of Educa- 
 tion. The Department of Health was accused of inter- 
 fering with the compulsory educational law, and was 
 indeed responsible for much truancy, with its con- 
 sequent illiteracy. Many of the conditions thus ex- 
 cluded by the Department of Health could safely be 
 allowed to attend school, provided that proper and 
 regular treatment was obtained.' 
 
 Wholesale exclusion from school for slightly con- 
 tagious diseases is clearly wrong, because, unless 
 there is some means of enforcing treatment, the ex- 
 cluded children are equally contagious out of school, 
 and are likely to infect other children both at home and 
 in the street. Consequently with regard to verminous 
 children and those suffering from other slightly con- 
 tagious diseases, compromise between the local sanitary 
 authority and the local education committee is essential. 
 The children may be separated into special classes 
 pending treatment, and kept under observation. But 
 to avoid any possible repetition of the situation created 
 at New York, the central education authority should 
 exercise some control, and should direct the methods 
 and practice of medical inspectors, who, in their turn, 
 should exhibit due appreciation of the educational 
 as well as of the sanitary aspect of the problem. 
 
 It is evident enough that the State will benefit by 
 an increased attendance of children at school. But 
 the cause of education can be further advanced by the 
 
THE STATE'S RESPONSIBILITY 51 
 
 systematic medical inspection of the individual children, 
 and that in two ways. Educational wastage can be 
 prevented, first, by preparing the children for their 
 education ; and secondly, by adapting the educational 
 system to the physiological requirements of certain 
 groups of children. 
 
 With regard to the first, he who would both sow 
 and reap does not begin by scattering his seed. He 
 first prepares the soil. Similarly, if the State is to 
 reap a full harvest, the children must be prepared 
 for their education by the school doctor. Normal 
 children need no special consideration at his hands ; 
 but a large number of children, owing to their physical 
 defects, are retarded in school work and require special 
 medical treatment. Such conditions include defective 
 vision, deafness, and general ill-health. On the other 
 hand, these defects, varying as they do in degree and 
 kind, do not necessarily retard progress in school. 
 
 Hence, if the argument is to be logical, there is 
 need to differentiate between those children who, owing 
 to physical defects, are actually retarded, and those 
 who, though suffering from slight defects, are not so 
 retarded. 
 
 An inquiry of this nature was undertaken in a poor 
 district of London, with a school population of 10,000. 
 Approximately one third of the children were back- 
 ward : but, out of 600 cases of backwardness systemati- 
 cally investigated, only 16 per cent, were solely due 
 to physical defects or ill health. Of these, nearly 
 one half were the result of prolonged absence from 
 
 E 2 
 
52 MEDICAL INSPECTION OF SCHOOLS 
 
 school, or of irregular attendance, rather than of the 
 actual defects. In a few more cases, physical defect 
 was regarded as a contributory cause of backwardness. 
 The same investigation showed that out of 1,360 
 children — normal and backward — attending two 
 schools, defective vision only directly accounted for 
 backwardness in 21 per cent, of cases, whilst 3-3 per 
 cent, were backward as a result of defective hearing 
 or of adenoid growths causing deafness. Slight defects 
 of vision or of hearing may to some extent impair 
 a child's mental alertness, but they are not sufficient 
 to retard educational progress. Such minor defects 
 do not make a case for State interference, but the 
 value of their inclusion in the general scheme of medical 
 inspection will, of course, be recognized. Then again, 
 with regard to infectious diseases, so many of the 
 children in crowded districts are attacked either before 
 school life, or while still in the infant department, 
 that any time lost can easily be made up later. Even 
 two or three months' absence does not necessarily delay 
 a child's progress from one standard to another, unless 
 it happens to come just before the time for promotion. 
 Sometimes, however, the effects of infectious disease 
 may appear secondarily as backwardness due to 
 anaemia, deafness, and so on. A considerable number 
 of anaemic and delicate children — especially girls — are 
 kept away from school, and, even when in school, they 
 are not considered fit to be ' pushed on ' with the 
 others. These are generally nervous children in a 
 condition of irritable excitability. 
 
THE STATE'S RESPONSIBILITY 53 
 
 Briefly, then, about 10 per cent, of the school children 
 in crowded districts are suffering from remediable dis- 
 eases and ailments of such a kind as to hinder their 
 educational progress to a serious extent. These 
 children cannot be dealt with by the teachers, nor do 
 they receive attention from their parents. The advan- 
 tage to the State of securing systematic medical in- 
 spection of such children, with a view to the remedy 
 of their defects and to the abolition of the present 
 waste of educational effort, is obvious. If it is worth 
 while to make every effort to increase the average daily 
 attendance of a school by 1 per cent. — and this 
 irrespective of whether the children are capable of 
 benefiting from their education or not — can there be 
 any doubt of the substantial advantages ensured by 
 transforming 10 per cent, ailing and backward children 
 into receptive children of ordinary intelligence, worthy 
 of the time and trouble which the teachers spend upon 
 them ? Yet this end can be attained by means of 
 a little common sense and medical advice. So that 
 the State, adopting, as it were, the methods of agri- 
 culture, will prepare the children for their education 
 by systematic medical inspection. 
 
 Educational wastage can be prevented in another 
 way. Quite apart from definite physical defects, there 
 are other causes of backwardness which are only dis- 
 covered by the school doctor. There is a large group 
 of children, who, by reason of natural dullness and 
 backwardness or mental defect, are scarcely capable 
 of benefiting from the present system of education in 
 
54 MEDICAL INSPECTION OF SCHOOLS 
 
 the elementary schools. Various estimates of their 
 number have been made. In London, probably not less 
 than 10 per cent, belong to this group, whilst another 
 10 or 15 per cent., in addition to those suffering from 
 physical defects, being backward, but not dull, fail 
 to derive much benefit from their education, chiefly 
 because they leave school at 14 years of age without 
 having reached the higher standards. 
 
 There is evident necessity for some scientific grouping 
 of school children, with the object of instituting special 
 educational routine for the various classes of children 
 in accordance with their physiological requirements. 
 And since the State has undertaken to provide educa- 
 tion for the children, it becomes a public duty to 
 examine into the fitness of the educational code for 
 the child, and to adapt it, where necessary, to the 
 child's requirements. To extend a previous metaphor, 
 it is just as important in agriculture to choose the seed 
 with care to suit special soil, as it is to prepare the 
 soil for the seed. Similarly, the system of education 
 must be deliberately chosen and adapted to the require- 
 ments of special groups of children. This principle 
 has already been recognized in the Elementary Educa- 
 tion (Defective and Epileptic) Act, 1899, which allows 
 provision to be made for the education of mentally 
 defective children in special schools. 
 
 No provision, however, has been made for the 
 dull and backward. To remedy this omission, the 
 Act of 1899 should now be made compulsory, and 
 permis.sive legislation introduced, empowering local 
 
THE STATE'S RESPONSIBILITY 55 
 
 authorities to establish special intermediate or lower 
 grade schools. 
 
 In these schools the aim, so far as reading, writing, 
 and arithmetic are concerned, should be to attain the 
 level of Standard IV. ' Education in these schools 
 should be in small classes, thirty pupils being a maxi- 
 mum. Formal class-teaching should be abandoned as 
 much as possible, and each child encouraged to inde- 
 pendent action. Handwork should be used extensively 
 and concrete things talked about, drawn, and described. 
 No books should be used, writing and printing being 
 entirely confined to blackboards and chalk. Arithmetic 
 and numbers should be dealt with as an oral subject, 
 and exercise, handwork, and drill should form a con- 
 siderable proportion of the school time-table '} 
 
 The facts and arguments adduced in this chapter 
 involve the inevitable conclusion that it is to the 
 advantage of the State to institute systematic inspec- 
 tion of school children : First, with a view to their 
 examination upon admission to school — and subse- 
 quently at intervals during school life — to discover if 
 any can be benefited by medical advice, and to obtain 
 the co-operation of the parents in the hygiene of the 
 home and of child life. The aim of such examination is 
 partly to anticipate any tendency to physical deteriora- 
 tion, and partly to secure the full benefits of education 
 for the children. Secondly, with a view to exclu- 
 
 * Dr. James Kerr: Annual Report of Education Committee. London 
 County Council, 1906. 
 
56 MEDICAL INSPECTION OF SCHOOLS 
 
 sion from the ordinar}^ schools of all mentally and 
 physically defective children, of all cripples, blind and 
 deaf children, and of those who are so dull or back- 
 ward that they cannot hope to benefit by their instruc- 
 tion, and who are moreover a hindrance to the others. 
 In brief the advantage to the State is twofold : 
 
 (1) The results of educational efforts will be en- 
 hanced not only by increased attendance and educa- 
 tional efficiency, but also by a more systematic and 
 scientific grouping of the children, and by adapting 
 school methods to the needs of the children. 
 
 (2) The physical condition of the children and of the 
 nation generally will be improved. 
 
CHAPTER V 
 SCHOOLS AND THE PUBLIC HEALTH 
 
 Definition of the Public Health: its Growth and Development. — 
 Sanitation of Schools. — Prevention of Infectious Disease in School. — 
 Daily Inspection Impracticable. — Dissemination in School. — Two Doubt- 
 ful Assumptions. — School a Place for Control rather than for Dissemina- 
 tion of Disease. — Other Communicable and Preventable Diseases. — 
 Chronic Affections. — Present Organization Inadequate. — Medical Practi- 
 tioners to prevent rather than to Cure. — School Doctor in New Role. — 
 School the Nursery of the Nation. — Co-operation of Teacher, Parent, 
 and Doctor. — Physical Deterioration an Educational Problem. — Sum- 
 mary. 
 
 The science of public health includes the prevention 
 and extinction of all manner of preventable disease, 
 its distant goal being the rearing of a healthy race 
 and the attainment of a high standard of national 
 physique. For the achievement of these ideals, there 
 is need of an extensive re-organization of the public 
 health service, and, as a first step, systematic medical 
 inspection of schools is necessary, in order to supple- 
 ment the present endeavours of public health authori- 
 ties in other directions. For instance, the national 
 duty of taking a physical census of the children is one 
 of the latest requirements of the public health. This 
 development indicates a marked contrast to the signifi- 
 cance of the term in the past, commonly restricted as 
 it has been to sanitation and the prevention of the so- 
 called dangerous infectious diseases. 
 
58 MEDICAL INSPECTION OF SC^HOOLS 
 
 To begin with this limited aspect of the problem, 
 and first of all with regard to sanitation. There are 
 thousands of school-houses throughout England which 
 are totally unfit for their purpose. Unsuitable build- 
 ings, overcrowded class-rooms without proper means 
 of ventilation, heating or lighting, unsatisfactory 
 cloak - rooms and water - closets, — these are their 
 characteristics : and in spite of all there is often 
 little enough attempt to carry out any approved 
 system of cleansing. 
 
 These deplorable facts are already well known to 
 educationalists, and there is not so much need for 
 systematic inspection and reports as for some well- 
 considered comprehensive scheme of amelioration 
 under each authority. It is easy enough to criticize 
 and to condemn, but it is often difficult to suggest 
 reasonable and satisfactory remedies. For instance, 
 one Education Committee proposed that their school 
 doctor should begin his duties by reporting upon the 
 sanitary conditions of the schools. But the County 
 Council threw out the recommendation on the ground 
 that the doctor would find something insanitary in 
 every school in the county, and that they were not 
 prepared to meet the expense of reconstruction. More- 
 over, such a survey occupies a considerable amount of 
 time^ and requires expert knowledge with regard to 
 school construction and methods of ventilation, heating 
 and lighting. 
 
 * In Blackburn, Dr. Greenwood devoted almost a year to the pre- 
 paration of a detailed report upon the structure and sanitary conditions 
 of iifty elementary schools. 
 
SCHOOLS AND THE PUBLIC HEALTH 59 
 
 Consequently from the sanitary point of view syste- 
 matic medical inspection, while bringing to light obvious 
 and gross defects not necessitating extensive structural 
 alterations, should from the first be more especially 
 directed to the instruction of teachers and school- 
 keepers as to how they can make the best of their 
 present unsatisfactory surroundings. In this way 
 good results may be expected, whereas detailed reports 
 as to the academic requirements of modern hygiene 
 and sanitation • are likely to be shelved by sceptical 
 committees. The school doctor's services, at first, will 
 be better employed in other directions, and in these 
 matters his constant aim should be to co-operate with 
 the architect and sanitary engineer with a view to 
 preventing the recurrence of insanitary conditions in 
 the future. With regard to the improvement of old 
 buildings, the principle should be invariably enforced, 
 that a consultation in which the teacher, architect 
 and doctor all take part, should be held on the spot. 
 
 The prevention of infectious disease has figured so 
 largely as the main function of public health work, that 
 at one time a serious suggestion was made — and was 
 actually carried into practice in the United States of 
 America — that a medical inspector should visit every 
 school every morning, for the purpose of excluding 
 any children suffering from infectious or contagious 
 diseases. But such a scheme, though undoubtedly 
 relieving the teachers of undue responsibility, savours 
 of gross extravagance. Daily health inspection at 
 school, to be of any real value, involves a medical 
 
60 MEDICAL INSPECTION OF SCHOOLS 
 
 examination of all children in the school and the 
 exclusion of those who are not in perfect health. It 
 is not enough for a medical officer to inspect such 
 children as are selected by the head teacher, or to 
 walk hurriedly through the class-rooms. For, in 
 either case, children in the early stages of measles 
 or scarlet fever may be passed over, while the whole- 
 sale exclusion of children suffering from headaches 
 and slight colds — although these are often the first 
 symptoms of an infectious disease — is scarcely justi- 
 fiable. 
 
 The impracticability of any satisfactory scheme 
 of daily health inspection is evident, partly on the 
 score of expense, and partly from the interference 
 with school routine. So that, as regards the pre- 
 vention of the acute infectious diseases, little advantage 
 is to be expected from any system of routine health 
 inspection. But, even in this restricted sense of public 
 health work, there is great need for medical super- 
 vision and for careful investigation conducted on 
 special lines, which may eventually lead to the com- 
 plete control of school outbreaks of epidemic disease. 
 
 The school is by no means such an exclusive centre 
 for the dissemination of acute infectious diseases as is 
 generally assumed. It should rather be regarded as 
 a convenient place for controlling their spread. In 
 the past, infectious diseases have been considered 
 mainly in their statistical aspect without exact 
 analysis as to the methods of transmission of 
 disease. Medical officers of health have been denied 
 
SCHOOLS AND THE PUBLIC HEALTH 61 
 
 the opportunity of studying the actual conditions and 
 routine of school life.' As a result two doubtful 
 assumptions have been accepted as maxims. 
 
 In consequence of the notable decrease of cases of 
 infectious disease during the school holidays — to which 
 Sir Shirley Murphy first drew attention in 1896 — it has 
 been generally assumed that the majority of cases are 
 spread by means of contact in school. It has also 
 been assumed that children between the age of 3 and 
 5 are more exposed to the infection of measles and 
 whooping-cough at school than at home or in the 
 street. As a matter of fact, more than one third of 
 town children entering school have already had measles 
 and whooping-cough ; and in Scotland, where children 
 are not admitted to school till 6 years old, the early 
 incidence of measles is no less marked than it is in 
 England, where a large number of children attend 
 school from the age of 3. The truth is that, at the 
 present time and under existing conditions, measles is 
 almost uncontrollable, whether in or out of school. 
 
 But with improved methods of investigation, and 
 with closer medical supervision in the schools, it will 
 be possible, as Dr. C. J. Thomas has proved by 
 practical experience in Woolwich, to diminish the 
 mortality rate of measles. 
 
 The first assumption is equally open to doubt. 
 Dr. Kerr has shown that, owing to the exodus of 
 children from the towns during the holidays, an altera- 
 tion in the distribution of population takes place which 
 to some extent may account for the decrease in the 
 
62 MEDICAL INSPECTION OF SCHOOLS 
 
 number of scarlet fever cases. Dr. Kerr has also 
 indicated from a consideration of the Registrar- 
 General's statistics, that before 1870 the incidence of 
 scarlet fever was greater among girls, who for the 
 most part remained at home and did not attend 
 school ; but that since 1870, the incidence upon girls 
 was progressively diminished for several years con- 
 currently with the enforcement of school attendance, 
 which, as a matter of fact, was directed more especially 
 to the attendance of girls than of boys. 
 
 The means of contact infection are distinctly limited 
 in school ; and even these sources of infection can be 
 definitely controlled, if hygienic precautions are intro- 
 duced into the schools. But there is no means of 
 controlling the scramble of play in the street, or the 
 intimate contact of small children in the homes. Up 
 to the present time, too large a proportion of cases has 
 been ascribed to school infection ; whereas the fact 
 that, if there were no schools, there would be a still 
 greater opportunity for the spread of infectious diseases, 
 has been ignored. So that judgment on this point 
 must be withheld until more is known about the exact 
 methods of transmission. It is 'certain that infectious 
 diseases are spread by contact in school, but probably 
 not to the extent which has been too hastily assumed. 
 
 But so far as systematic medical inspection is con- 
 cerned, sanitation and the prevention of acute infec- 
 tious disease are merely secondary considerations, 
 and in no sense its main function. 
 
SCHOOLS AND THE PUBLIC HEALTH 63 
 
 The significance of the term public health has 
 naturally been extended to include investigation of 
 other communicable and preventable affections quite 
 apart from epidemic disease. Of these tuberculosis 
 was the first to attract attention, and its prevention 
 now occupies a prominent place in public health 
 administration. The study of epidemic diarrhoea in 
 relation to infantile mortality soon followed, and now 
 influenza and pneumonia — to say nothing of cancer 
 and alcoholism — have found their way into the reports 
 of medical officers of health. 
 
 But in spite of these rapid developments, there is 
 a large group of communicable diseases, affecting not 
 only the individual but also the public at large, which 
 have so far been almost entirely neglected by public 
 health authorities. Such affections are ringworm, 
 verminous and parasitic conditions, skin diseases, 
 ophthalmia, and other eye diseases. These have one 
 characteristic in common, namely, that they are 
 chronic : and being chronic, and being for the most 
 part diseases of childhood, they are chiefly concerned 
 with the schools. It is due to the work of school 
 doctors, and of medical officers of health, who have 
 placed a wide interpretation upon the scope of their 
 duties, that such diseases in their relation to the school 
 have been brought to light. For years these condi- 
 tions passed unheeded. Inspectors of schools, sanitary 
 committees and medical officers of health took little 
 enough notice of them. However, now that they 
 are recognized, their spread can be completely con- 
 
64 MEDICAL INSP!^:CTION OF SCHOOLS 
 
 trolled, if a thorough system of health inspection is 
 adopted. 
 
 Parents whose children attend public elementary 
 schools have the right to expect that their children 
 should not be exposed to the danger of contracting 
 those diseases. Consequently every effort must be 
 made to prevent them. Weekly routine examination by 
 medical men, or by nurses acting under the supervision 
 and direction of medical men, will be necessary at 
 first, and it becomes the duty of the local education 
 authorities to direct their system of medical inspection 
 towards this object. It is manifestly unfair to leave 
 the responsibility for admission or for exclusion to the 
 head teachers, which has been the practice in the past ; 
 and it is notorious that many members of the medical 
 profession certify children suffering from these diseases 
 (e. g. ringworm or ophthalmia) as fit or unfit to attend 
 schools according to the wishes of the parents.^ 
 
 One of the first functions of any system of health 
 inspection must be to get the children clean and free 
 from parasitic and contagious diseases. It is of more 
 immediate importance than a physical census of the 
 children or an examination for defective vision. Hence 
 it is necessary to assign a local school doctor and 
 a nurse to each small group of schools, in order to keep 
 the children under frequent observation and to ensure 
 the close co-operation of teacher, nurse, and doctor. 
 In this way, these direct efforts to limit the spread 
 and to promote the extinction of the minor contagious 
 
 ' Cf. cliap. xiv, p. 231. 
 
SCHOOLS AND THE PUBLIC HEALTH 65 
 
 diseases constitute an important extension of public 
 health administration. 
 
 A momentary digression from the main issue is 
 necessary. For the science of public health has con- 
 tinued to develop itself on far broader lines, and now in 
 addition to problems of sanitation and communicable 
 disease, it includes the consideration of : (1) Factory 
 legislation and occupational disease. (2) Control of 
 milk and food supplies. (3) Housing reform. (4) Alien 
 immigration. Thus we read as one of the duties of 
 a local medical officer of health, ' that he shall inquire 
 into all causes affecting the health of the people in 
 his district '. But the means of carrying out this 
 counsel of perfection are distinctly limited. The 
 administration of the laws relating to public health 
 has become somewhat confused. The developments 
 have been so great and so widely different in character 
 that new duties have been assigned to what is appar- 
 ently the most appropriate body, with little attempt 
 to prevent overlapping and conflict of function. Hence 
 the supervision and responsibility of public health 
 administration is divided among the Local Government 
 Board, the Home Office, the Board of Customs, the 
 Board of Agriculture, and other offices.^ 
 
 The State has accepted many responsibilities, but 
 has provided no satisfactory central machinery for 
 supervision and control. The code of public health, 
 though adequate in substance and capable of broad 
 interpretation, is through negligent administration 
 
 ^ See chap, viii, p. 97. 
 
 HOGARTH J, 
 
66 MEDICAL INSPECTION OF SCHOOLS 
 
 actually in a chaotic state ; and responsibility is for 
 the most part left to local authorities. In fact, the 
 State regards public health chiefly as a matter for 
 local administration, and not as requiring any 
 uthoritative central machinery. So that the Local 
 Government Board, with its inadequate medical sub- 
 department, is often regarded as the State department 
 responsible for the health of the nation. 
 
 What is the remedy ? Many points of re-organization 
 suggest themselves. Owing to the vast development of 
 the science of public health during the last twenty years, 
 the time has undoubtedly come for the creation of 
 a special Government Department, or Board of Health,^ 
 on the lines of similar institutions in those countries 
 where civiUzation is of more recent growth. 
 
 Co-ordination will then, and only then, become pos- 
 sible ; and all branches of public health can be arranged 
 in their proper perspective with a view to simplifying 
 and improving the present chaotic system of adminis- 
 tration. Then it will, perhaps, be practicable for the 
 medical officer of health to inquire into all causes 
 affecting the health of the people of his district ; and 
 the significance of the term public health may perhaps 
 be extended still further to include the investigation 
 of other incipient diseases which are slowly under- 
 mining the physical and mental efficiency of the growing 
 generation. 
 
 To return to the school aspect of public health work : 
 
 ^ The creation of an Advisory Council was recommended by the Inter- 
 departmental Committee on Physical Deterioration (1904). See Appen- 
 dix II, E. 
 
SCHOOLS AND THE PUBLIC HEALTH 67 
 
 most diseases, and not merely those that are spread 
 through infection, are preventable, and it should become 
 more and more the duty of medical practitioners to 
 prevent rather than to cure. To attain this object, 
 there is need for the doctor to play an entirely new 
 part in the schools. He must detect the hitherto 
 unrecognized defects such as mouth-breathing, defec- 
 tive vision, carious teeth, discharging ears, rickets, 
 anaemia, St. Vitus' dance, heart disease, all of which 
 can be prevented or remedied. These diseases are 
 unrecognized because the symptoms are unknown to 
 parents and teachers. No particular remedy can be 
 suggested without recourse to systematic health 
 inspection of all children. 
 
 Up to the present time, there has been no organization 
 for dealing with these conditions from the pubhc health 
 point of view, as they fall outside the purview of the 
 medical officer of health, and belong to the general 
 practitioner. But if the latter fail to recognize their 
 presence, or if there is no family doctor, it obviously 
 becomes a national duty to establish some new organi- 
 zation for the detection of such conditions. Their 
 prevention is a factor of the utmost importance in any 
 scheme for the improvement of the national physique. 
 
 The school is the nursery of the nation, and, by 
 reason of the ignorance of the parents, this aspect of 
 the whole question should be treated as an educa- 
 tional problem ; for the best way of combating phy- 
 sical deterioration is by means of physical education 
 and by the instruction of teachers and children in 
 
 F 2 
 
68 MEDICAL INSPECTION OF SCHOOLS 
 
 the elementary principles and essentials of healthy 
 living. 
 
 The value of physical education very largely depends 
 upon the age at which it is begun. ' We are taught to 
 live when our life is wellnigh spent,' says Montaigne. 
 But this ought not to be equally true in the twentieth 
 century. 
 
 Nor again is physical education to be regarded as 
 merely synonymous with physical training or physical 
 exercises. It concerns the whole physical upbringing 
 of children. The school is the nursery of the nation ; 
 and, owing to the ignorance of parents, children must 
 be taught the most elementary habits of cleanliness — 
 the use of a pocket-handkerchief, the habit of nasal 
 breathing, the cleansing of teeth : in a word, they 
 must be taught how to live healthy and cleanly lives.^ 
 These habits cannot be taught by the enforcement of 
 sanitary laws or by health visiting at the home ; but 
 they can be gradually instilled by means of a practical 
 system of education in the infant schools. Then the 
 good effects of the natural reaction will be observed 
 in the homes of the poor. Ignorance can only be 
 conquered by sympathetic education, which is the 
 function of the school. It can scarcely be overcome 
 by the pious exhortations of social workers. Health 
 visitors may be useful for the instruction of parents 
 in a few practical points of hygiene in the home, but 
 their work entails a great deal of wasted energy. No 
 amount of advice or of benevolent effort can take the 
 
 * Cf. chap, vii, p. 83. 
 
SCHOOLS AND THE PUBLIC HEALTH 69 
 
 place of the demonstration and practice of personal 
 hygiene and cleanliness in the schools. The health 
 visitor, moreover, has no legal standing, and her 
 welcome depends upon the courtesy of parents, whereas 
 education both physical and mental is compulsory. 
 
 The general purport of this chapter has been to 
 show that the growth and development of public 
 health work has been so extensive that the present 
 organization is inadequate to cope with routine health 
 inspection. In order that the ideals and aims of the 
 science of public health may be attained, extensive 
 re-organization of the service is necessary, besides the 
 institution of systematic health inspection at school. 
 
 The school doctor is the embodiment of a new idea. 
 He is entering a new field, hitherto unexplored. He 
 will find new duties and new opportunities : and with 
 him will come many improvements in education. 
 Consequently there is need from the outset for close 
 co-operation on the part of teacher, parent, and 
 doctor — to an extent which is only possible at school — 
 in the physical upbringing of the children. Moreover, 
 the whole subject of physical deterioration, though 
 nominally included under public health administra- 
 tion, is in reahty an educational problem. 
 
CHAPTER VI 
 THE CLAIM OF THE INDIVIDUAL CHILD 
 
 Benefits to Individual Child. — Analogy from Secondary Schools. — 
 Evil Results of Unrecognized Disease. — Short Sight. — Astigmatism. — 
 Anaemia. — School Headaches. — Defective Teeth. — Ignorance and Neglect 
 among the well-to-do. — Medical Inspection of Secondary Schools. — Gross 
 Neglect in Poor Districts, — A Fortiori Case for Medical Inspection. — The 
 Duty of Humanity. — The Claim of the Individual. 
 
 Systematic medical inspection at school has now 
 been discussed from the points of view of the State 
 and of the public health. There remains for con- 
 sideration the claim of the individual child — a claim 
 which is seldom fully appreciated. Quite apart from 
 the children's value as a State asset, or as a factor 
 in the public health, there can be no doubt of the 
 individual benefits to be derived from a system of 
 health inspection. 
 
 For the moment, an analogy may be drawn from 
 the case of children in secondary schools. Their 
 parents may be well-to-do, with a family doctor in 
 constant attendance. The child's obvious needs and 
 requirements are met ; he may be, to all appearance, 
 the picture of physical health, and as regards educa- 
 tional progress he may be fully up to the average 
 level of his class. But, none the less, he is afflicted 
 with short sight, or with astigmatism, and no one has 
 
THE CLAIM OF THE INDIVIDUAL CHILD 71 
 
 realized the seriousness of his defect. In cases of 
 astigmatism, from which a large number of school 
 children suffer, neglect of this nature is particularly 
 common. An astigmatic child frequently appears to 
 have normal vision, and can generally pass an ordinary 
 test of visual acuity. He can read the blackboard at 
 school and may sometimes be recognized as endowed 
 with unusually sharp vision. The symptoms of his 
 condition pass unnoticed. He suffers from headache 
 or from aching and watering eyes with inflammation 
 of the eyelids. These symptoms result from the un- 
 natural strain to which the eye muscles are subjected 
 in order to secure adequate vision. Such a child 
 requires careful attention at the hands of an oculist. 
 
 Even definite shortness of sight may pass unrecog- 
 nized for many years. At school the child may have 
 said he was unable to see the blackboard, and have 
 been allowed to sit in front. At home his complaint 
 is ignored. The more obvious results of his inability 
 to see properly are ascribed to carelessness, or to 
 innate stupidity : and it would be difficult to estimate 
 the amount of misery that has been caused in this 
 way to sensitive children. In secondary schools there 
 are many such children, whose slight visual and aural 
 defects pass unrecognized until it is too late. Although 
 not sufficient to impair their usefulness as citizens, 
 they affect their chances and opportunities in later 
 life, entailing, as they do, diminished alertness and 
 power of observation. 
 
 The case is the same in respect of defective teeth. 
 
72 MEDICAL INSPECTION OF SCHOOLS 
 
 No attention is paid to a child's mouth until he 
 complains of toothache. Even this complaint may be 
 regarded by the more Spartan parents as a piece of 
 affectation, and it is not until permanent injury is 
 caused that the need for treatment is reahzed. 
 
 Anaemia, again, has its own tale to tell. How many 
 children — especially girls — pass through a period of ill 
 health owing to debility and anaemia, which is looked 
 upon by their parents as a purely normal condition 
 inevitable at the age of puberty. The doctor is not 
 consulted except as a last resort. The languid, drowsy 
 condition of the child may be ascribed to laziness, 
 and the pale complexion, so far from being regarded 
 as a symptom of ill health, is often referred to with 
 pride by admiring relatives as especially beautiful. 
 The child is pressed on to win a scholarship, though 
 already suffering from general overstrain, or urged to 
 take violent exercise, though troubled with constant 
 breathlessness. The anaemia may be an expression of 
 (1) general debility and malnutrition ; (2) circulatory 
 changes at puberty ; (3) rheumatism ; or (4) tuber- 
 culosis. Each of these conditions should therefore 
 receive careful consideration with a view to appro- 
 priate modifications in the routine of school life. Such 
 children may or may not be materially impaired in 
 health, but in all cases they experience unnecessary 
 suffering. 
 
 School headaches, also, are commonly met with at 
 secondary schools. Such headaches are frequently 
 either undetected or ignored, though they require 
 
THE CLAIM OF THE INDIVIDUAL CHILD 73 
 
 special investigation at the hands of a school doctor — 
 often a very difficult task. Headache may be the first 
 sign of some acute infectious disease or may be due to 
 temporary conditions such as overwork or want of 
 adequate ventilation. On the other hand, it may result 
 from constant overpressure or from some defect of 
 vision. It may indicate the presence of dyspepsia or 
 of some nervous disorder, or it may be a symptom of 
 anaemia or malnutrition. Even decaying teeth or 
 nasal obstruction by adenoid growths may cause con- 
 stant headache in the school child. Any of these 
 conditions, and even marked mental fatigue and over- 
 pressure, may pass unheeded. Therefore, it is due to 
 the individual that some means shall be established 
 for the discovery of these and similar unrecognized 
 conditions. 
 
 Then again, the weakly, delicate, and strumous 
 children with long silken eyelashes and ' beautiful ' 
 complexions — generally a sign of insidious disease — 
 pass through school life inadequately cared for both 
 educationally and physically. There are also a large 
 number of spoiled and pampered children who, being 
 subjected to much unnatural restraint and arti- 
 ficiality at home and in the school, become neurotic 
 and delicate. These children together constitute a 
 large group of individuals who, for their own sakes, 
 require the kindly intervention of the school doctor. 
 
 The remedy lies first in systematic medical inspection, 
 and secondly in the provision of a specially modified 
 educational curriculum at open-air recovery schools. 
 
74 MEDICAL INSPECTION OF SCHOOLS 
 
 The regime of such schools, even if limited to periods 
 of six months, should be sufficient to restore the children 
 to health, to lay the foundation of a good physique, 
 and finally to lead to improved conditions of life at 
 home. 
 
 If any further instances of these slighter defects are 
 needed, it is only necessary to mention the importance 
 of the early detection of slight curvature of the spine 
 or deformities of the toes and feet, of which seldom 
 any notice is taken, even by careful parents. But 
 whatever the nature of the particular infirmity or 
 defect, case after case will occur to the mind of any 
 experienced observer, where well-intentioned neglect or 
 complacent ignorance on the part of well-to-do parents 
 has resulted in permanent deterioration, whether of 
 vision, or hearing, or general physique. 
 
 The careful consideration of all these matters is of 
 the utmost importance to the individual child. At the 
 same time, these points serve as an almost incontro- 
 vertible argument for the introduction of systematic 
 medical inspection at secondary schools. 
 
 In many of the preparatory and secondary schools 
 of the well-to-do, the doctor has been a daily visitor 
 for many years. But cases of accident and sudden 
 illness have generally been the excuse for his atten- 
 dance. In his capacity as school doctor he visits the 
 sanatorium or infirmary, but not the classroom, the 
 study, or the playing fields. He sees only those children 
 to whom the master or mistress directs his attention. 
 However, in one or two of the more modern and up- 
 
 X 
 
THE CLAIM OF THE INDIVIDUAL CHILD 75 
 
 to-date residential schools the responsible authorities 
 have recognized the value of the doctor's services quite 
 apart from infection and accident. In course of time, 
 no doubt, their example will be followed in all secondary 
 and preparatory schools. 
 
 If, therefore, in the schools of the well-to-do, syste- 
 matic medical supervision is necessary for the sake 
 of a neglected minority, how much more is it a duty 
 of humanity to provide for the medical inspection 
 of children attending the public elementary schools. 
 
 It requires no very intimate knowledge of the lives 
 of those who dwell in the poorer districts of large 
 towns to recognize that children's special senses, their 
 eyes and ears, and even their very lives, are sacrificed 
 through parental neglect or ignorance. For example, 
 ill-nourished and weakly children often suffer from 
 inflammation of their eyes — a condition which calls for 
 careful attention from the first. Neglect results in an 
 extension of the process of infiammation. An ulcer 
 may be formed on the transparent membrane in 
 front of the eye. In course of time the ulcer heals, 
 but leaves a permanent scar which interferes with 
 perfect vision. Sore eyes also, if neglected, may lead 
 to serious injury, while neglect to remedy a squint 
 generally results in complete loss of vision in the 
 squinting eye. 
 
 The case is the same with discharging ears — a condi- 
 tion which commonly follows an attack of scarlet fever 
 or measles. Neglect may lead to an extension of 
 the disease to the cranial cavity, thereby imperilling 
 
76 MEDICAL INSPECTION OF SCHOOLS 
 
 the life of the child. It should be a matter of common 
 knowledge that pitiful examples of ignorance and 
 neglect are met with daily in the routine work of the 
 school doctor. In a word, the children of the poor 
 are handicapped throughout life, not so much by their 
 squalid surroundings, as owing to parental ignorance 
 and obstinacy. 
 
 Physical and mental defects, sufficient to retard 
 a child's educational progress and bring it under the 
 cognizance of the State in the elementary schools, have 
 already been considered ; ^ but there are many children 
 with lesser defects, which only prove a hindrance in 
 later life. For instance, there are about 10 per cent, 
 with defective vision, 2 or 3 per cent, suffering from 
 deafness, and many others suffering from anaemia and 
 general debility, to say nothing of a large percentage 
 with defective teeth. Who will deny these children all 
 the benefit that is to be derived from medical advice ? 
 
 Surely it is better to prevent and to cure disease in 
 infancy and childhood, than to seek to prolong life 
 to 100 years or to support overcrowded Poor Law 
 infirmaries. To bring medical aid and knowledge 
 within the reach of the ignorant poor is to help them 
 out of their slough : it becomes an education in itself. 
 The school doctor cannot abolish all this ignorance 
 and neglect, nor will he educate all the parents at 
 once, but in the course of a few years a vast improve- 
 ment will be noticeable if an adequate system of 
 inspection is introduced. 
 
 ^ Cf. chap, iv, pp. 51-54. 
 
THE CLAIM OF THE INDIVIDUAL CHILD 77 
 
 Further, the teacher cannot do justice to any indi- 
 vidual child without such knowledge of its mental, 
 moral, and physical development as can scarcely be 
 acquired without the doctor's help. A child in its 
 early stages of growth and development is a composite 
 structure, which only trained and experienced observa- 
 tion can hope to understand. And though the teacher 
 may be able to form an adequate judgment of the 
 child's general capacity, yet every schoolmaster will 
 recall many a difficult case, in which he would have 
 been glad of the advice of a school doctor interested 
 in the study of child life. 
 
 For these reasons, systematic medical supervision 
 of schools is necessary, for the sake of the individual 
 child. It is ' the claim of the individual to be studied 
 and treated with due consideration for his tendencies 
 or idiosyncrasies, whether they are due to hereditary 
 transmission or not. He asks that he may not, without 
 due inquiry, be forced into the average mould in the 
 matter of drugs, education, or employment ; that the 
 personal equation may be noted as early in life as 
 possible ; and that his anatomical and functional 
 capacity may be regarded in the consideration of any 
 questions likely to involve his health and well-being '.^ 
 
 ^ The Prevention of Disease. Introductory chapter by H. Timbrell 
 Bulstrode. Constable & Co., 1902. 
 
RECAPITULATION 
 
 THE CASE FOR MEDICAL INSPECTION 
 
 The claims of medical inspection at school, in so 
 far as they concern the State, the Public Health and 
 the Individual have now been analysed ; and the 
 State control of a system of routine inspection has 
 been substantially justified. Briefly to recapitulate 
 the main points : — 
 
 1 . The State requires a physical census of the children 
 for the discovery of unrecognized defects, partly with 
 a view to the improvement of the national physique, 
 and partly with a view to the preparation of all children 
 for school life. It is also a national duty to arrange 
 for the classification of children according to their 
 mental capacities, and to adapt the educational system 
 to the requirements of the several groups of children, 
 in order to diminish the present economic wastage of 
 misdirected educational efforts. 
 
 2. It is the dut}^ of local authorities to protect the 
 individual against communicable diseases in school, to 
 supervise school buildings, and to secure healthy sur- 
 roundings for the school child. 
 
 3. Owing to ignorance, neglect, or apathy on the 
 part of parents, it becomes a requirement of the 
 merest humanity to bring medical aid and special edu- 
 cational methods within reach of the individual child. 
 
 These aims and ideals can only be attained by the 
 introduction of a system of routine inspection of the 
 children by medical men interested, not only in public 
 health, but also in education. 
 
>^ O? THE 
 
 CHAPTER VII 
 
 THE GENERAL PRINCIPLES AND AIMS OF 
 MEDICAL INSPECTION 
 
 Medical Inspection only one Branch of School Hygiene. — A Science 
 of Education. — School Hygiene Defined. — An Unexplored Field. — 
 Differentiation of Children. — Physical Education. — Teaching of Hygiene. 
 — The Apperception of Education. — Routine Medical Inspection : (a) of 
 Schools ; (6) of Scholars. — Their Hygienic and Educational Aspects. — 
 First Examination superficial. — Second Examination more searching. — 
 Co-operation of Teacher and Doctor. — Outline of General Advantages. — 
 Objections. — Fundamental Definition of Medical Inspection. 
 
 Medical inspection of schools should have been the 
 first step in any compulsory system of State education. 
 In England it is almost the last. The past generation 
 of educationalists had few ideas beyond that of teaching 
 reading, writing and arithmetic to all and of training 
 the more intelligent children to win scholarships. 
 There was no idea of educating each child to play his 
 part as a citizen of the State. In consequence the 
 one essential step was overlooked and educational 
 progress has been conducted on wrong lines for many 
 years. Now it is necessary for educationalists to retrace 
 their steps and to begin again from the beginning. 
 As a result of this inverted method of progress, 
 education has become a highly complex and involved 
 subject. Development has been one-sided and there 
 has been a singular absence of clear thinking. 
 
80 MEDICAL INSPECTION OF SCHOOLS 
 
 Hence it is that three chapters of this book have been 
 necessary for the adequate analysis of the subject of 
 medical inspection at school and for its justification 
 as an integral factor in any educational system — 
 a justification that should have been obvious to 
 educationalists thirty or forty years ago. 
 
 For our purposes school hygiene may be regarded 
 as the latest development of education in its more 
 comprehensive aspects. So that medical inspection, 
 rightly considered, so far from being an end in itself, 
 is actually but the initial step in a great scheme of 
 progress — a scheme which involves the improvement 
 of the existing conditions of mental, moral, and physical 
 development of the children. The scheme also aims 
 at the prevention of disease in childhood, and at 
 raising the standard of the national physique. Its 
 final goal is the development of a science of education 
 itself. These aims are definite and practical and may 
 be summarized under the following heads : — 
 
 1. Routine medical inspection. 
 
 2. Physiology and psychology of ordinary educational 
 methods and curricula, including fatigue, neurasthenia, 
 hysteria, questions of sex, &c. 
 
 3. Special educational methods for abnormal children 
 of all the many different types— the mentally and 
 physically defective, the dull and backward, the blind, 
 deaf, and the debilitated, &c. 
 
 4. Scientific supervision of school methods, i.e. of 
 nursery schools, school furniture, buildings, baths, 
 douches, ventilation, lighting, &c. 
 
AIMS OF MEDICAL INSPECTION 81 
 
 5. Physical education, including supervision of 
 manual training, gymnastic exercises, organized games, 
 dancing, &c. 
 
 6. Teaching of hygiene to teachers and others, and 
 lastly, 
 
 7. Prevention of infectious diseases and attention 
 to the sanitary condition of the premises. 
 
 These together constitute a special group of medical, 
 pedagogical and educational factors known as school 
 hygiene. This is a convenient term, but school hygiene 
 is as far removed from general hygiene as surgery is 
 from medicine. There is, naturally, a common meeting 
 ground, but generally speaking the problems of school 
 life must be approached in a different light and with 
 a different mental attitude from those of ordinary 
 hygiene and sanitation. Nor in this instance is the 
 part necessarily less than the whole, except in the 
 same way and to the same extent that surgery is merely 
 a branch and a part of medicine. - 
 
 Each of these headings merits consideration, but 
 they can only be very briefly dealt with here. The 
 physiology and psychology of ordinary educational 
 methods is, to all intents and purposes, an unexplored 
 field, full of possibilities and suggestions. Something 
 is known about the growth and development of the 
 child's brain, but the educational system has not been 
 adapted to the biological requirements of the child 
 at different periods of its growth and development. 
 About the manifestations of overpressure, neurasthenia 
 and hysteria in the school child, little is known ; still 
 
 HOGARTH Q 
 
82 MEDICAL INSPECTION OF SCHOOLS 
 
 less about fatigue in its relation to school work. Much 
 research work remains to be done before approved 
 educational methods can be established. Only when the 
 fundamental truths of the physiology and psychology 
 of the school child have been accurately defined, can 
 an educational system, which will be satisfactory in 
 all respects, be based on the sure foundation of 
 these truths. 
 
 Secondly, the differentiation of types of children has 
 begun. There are the physically and mentally defec- 
 tive, the dull and backward, the blind and deaf. But 
 the problem of their educational treatment has scarcely 
 been faced. Yet the economic saving of such a course 
 becomes obvious, when the subject is considered from 
 the following standpoint. The purpose of education 
 is to fit each individual child to play its part as a good 
 and efficient servant of the State to which it belongs. 
 As there are different types of children, so there must 
 of necessity be educational systems to suit each type 
 or class of child. The educational treatment of children 
 according to their mental and physical capacities effects 
 a great economic saving by which the State profits on 
 the one hand and the child on the other. 
 
 Thirdly, there is the subject of physical education 
 about which so much has been said and written. First 
 one theory holds the field, then another. Some believe 
 only in physical exercises, others only in organized 
 games, and others in both. But while amateurs dispute, 
 there is at least room for the open-minded doctor and 
 educationalist to give advice as to practical methods 
 
AIMS OF MEDICAL INSPECTION 83 
 
 of physical training, and as to the educational value 
 of manual training at certain ages as well as of dancing 
 and singing. All of these may be made interesting 
 to the children and may be educationally valuable, 
 which is anything but true of the dull, lifeless exercises 
 and practice in dancing and deportment that are taught 
 in many schools. 
 
 Fourthly, there is the consideration of teaching 
 hygiene to both children and teachers. It would 
 appear to be easy enough to introduce into the time- 
 tables an hour or so for instruction in hygiene. But 
 hygiene is a difficult subject to teach, and those who 
 are to teach it must themselves be taught. First of 
 all the teachers must acquire definite knowledge of 
 certain anatomical and physiological facts : they must 
 also be taught how their knowledge can be applied 
 to the practical problems of hygiene and education. 
 They must be instructed in the theory and prac- 
 tice of physical training. But though this elementary 
 knowledge will be useful by itself and is necessary to 
 enable the teacher to appreciate the doctor's sugges- 
 tions and directions, yet it is still more essential that 
 teachers should themselves acquire a broader sense 
 of perspective, a wider outlook, an altered mental 
 attitude, so that they can approach the problems of 
 education and school life from the scientific standpoint. 
 This habit of mind, this apperception, cannot be 
 acquired by the learning of facts, but by an improved 
 system of education in the training colleges. Then 
 and not till then will it be possible for teachers to 
 
 G 2 
 
84 MEDICAL INSPECTION OF SCHOOLS 
 
 instruct children in the elementaryprinciples of healthy 
 living and to instil into their minds an interest in 
 physical training and in personal hygiene. 
 
 Each of these branches of school hygiene requires 
 more detailed consideration than it is possible to give in 
 the limits of this book. The subject of routine inspec- 
 tion alone will be considered at full length. It is the 
 first step in virtue of which the doctor has claimed 
 official recognition in the school world as a servant 
 of the State. This point of view has already been 
 maintained in a previous chapter. It remains now 
 to recapitulate the general principles of systematic 
 inspection, and at the same time to introduce certain 
 incidental factors, with a view to drawing up an ideal 
 scheme of organization. 
 
 Routine medical inspection may be practically 
 divided into the inspection of schools and the inspection 
 of school children, and each of these may be subdivided 
 according to its hygienic and its educational aspects. 
 The distinction between inspection of schools and 
 inspection of school children is purely arbitrary, but 
 it is convenient. 
 
 Medical inspection of schools in its hygienic aspect 
 consists chiefly in criticizing and approving plans of 
 new school buildings as to ventilation, lighting, heating 
 and sanitary accommodation ; and in suggesting, as 
 far as practicable, remedies as regards these things in 
 old buildings erected without medical advice. There 
 are already a considerable number of accepted rules 
 for school architecture and sanitation upon which the 
 
AIMS OF MEDICAL INSPECTION 85 
 
 school doctor can base his opinions. Yet there is room 
 for much careful observation and experiment as to 
 methods of building as well as of lighting, ventilation 
 and heating. Therefore a medical inspector should 
 undertake this part of his duty with an open, un- 
 prejudiced mind and should be ready to co-operate 
 with the architect and sanitary engineer. 
 
 In its educational aspect, routine medical inspection 
 consists in the supervision of school curricula and 
 general methods, more especially in the infant schools. 
 It is essential that more discretion should be exercised 
 in drawing up school time-tables so as to secure a correct 
 proportion of recreation and physical exercises between 
 the hours of mental stress, and so as to ensure a satis- 
 factory sequence of subjects in the course of a school 
 session. Little attention has been given to these 
 matters, and it will become one of the duties of a 
 medical inspector to discuss these points generally 
 with the teachers in relation to whole classes as well 
 as to individual children. Certain occupations must 
 be abolished altogether from the infant schools, while 
 more manual work might be introduced with great 
 advantage into the lower standards of the elementary 
 schools. 
 
 In every school, in fact, the time-tables should be 
 signed by the school doctor as well as by the ordinary 
 inspector of schools. There is also need for better 
 judgment in the choice of pens, paper, ink, blackboards 
 and other school materials. These things may appear 
 insignificant, but they are all important in practice ; 
 
 ?' 
 
86 MEDICAL INSPECTION OF SCHOOLS 
 
 and it may be said with truth that, owing to want of 
 medical advice in the past, spinal deformity, eye- 
 strain, overpressure, and ' brain-fag ' have been caused. 
 No one but a medical man — and a medical man with 
 special educational knowledge — has the proper training 
 to decide what in these matters is hygienic and what 
 is not. Unhygienic conditions and faulty methods, 
 approved by the ' expert ' who does not know, have 
 existed long enough ; and only now that the doctor 
 has found an entrance into the schools have they been 
 recognized with any prospect of eventual remedy. 
 . Medical inspection of the children in its hygienic 
 and in its educational aspect has been dealt with in 
 considerable detail already. It consists in the super- 
 ficial examination of all children on their admission 
 to school as to cleanliness, obvious defects such as 
 squints, deformities, and ear discharges, as to their 
 general fitness for school life, and as to their previous 
 medical history. Measurements of height and weight 
 may also be taken if considered necessary. 
 
 This first examination should, if possible, be con- 
 ducted in the presence of the parents. No children who 
 are in an uncleanly state or suffering from verminous 
 and parasitic conditions, or who are in other respects 
 unfit for school life, would be admitted ; the previous 
 medical history of every child would be obtained ; and 
 the attention of parents would be called to obvious 
 and gross defects needing immediate attention, such 
 as squints and defective teeth. There is no need for 
 any examination of vision or of mental capacity, as 
 
AIMS OF MEDICAL INSPECTION 87 
 
 infants are generally admitted to school at five years 
 of age, and a very large number are also brought at 
 three or four. Any more thorough examination at 
 this early age is impracticable and may be less useful 
 than is generally supposed. For the rest, all children 
 in the infant schools should be kept under systematic 
 medical supervision at least once a term, with a view 
 to early detection of disease. 
 
 At the time of promotion of the children from the 
 infant schools, say at seven or eight years of age, it 
 would be necessary for the school doctor to hold a more 
 searching examination. There would be no necessity 
 for the presence of the parents : ^ the children would have 
 grown accustomed to their surroundings, to the teachers, 
 to the school nurse, and even to the doctor himself. It 
 would be advisable to devote ten minutes or a quarter 
 of an hour to the examination of each child. It would 
 be advantageous if the rough testing of the children's 
 vision had previously been undertaken by the teacher, 
 and if the measurements of height and weight had 
 been entrusted to the nurse. This would give the doctor 
 additional time to estimate the physical and mental 
 characteristics of the child and to investigate any 
 abnormal conditions. With the co-operation of the 
 head teacher, the doctor should be in a position to 
 decide what special educational system is adapted to 
 the child's requirements. For instance, if the child were 
 normal, he would be allowed to proceed to the elemen- 
 
 * It is advisable that a third person should be present at any examina- 
 tion of school children. 
 
88 MEDICAL INSPECTION OF SCHOOLS 
 
 tary school : if dull and backward, he would be recom- 
 mended for transference to a special class, or to a lower 
 grade school where manual work and oral instruction 
 would be more in evidence than at the ordinary schools. 
 Similarly, if the child could be certified as mentally or 
 physically defective under the Elementary Education 
 (Defective and Epileptic) Act, 1899, he would be 
 recommended as a suitable case for admission to a 
 special school. 
 
 At this examination, also, the doctor would make 
 a careful investigation as to defective vision, dis- 
 charging ears, deafness, adenoids, teeth, &c., and would 
 issue printed instructions to the parents as to the 
 necessity for seeking further medical advice. The 
 doctor would also examine thoroughly as to the 
 condition of the child's heart and lungs. The nurse 
 would meanwhile investigate carefully the child's 
 freedom from verminous and parasitic conditions. 
 As a result of this examination it would be possible 
 for the doctor to complete the child's medical register 
 or schedule.^ 
 
 In addition to this detailed examination, routine 
 supervision of all the children in the different classes 
 should be undertaken at least once a term, to 
 call attention to any defective conditions and to 
 give the teacher the advantage of consulting the 
 doctor about any special cases. It is this co- 
 
 1 Cf. also chap, x, p. 166. It would be better to have cards of a 
 different colour for the normal children and for the abnormal who 
 require further supervision. In Germany abnormal children are given 
 pink cards and are labelled Unter KontroUe. 
 
AIMS OF MEDICAL INSPECTION 89 
 
 operation of the teacher and doctor in the school 
 which is essential for the improvement of our edu- 
 cational system. At first teachers may be apt to 
 view the interference of the doctor and the addi- 
 tional duties thereby imposed on themselves with 
 prejudice ; but as soon as they grasp the meaning 
 and importance of the work they will at once begin 
 to take personal pride and interest in the physical 
 welfare and cleanliness of the children. The beneficial 
 results may be increased if a medical register is kept 
 in each classroom for notes by doctor, nurse, and 
 teacher. Friendly relations can also be established 
 by means of informal lectures and conferences. 
 
 The general advantages of systematic health inspec- 
 tion far outweigh anything that has been urged against 
 its introduction. The doctor is admitted as a member 
 of the school staff, and by him the foundations of the 
 elementary principles of school hygiene may be securely 
 laid in each school, leading eventually to the develop- 
 ment of a science of education. 
 
 The school doctor's work is medical, psychological, 
 and pedagogical. It is difficult to say where it should 
 definitely begin or end. He helps the teachers in 
 their work and is a powerful influence, educating both 
 teachers and parents in the essentials of healthy living. 
 At the same time he exerts both directly and indirectly 
 a beneficial influence upon the physical, mental, and 
 moral development of each individual child. Delicate 
 and backward children are kept under medical super- 
 vision. The regularity of attendance at school is 
 
90 MEDICAL INSPECTION OF SCHOOLS 
 
 increased. And, finally, all educationalists are stimu- 
 lated to a sense of their duties and responsibilities ; 
 and all this is effected in addition to the fulfilment of 
 the fundamental requirements — the discovery of un- 
 recognized physical and mental defects among the 
 children. 
 
 This is but an outline of the general advantages. 
 On the other hand, nothing has been urged against 
 medical inspection but the individual prejudices of a 
 few teachers, the interference with school routine, the 
 undermining of parental responsibility, and the expense. 
 The first three of these objections have been raised only 
 in ignorance of the true conditions and without any 
 understanding as to the real meaning of education. The 
 plea of expense can be answered in two ways. Firstly, 
 no amount of money that is spent in perfecting an 
 educational system should be regarded as misspent or 
 unreasonably be withheld. Secondly, the economic 
 gain that will follow from improved health conditions 
 and enhanced educational results will far outweigh the 
 infinitesimal cost of systematic medical inspection. 
 
 In conclusion, the fundamental idea of medical 
 inspection may be emphasized in a few words. It 
 implies more than the appointment of a medical 
 adviser to local education committees, more than 
 the prevention of infectious disease in schools, more 
 than a spasmodic attempt to deal with such problems 
 as defective vision, ventilation and sanitation of 
 
AIMS OF MEDICAL INSPECTION 91 
 
 schools, and more than the separation of mentally and 
 physically defective children. It involves the systematic 
 inspection, from a medical point of view, not only of 
 the school premises, appurtenances, and methods, but 
 also of the children. It impHes that every teacher, in 
 dealing with the difficult problems of school life, may 
 have the advantage of medical guidance; and that 
 every child, normal or abnormal, healthy or un- 
 healthy, may have the advantage of being inspected 
 by a medical man once or twice during school life 
 and at such other times as may be necessary. 
 
 This constitutes the fundamental definition of 
 medical inspection of schools, forming, as it does, only 
 one branch of school hygiene. 
 
CHAPTER VIII 
 
 SCHOOL HYGIENE AS A FACTOR IN STATE 
 
 MEDICINE. 
 
 Organization of a Central Department 
 
 School Hygiene the Newest Branch of State Medicine. — New Wine 
 and Old Bottles. — Hasty Legislation. — Local Authorities Unprepared. — 
 Letter and Spirit. — State Medicine Defined. — An Incongruous Medley. — 
 A Ministry of Pubhc Health. — Different Methods of Organization. — 
 Fallacious Arguments. — Co-ordination and Subordination. — School 
 Hygiene a Branch of Education, not of Public Health. — Medical Bureau 
 at Education Department. — Its Function. — A Centre for the Acquisition 
 and Distribution of Knowledge. — Knowledge and Information. — Staff 
 at Present Inadequate. — A Model Department. — Pioneer Investigation 
 and Research. 
 
 From ignominious obscurity, school hygiene has 
 been suddenly thrust into prominence as the newest 
 branch of State Medicine. It must, therefore, be fitted 
 gradually and unobtrusively into the established order 
 of things. Unfortunately, in the case of every new 
 organization, there is always a tendency to look back 
 in order to see how the new can be temporarily adjusted 
 to suit the old with the least trouble and inconve- 
 nience, rather than to look forward and consider the 
 possibility of further development upon new lines. 
 New wine is seldom adapted to the capacities of old 
 bottles. Nor can school hygiene, concerning as it does 
 both medicine and education, ever be regarded for 
 administrative purposes as an independent section. 
 Space and opportunity for expansion are essential. 
 
SCHOOL HYGIENE AND STATE MEDICINE 93 
 
 When the demand for health inspection was first 
 raised ten or twelve years ago, even the more advanced 
 educationalists were, for the moment, content to offer 
 any plea that seemed to justify their cry. Groping 
 in the dark, without any real insight into the difii- 
 culties that would inevitably be involved, they made 
 little effort to arrive at any accurate analysis of the 
 situation, or at any reasoned statement of their own 
 case. They were voicing an instinct, and only in 
 a very secondary degree following the dictates of their 
 judgment. In course of time, as has been already 
 shown, the recommendation found support in the 
 reports of Interdepartmental Committees ; and as 
 a result of careful inquiries, additional needs began 
 to secure recognition. The demand became insistent, 
 and at last found expression in legislation. By the 
 Education (Administrative Provisions) Act of 1907 the 
 Government created compulsory powers for systematic 
 medical inspection ; whereupon the Board of Education 
 at once devolved a sum of new responsibilities upon 
 local authorities quite unprepared to cope with them. 
 
 Partly through a desire to avoid innovation and to 
 utiUse only existing agencies, partly through a mis- 
 conception of the term * school hygiene ', the scheme 
 which was originally advocated at head quarters fell 
 short of its object. It failed to recognize fully 
 variations in local conditions and requirements, and 
 showed little appreciation of the manifold possibilities 
 of development in the near future.^ Local authorities 
 
 ^ Since these remarks were written, the Board of Education, thank 
 
94 MEDICAL INSPECTION OF SCHOOLS 
 
 have to a considerable extent, and not unnaturally, 
 proved unequal to their responsibihties. They seek to 
 interpret the letter rather than the spirit of the law. 
 
 The whole situation is typical of the administrative 
 methods peculiar to this country. We may contrast 
 the manner in which health inspection gradually 
 became an established fact in the schools of Germany, 
 Sweden and Switzerland.^ In these instances progress 
 was, generally speaking, the outcome of local demands 
 stimulated by sympathetic interest and guidance on 
 the part of some central authority. Had we not 
 disdained to follow in the same path, the first step 
 in this country might have been the institution of 
 a campaign to educate public opinion as to the neces- 
 sity of health inspection. A further step might have 
 been to make the grant for efficiency in the case of 
 every school conditional upon a medical man's name 
 appearing in the capacity of school doctor upon the 
 roll of school officials. x4gain, in large towns Education 
 Committees might have been urged to employ the 
 services of a medical superintendent of schools. In 
 these and similar ways an organized system of school 
 hygiene would by degrees have been tentatively 
 evolved throughout the country — always under sym- 
 pathetic guidance and supervision from the Board of 
 Education. Nor need there necessarily have been 
 any recourse to Parliamentary legislation ; the ordinary 
 
 to the efforts of Dr. George Newman, have issued a further memorandum 
 which deals with school hygiene in its broadest sense and which shows 
 full appreciation of the possible developments of the subject. 8ec 
 Appendix II. C. 
 * School Doctors in Gtrmanijy p. 30. Board of Education pamphlet. 
 
SCHOOL HYGIENE AND STATE MEDICINE 95 
 
 Education Code, supplemented by special memoranda 
 from time to time, would not have proved inadequate. 
 The contrast with the actual situation now before 
 us is sufficiently obvious. After a prolonged period 
 of general and complete inaction, broken only in a few 
 favoured districts by enterprising Education Com- 
 mittees, a compulsory system has been enforced 
 by Act of Parliament — with the natural result that 
 the demands of systematic health inspection are con- 
 sidered excessive and impossible ; while, in most places, 
 neither the organization nor the resources which are 
 forthcoming are sufficiently adequate. 
 
 Professor Burgerstein, of Vienna, commenting upon 
 the position of school hygiene in England,^ says, 
 * As things stand at present, the English school hygiene 
 law will in practice be of little effect, as has been the 
 case in other great countries, for example, France and 
 Portugal : and England does not seem to have learnt 
 anything from the experience and mistakes of other 
 countries. ... If people go to the trouble of putting 
 legal machinery into motion, it should not be done 
 without some guarantee for a sweeping measure of 
 success. And this is what we miss in the procedure 
 which has been adopted in England.' 
 
 For the time being school hygiene is regarded as 
 one of the less important elements in the rather motley 
 congerie of public services, grouped together under the 
 term State Medicine, which includes the following 
 diverse branches of medicine : — 
 
 1. Lunacy. 
 
 * Zeitschrift filr Schulgesundheitspflcge, xxi, 1908. 
 
96 MEDICAL INSPECTION OF SCHOOLS 
 
 2. Sanitation. 
 
 3. Public Health. 
 
 4. The Poor Law Medical Service. 
 
 5. Alien Immigration. 
 
 6. School Hygiene. 
 
 Apart from the Poor Law, municipalities are held 
 responsible for the clinical treatment of infectious 
 diseases, thus necessitating, in large towns, a separate 
 service from that of the medical officer of health. In 
 addition the Home Office is directly responsible for 
 the discharge of statutory obligations as to factories 
 and the Local Government Board as to vaccination, 
 each appointing local medical men as their repre- 
 sentatives : whilst a number of local medical men 
 such as Post Office doctors are pressed into the service 
 of the State for the examination of candidates for the 
 Board of Education Superannuation Scheme, or for 
 admission to Government service. Thus, in the absence 
 of a central department of State Medicine, there is 
 a lack of systematized co-ordination between the 
 various public medical services. For instance, the 
 local sanitary and public health authority, though 
 responsible for the prevention of infectious disease, 
 has no direct control over the public vaccination 
 service ; and though the medical officer of health is 
 responsible for the knowledge and supervision of 
 occupational disease, yet he has no concern in the 
 duties of the certifying factory surgeon or of the 
 inspector of factories. 
 
 The following table illustrates the present condition 
 of medley and chaos. 
 
SCHOOL HYGIENE AND STATE MEDICINE 97 
 
 Date 
 
 
 Besponsible 
 
 
 
 of 
 
 
 State 
 
 Local 
 
 Local 
 
 State 
 
 Subject. 
 
 Department, 
 
 Administrative 
 
 Executive 
 
 Con- 
 
 
 or Central 
 
 Committee. 
 
 Officers. 
 
 trol. 
 
 
 Authority. 
 
 
 
 1752 
 
 Quarantine. 
 
 Board of Cus- 
 
 Customs and 
 
 Customs Pre- 
 
 
 
 toms and 
 
 Port Sanitary 
 
 ventive 
 
 
 
 Local Gov- 
 
 Committee. 
 
 Officer and 
 
 
 
 ernment 
 
 
 Port Medical 
 
 
 
 Board. 
 
 
 Officer. 
 
 1774 
 
 Mental diseases. 
 
 Commission in 
 
 Asylum Com- 
 
 Medical Super- 
 
 
 
 Lunacy and 
 
 mittee. 
 
 intendent. 
 
 
 
 Home Office 
 
 
 
 1847 
 
 Poor Law Medi- 
 
 Local Govern- 
 
 Poor Law Guar- 
 
 Superintendent 
 
 
 cal Service. 
 
 ment Board. 
 
 dians. 
 
 of Infirmary 
 and Parish 
 Doctors. 
 Medical Officer 
 
 1848 
 
 Sanitation, Pub- 
 
 Local Govern- 
 
 Sanitary Com- 
 
 
 lic Health and 
 
 ment Board 
 
 mittee. 
 
 of Health, 
 
 
 Food Supplies 
 
 and Board 
 of Agricul- 
 ture. 
 
 
 Pubhc 
 Analyst, 
 Board of 
 Agriculture 
 
 1854 
 
 Vaccination. 
 
 Local Govern- 
 
 Poor Law Guar- 
 
 Inspectors. 
 Pubhc Vac- 
 
 
 
 ment Board. 
 
 dians. 
 
 cinators. 
 
 1866 
 
 Fever Hospitals. 
 
 Local Govern- 
 
 Metropohtan Asy- 
 
 Special Medical 
 
 
 
 ment Board 
 
 lums Board or 
 
 Superinten- 
 
 
 
 and County 
 
 Isolation Hos- 
 
 dent or Medi- 
 
 
 
 Councils. 
 
 pitals Com- 
 mittee. 
 
 cal Officer of 
 Health. 
 
 1878 
 
 Factories and 
 
 Home Office 
 
 Sanitary Com- 
 
 Home Office 
 
 
 Workshops. 
 
 and Local 
 
 mittee (for 
 
 Inspectors, 
 
 
 
 Government 
 
 Sanitation). 
 
 Factory Sur- 
 
 
 
 Board. 
 
 
 geon and 
 Medical 
 Officer of 
 Health. 
 
 1898 
 
 Elementary 
 
 Board of Edu- 
 
 
 Post Office 
 
 
 School 
 
 cation. 
 
 
 Doctors or 
 
 
 Teachers' Su- 
 
 
 
 General Prac- 
 
 
 perannuation. 
 
 
 
 titioners. 
 
 1902 
 
 jMidwifery. 
 
 Central Mid- 
 wives' Board. 
 
 County Council. 
 
 Superintendent 
 of Midmves. 
 
 1906 
 
 Alien Immigra- 
 
 Home Office. 
 
 immigration 
 
 Port Medical 
 
 
 tion. 
 
 
 Board. 
 
 Officer. 
 
 1908 
 
 School hygiene. 
 
 Board of Edu- ] 
 
 Education Com- 
 
 School Medical 
 
 
 
 cation. 
 
 mittee. 
 
 Officer. 
 
 
 Medical Statis- 
 
 General Regis- 
 
 
 Medical Officers 
 
 
 tics. 
 
 ter Office. 
 
 
 of Health,and 
 
 
 
 
 
 Registrar. 
 
 HOGARTH 
 
98 MEDICAL INSPECTION OF SCHOOLS 
 
 In this incongruous and uncompromising medley 
 school hygiene has to take its place as the newest 
 branch of State Medicine. It is not surprising that 
 there has been some difference of opinion as to the 
 best method of organization. 
 
 At one time it was seriously argued that medical 
 inspection of schools was merely a subordinate part of 
 public health and that the aims and objects of health 
 inspection concerned medical officers of health and 
 sanitary committees, only incidentally becoming a 
 matter for the consideration of education authori- 
 ties. This argument was strengthened by the special 
 prominence that has lately been given by certain 
 sanitary committees to considerations of home hygiene 
 and health visiting. The home is regarded as the 
 point at which the ultimate hygienic control of the 
 child is to be maintained. But this point of view is 
 far in advance of anything that has been intended, 
 or provided for, in any of the Education or Public 
 Health Acts. Moreover, its importance has been 
 somewhat exaggerated, as some medical officers of 
 health refrain from advising their sanitary committees 
 to appoint health visitors. Neither the medical officer 
 of health, nor the school doctor, has any legal standing 
 or control with regard to matters of health visiting 
 and it is inadvisable to push this point of view too far.^ 
 
 The fallacy of these arguments was soon exposed, 
 and it was shown that although school hygiene is 
 undoubtedly an integral factor in the health of the 
 
 ^ Cf. chap. V, p. 08. 
 
SCHOOL HYGIENE AND STATE MEDICINE 99 
 
 nation, it is also a very important factor in the educa- 
 tional system. In other words, experience proved 
 that school hygiene should be regarded as co-ordinate 
 with, and not subordinate to, public health, and that 
 both branches of State Medicine could be administered 
 side by side without fear of friction or of overlapping 
 of function on the part of the executive officers. The 
 school doctor naturally will place his records at the 
 disposal of the medical officer of health, and both 
 will necessarily work together in the case of public 
 health problems. 
 
 Another point of view was that, although education 
 was essentially distinct from public health, yet for 
 administrative purposes and to avoid dual jurisdiction 
 it would be well to subordinate the educational re- 
 quirements to those of public health and to allow 
 both branches to come under the administration of 
 one man — the local medical officer of health. This 
 argument arose from a laudable desire to place the 
 medical services of the country upon a broader basis 
 with a view to securing progressive unification. But 
 the end should not be sacrificed to the means. 
 Education is too important a subject to be sub- 
 ordinated to other interests. At present in all large 
 towns there is ample scope for two medical officers — 
 the one responsible for hygiene and sanitation, and the 
 other for schools and scholars. For under hygiene 
 and sanitation is included the consideration of : — 
 
 1. Water supply, 
 
 2. Sewage disposal, 
 
 h2 
 
100 MEDICAL INSPECTION OF SCHOOLS 
 
 3. Housing of the people, 
 
 4. Milk supply, food inspection, 
 6. Infectious diseases, &c., 
 
 6. Tuberculosis, 
 
 7. Occupational diseases, 
 
 8. Infantile mortality, and 
 
 9. many other problems. 
 
 The two officers should be co-equal, each representing 
 totally different interests but meeting on the common 
 ground of home hygiene and infectious diseases. 
 
 If it be not for practical, but for administrative, 
 purposes that unification is desired, then what is 
 needed for every large town or county borough is one 
 Principal Medical Officer (not necessarily the medical 
 officer of health), who should be responsible for the 
 co-ordination of all the co-equal but totally distinct 
 branches of State Medicine. This arrangement secures 
 the right perspective and proportion. The medical 
 officer of health is not the only representative of State 
 Medicine, and whoever proves himself the greatest 
 administrator should necessarily have the opportunity 
 of becoming the principal medical officer — the repre- 
 sentative of the State or of a Supreme Board of Health. 
 
 The last chapter was devoted to an explanation of 
 the aims and objects of medical inspection of schools ; 
 and incidentally attention was drawn to the funda- 
 mental principles of school hygiene. So intimate 
 is the association of health inspection and school 
 hygiene that no adequate system of medical inspection 
 can be organized unless at the same time provision is 
 
SCHOOL HYGIENE AND STATE MEDICINE 101 
 
 made for the various branches of school hygiene. 
 Nor is it possible to adopt the principles and practice 
 of school hygiene without at the same time instituting 
 an adequate system of routine health inspection. 
 It is a shortsighted policy to attempt to establish the 
 one without the other. 
 
 School hygiene is a branch of education, as surgery 
 of medicine. But school hygiene is no more a branch 
 of ' public health ' than anaesthetics is of surgery .^ The 
 surgeon and the anaesthetist meet on the common 
 ground of the operating theatre. Both work together 
 and, if there is to be any good result, they are mutually 
 dependent the one on the other. So with the medical 
 officer of health and the school doctor. They meet 
 on the common ground of the school, and the medical 
 officer of health should welcome the school doctor as 
 an ally, not as a mere subordinate. There should be 
 neither friction nor overlapping of function. 
 
 Organization of a Central Department 
 
 A scheme of organization which is likely to ensure 
 effective results must now be considered. The ultimate 
 administration very properly has been left in the 
 hands of the local authorities and this aspect of the 
 problem will be considered in detail later : but there 
 must first of all be adequate provision for a central 
 authority to supervise and to direct. If there were 
 a Minister of Public Health at the head of a Govern- 
 
 ^ Health inspection at school may be regarded as a branch of public 
 health, but health inspection is not school hygiene. 
 
102 MEDICAL INSPECTION OF SCHOOLS 
 
 ment Office responsible for all branches of State 
 Medicine, the control of medical inspection would 
 naturally constitute one of the functions of a sub- 
 department of school hygiene — such as may be found 
 in the Argentine Republic, Australia, and in other 
 countries — working in close association with the Board 
 of Education. But these considerations take us too 
 far into the future ; and it is hardly wise to dwell 
 upon such a hypothesis until it has come within the 
 range of practical politics. It is an ideal which should 
 be kept in view, and present plans should be laid 
 accordingly so that, when the time comes, at least this 
 branch of Administrative Medicine — namely School 
 Hygiene — may be complete in itself and ready for 
 absorption into the greater whole. For the present, 
 attention must be confined to a more immediate and 
 practical scheme of organization, and the question of 
 supervision is all important. 
 
 It was at one time suggested that the Local Govern- 
 ment Board should be made responsible for school 
 hygiene, as it was the health aspect of the problem 
 which attracted most attention and gave rise to all the 
 speculations concerning physical deterioration. But 
 such a scheme was opposed to the obvious intention 
 of Parliament. The provision for medical inspection 
 of schools was embodied in an Education Act which 
 was to be construed as one with all the other Education 
 Acts from 1870. Moreover, the Local Government 
 Board, in spite of its small medical department, does 
 not in any sense represent a national Board of Health. 
 
SCHOOL HYGIENE AND STATE MEDICINE 103 
 
 And as the matters connected with medical inspection 
 and school hygiene concern the very objects for which 
 the Board of Education was constituted, it would 
 obviously have been a shortsighted policy to transfer 
 the administration to the Local Government Board. 
 Though possibly a satisfactory scheme might have been 
 established for health inspection and for a physical 
 census of the children, yet there would have been no 
 guarantee whatever of any advance in education, which 
 is in itself one of the chief objects of school hygiene. 
 Accordingly a medical department has been established 
 at the Board of Education. 
 
 The Education (Administrative Provisions) Act, 1907, 
 clearly defines the duties of the Board of Education 
 with regard to medical inspection.. The Board in the 
 first place should advise and direct local education 
 authorities as to the manner in which they are to 
 carry out the provisions of the Act ; and, secondly, they 
 must consider and sanction arrangements for attending 
 to the health and physical condition of the children. 
 
 The function, how^ever, of any central department 
 of school hygiene, and in England of the medical 
 bureau at the Board of Education, is partly adminis- 
 trative, but chiefly consists in providing a centre for 
 the acquisition and diffusion of knowledge. This 
 knowledge must, to a large extent, be the result of 
 actual first-hand experience. Information by itself is 
 likely to be misleading. ' In the capacity to differen- 
 tiate between information and knowledge lies the 
 essence of what may be called sagacity in counsel.' 
 Without this knowledge and practical experience, the 
 
104 MEDICAL INSPECTION OF SCHOOLS 
 
 central authority can scarcely be in a position to 
 advise or direct local authorities. Another function of 
 the medical bureau is to study and to digest the reports 
 of the various local authorities and to submit to 
 Parliament a carefully considered statement of the 
 practical results of medical inspection, as well as any 
 further recommendations that may be necessary for 
 future action. To these ends a model department 
 must gradually be built up, as free as possible from the 
 trammels of precedent. Medicine and education are 
 both still at an early stage of evolution, and cannot 
 afford to be hampered by red tape. 
 
 In no country as yet is there an adequate State 
 department of school hygiene. But some countries, 
 where modern civilization is only a development of 
 recent date, as for instance the Argentine Republic, 
 Japan and Australia, have laid the foundation of such 
 a department upon broad lines, with a view to future 
 extension and to co-ordination with public health 
 work. Thus in Argentina there is a School Medical 
 Board, acting as a special department of the National 
 Council of Education. It was appointed in 1888, and 
 consists of a president, a vice-president and fourteen 
 members. In addition there is a special staff, consist- 
 ing of a chief, eight inspectors and a lady doctor, to 
 deal with the secondary and higher schools. Unfor- 
 tunately the members have to undertake routine 
 inspectorial duties, and are prevented from devoting 
 as much time as they desire to research and special 
 inquiries. But they have formulated the outline of 
 a satisfactory scheme. 
 
SCHOOL HYGIENE AND STATE MEDICINE 105 
 
 In Japan a number of specialists have been appointed 
 by the Department of Education to advise the local 
 school physicians as to their duties and methods. 
 With regard to the collection and digestion of statis- 
 tics, considerable difficulties have been encountered. ^ 
 
 In England the medical department at the Board of 
 Education for the moment consists only of a chief 
 medical officer and two assistants, one of whom has 
 for many years paid special attention to defective 
 children, and the other — a lady doctor — to training 
 colleges and the teaching of hygiene. There is need 
 for a considerable increase of staff. The general 
 guiding principle of appointments should be that 
 medical men and women are required for research, 
 with a view to their becoming specialists in particular 
 branches of the work. At present, where all is either 
 ignorance or speculation, there is room for knowledge 
 and investigation ; and special inquiries should be 
 made into the methods and experience of certain 
 foreign countries, which are in some respects in advance 
 of this country.^ 
 
 ^ ' The results are not quite satisfactory. This is owing either to 
 the want of skill in preparing statistics or to the lack of experience on 
 the part of physicians. In spite of much correspondence, doubtful 
 points have not yet been cleared up. Still time will make the required 
 improvements.' {Annual Report of the Minister of State for Educatio7i, 
 Japan. 1907.) 
 
 ^ Even in 1906, Mr. Birrell, the Minister of Education, speaking in 
 the House of Commons said, ' The Board of Education was equally 
 willing to receive inspiration from the House in the direction of strength- 
 ening its medical staff at head quarters for the purpose of seeing that 
 the local^authorities are discharging their duties, and also to keep in 
 touch with what was going on in continental towns.' 
 
106 MEDICAL INSPECTION OF SCHOOLS 
 
 The chief medical officer will from time to time 
 require reports upon special subjects from his assistants, 
 and, being appointed for supervisory and administra- 
 tive purposes, he will be in a position to retain the 
 breadth of outlook and the sense of proportion which 
 are necessary in order to prevent excessive specializa- 
 tion, or the introduction of medical faddism — a fear 
 which has already found vague expression in certain 
 quarters. But such tendencies can also be obviated 
 by arranging for the medical experts to visit foreign 
 countries, and also by allotting to each of them some 
 general inspectorial work, in addition to the special 
 work of his own branch. Moreover, it is not necessary 
 that all the assistants should be medical men. Statis- 
 ticians are wanted to help in the collation and digestion 
 of statistics. There is also great scope for scientific 
 research and inspectorial work by those who have 
 already gained practical experience as teachers. 
 
 Although such a medical department must be the 
 outcome of a gradual development, yet at the present 
 time a very considerable increase in the staff is 
 essential. A medical expert is wanted who will study 
 as his own particular province all that is to be learnt 
 in connexion with school architecture and equipment 
 and as regards problems of school ventilation, lighting 
 and heating, from the medical and educational points 
 of view. He should also acquire an up-to-date know- 
 ledge concerning school baths, desks and furniture. 
 Such points open up a wide field for inquiry ; but 
 there is immediate need for such an expert authority 
 to confer with school architects and sanitary en- 
 
SCHOOL HYGIENE AND STATE MEDICINE 107 
 
 gineers and to issue instructions and advice to local 
 authorities. 
 
 Similarly, a medical expert is required to study 
 various methods of physical training, to confer and 
 combine with the experts on the same subject at the 
 Admiralty and War Office, and to supervise or co- 
 operate with the staff of inspectors which is already 
 employed by the Board of Education. In this branch 
 also assistants should be included for the study of 
 hygienic and educational methods of manual training. 
 There is already a branch of sub-inspectors of manual 
 training at the Board of Education, but so far no 
 special knowledge as to hygienic requirements has 
 been necessary. Nothing but good can result from 
 the active co-operation of the medical expert with these 
 inspectors in the interests both of medicine and of 
 education. 
 
 Again, adequate knowledge of medicine and school 
 hygiene is indispensable for the proper supervision of 
 infant schools and of the ' nursery schools ' recently 
 recommended by the Consultative Committee of the 
 Board of Education.^ This is essentially a department 
 of the work in which there is need for some departure 
 from the traditional requirements of discipline and 
 routine and in which there is great scope for individual 
 activities on the part of the teachers, always under 
 the sympathetic guidance and supervision of inspectors 
 who know and understand their subject. Further, the 
 present system of inspection of mentally and physically 
 
 ^ Report of Consultative Committee'^uyon the School Attendance of 
 children below the age of five, 1908. 
 
108 MEDICAL INSPECTION OF SCHOOLS 
 
 defective children requires vast extension, and more 
 assistants are needed for research and inquiry into 
 special educational methods for different groups of 
 children. 
 
 Then, again, the Board of Education has no special 
 knowledge about the incidence, or the methods of the 
 spread, of infectious disease in schools. This subject 
 demands careful investigation on the part of medical 
 men who can devote time to the work. The Board 
 of Education will scarcely be expected to lay down 
 exact rules for the exclusion of children or for the 
 closure of schools, until they have made a study of 
 this matter by means of special inquiries. 
 
 Further details and elaboration are unnecessary, 
 but the immediate requirements of the medical depart- 
 ment may be illustrated by the following table : — 
 
 Chief Medical Officer. 
 
 — Medical Adviser as to Physical and Manual Training. 
 
 Staff of Inspectors. 
 
 — Medical Adviser re School Buildings and Equipment. 
 
 — Medical Adviser re Instruction in Hygiene at Training 
 Colleges and Secondary Schools and to Teachers. 
 
 — Medical Superintendent of Defective Children. 
 
 Staff of Inspectors of Special Schools. 
 
 — Superintendent of Psychological Research and of Special 
 
 Educational Methods. 
 
 — Medical Inspector of Nursery Schools, Infant Depts., 
 
 Open-air Schools, &c. 
 
 — Medical Adviser re Infectious and Contagious Disease. 
 
 — Superintendent of Medical Statistics. 
 
SCHOOL HYGIENE AND STATE MEDICINE 109 
 
 Thus a model department would consist of a chief 
 medical officer (who, if necessary, should have direct 
 access to the responsible Minister of Education), and 
 of ten or more assistants for different branches of the 
 work, with a small staff of inspectors. There must 
 be provision for the chief and for his assistants 
 to co-operate closely with inspectors and officers in 
 other departments of educational work, with a view 
 to general co-ordination and improved methods of 
 administration, as well as to building up gradually 
 a science of education. 
 
 The reason for this large staff of medico-educational 
 experts is obvious. At present no one is possessed of 
 accurate knowledge, and it is wrong for any medical 
 man in an official position to recommend, or condemn, 
 a system of progress in educational hygiene solely upon 
 hearsay evidence and secondhand information. For 
 it is imperfect knowledge at head quarters which is 
 mainly responsible for the mistaken and faulty systems 
 which are so constantly perpetuated. 
 
 At the same time and concurrently with the forma- 
 tion of this medical department, the present staff of 
 inspectors should be reinforced by men possessed of 
 special insight into the requirements of educational 
 hygiene. It would be advantageous if a certain pro- 
 portion of H.M.'s inspectors of schools had had previous 
 medical training. In this way it would be possible 
 to recruit the staff of the medical department from 
 men already in the office, who had gained some 
 experience in the field of education. Education is 
 
110 MEDICAL INSPECTION OF SCHOOLS 
 
 the most difficult of all arts, and previous medical 
 training can only be productive of good in educational 
 work. 
 
 A constant search after knowledge and truth should 
 be the basis of the work of any central education 
 authority. Pioneer investigation and research in the 
 field of school hygiene should be required of all 
 assistants in the medical department. It is work of 
 national importance, and should no longer be left, 
 as in the past, entirely to the zeal of local authorities. 
 In this and in other ways a medical department at 
 the Board of Education would become a centre for the 
 acquisition and diffusion of knowledge and would be 
 in a position to advise and direct local authorities in 
 all matters relating to educational hygiene. 
 
 Note. — The following statement by Dr. William 
 H. Maxwell, City Superintendent of Schools of New York, 
 just pubHshed in Medical Inspection of Schools by Gulick 
 and Ayres, concerns the argument contained in the earlier 
 part of this chapter. 
 
 * Dual responsibility in the school — that of the Board of Education 
 and that of the Department of Health — always has resulted, and 
 always will result, in confusion and inefficiency in the work effected. 
 It is owing to this dual responsibility that the large annual appropriation 
 made by the city for the physical examination of school children is to 
 a great degree wasted. Efficient service will be obtained only when 
 the Board of Education is made responsible for all the work that goes 
 on in the schools. 
 
 ' The physicians employed by the Board of Health do not perform any 
 of the functions which it is highly advisable should be performed by 
 a truly educational department of hygiene, such as studying hygienic 
 conditions in the schools and advising teachers regarding the pedagogical 
 treatment of children in cases of fatigue and nervousness.' 
 
CHAPTER IX 
 LOCAL ORGANIZATION OF SCHOOL HYGIENE 
 
 General Aims. — Local Conditions and Requirements. — Scope for 
 Variety. — Slow and Unobtrusive Progress — Expert Knowledge essential. 
 — Large Towns. — Medical Superintendent of Schools distinct from 
 Medical Officer of Health. — His Duties. — School Districts. — Local v. 
 Itinerant System of Inspection ; Advantages and Objections. — Illustra- 
 tions : Boston, Paris, Berlin, Wiesbaden and London. — Permanent and 
 Temporary Staff. — School Doctors, Assistant School Doctors, and School 
 Nurses. — Small Towns : Medical Officer of Health also School Medical 
 Ofi&cer. — Rural Districts : Four main schemes and Summary. — Financial 
 Considerations. — A National Charge. — Small Outlay. — Phantom of the 
 Ratepayer. — Standard of Remuneration. 
 
 The last chapter dealt with the organization of an 
 adequate controlling and supervisory department, 
 whose functions would be to acquire an up-to-date 
 knowledge of school hygiene, to investigate the pro- 
 gress of thought and discovery in other countries, to 
 be in a position to guide and direct local authorities 
 as to their obligations, and finally to collate and make 
 practical use of the reports and statistics resulting 
 from routine inspection. 
 
 The ultimate administration of health inspection 
 and of school hygiene has been left in the hands 
 of local authorities. The immediate application of 
 a scheme of organization must be based upon the 
 provisions of the Act and upon the several circulars 
 
112 MEDICAL INSPECTION OF SCHOOLS 
 
 which have been issued by the Board of Education ; ^ 
 but its general aims should from the very outset be 
 directed towards the fulfilment of the main purposes 
 of school hygiene : — 
 
 1. To improve the mental, moral, and physical 
 development of the children. 
 
 2. To educate teachers, parents, and children in the 
 elements of healthy living. 
 
 3. To protect the individual from communicable 
 diseases by the prevention of infection and by the 
 cleansing of all verminous and parasitic conditions. 
 
 4. To institute a scientific study of child life in its 
 educational aspects. 
 
 These objects will be readily attained by any system 
 which provides for the statutory examination of all 
 children once or twice during school life, for the more 
 frequent examination of special cases — some by doctors, 
 others by nurses — for systematic lectures to teachers 
 and conferences with parents, and for the appointment 
 of medical men in the larger towns for the special study 
 of educational problems. An adequate scheme of 
 organization admits of great scope for variety to suit 
 local conditions and local requirements. 
 
 Three different schemes will be considered in their 
 application to : — (1) Large towns and county boroughs, 
 (2) small towns, and (3) country districts. 
 
 In all cases it is advisable to allow the school medical 
 service to grow up slowly and unobtrusively in accord- 
 ance with local experience. But the following general 
 
 ^ Vide Appendix II, A, B, C. 
 
ORGANIZATION OF SCHOOL HYGIENE 113 
 
 principles will be for the most part applicable. The 
 first essential in any preliminary scheme of organiza- 
 tion (and an essential common to all localities) is 
 that every Education Committee should secure the 
 services of a competent medical adviser whose first 
 duty should be to acquire expert knowledge of all 
 matters relating to school hygiene. He will, so to 
 speak, be the foundation upon which all local efforts 
 must be based. He must therefore be free to attend 
 the meetings of the Committee and of the various Sub- 
 Committees, so that he may acquaint members with 
 the medical aspect of all educational problems. 
 
 The School Board or Commission in every small 
 district in Switzerland has either a private doctor or the 
 school medical officer as one of the members of the 
 Board. In Sweden, as far as school hygiene is concerned, 
 the school medical officer is not merely an advisory 
 member of the staff : he is also empowered to assist in 
 framing decisions. In England the system of local 
 government is different. But the advice and services 
 of a medical man would obviously be invaluable in 
 committee for the clearer appreciation of many scien- 
 tific and educational problems. At present the mem- 
 bers of Education Committees necessarily have but 
 slight acquaintance with the problems of school 
 hygiene. One of the main duties of the medical officer 
 would be to explain to the Local Education Committee 
 what is expected of them in the discharge of their 
 duties to the children and to the nation in order to 
 fulfil the spirit rather than the letter of the law. Such 
 
 HOGARTH J 
 
114 MEDICAL INSPECTION OF SCHOOLS 
 
 a specially appointed officer should therefore be free to 
 devote a considerable part of his time to the study of 
 school hygiene, and should] be paid an adequate 
 salary. 
 
 The next step must be for each local authority to 
 make some attempt to carry out the statutory obliga- 
 tions of health inspection ; for it would be impossible, 
 except in the smallest towns, for the responsible 
 medical officer of the Education Committee to under- 
 take all the routine inspection required by the Board 
 of Education. i 
 
 All organization, then, should first aim at securing 
 these two preliminary steps, and under the guidance 
 and direction of an experienced medical officer a system 
 will gradually grow up to suit local conditions and 
 requirements. There is no need for excessive haste. 
 It matters not if only a few children are examined 
 during the first few years so long as the foundation 
 for future developments is securely laid. 
 
 Large Towns 
 
 Let us begin with the consideration of large towns 
 and county boroughs where the immediate needs are 
 greatest owing to the aggravation of the evil results 
 of ignorance and neglect. 
 
 In addition to making provision for the statu- 
 tory examination of all children in accordance with 
 the requirements of the Board of Education, the 
 specially appointed officer of the Education Com- 
 mittee, whether he be called Medical Superintendent 
 
ORGANIZATION OF SCHOOL HYGIENE 115 
 
 of Schools, Director of School Hygiene, or School 
 Medical Officer, would from the first have the following 
 duties : — 
 
 1. To carry out the provisions of the Education 
 
 (Defective and Epileptic Children) Act, 1899. 
 
 2. To supervise the arrangements for the special 
 
 instruction of those children who require special 
 educational treatment. 
 
 3. To approve sites and plans for new buildings and 
 
 to suggest alterations in old, in co-operation 
 with the architect and sanitary engineer. 
 
 4. To supervise school furniture, equipment, and 
 
 methods. 
 
 5. To co-operate with the local medical officer of 
 
 health in case of infectious disease in the 
 schools. 
 
 6. To advise as to methods of physical and manual 
 
 training. 
 
 7. To examine scholarship candidates, teachers, and 
 
 other employees of the Education Committee. 
 
 8. To supervise nurses, and their routine in the 
 
 schools. 
 For the efficient discharge of these duties in large 
 towns the Education Committee would require the 
 whole-time services of a medical man. So that it 
 would be unwise to attempt to make use of the already 
 overburdened medical officer of health, even for 
 administrative purposes, for his interests are concerned 
 rather with the health of the children than with their 
 education. Any danger of friction or of overlapping of 
 
 I 2 
 
116 MEDICAL INSPECTION OF SCHOOLS 
 
 function has been proved to be more imaginary than 
 real : and the work is too important to be assigned to 
 an assistant of the medical officer of health, as some 
 local authorities have done. In course of time, as the 
 work develops, the school medical officer would require 
 two or three assistants on his permanent staff to 
 undertake certain duties, and a number of nurses for 
 routine inspection. 
 
 As far as statutory inspection is concerned, it would 
 be advisable to divide each town into school districts 
 as in Paris, and to allot a small group of schools to 
 a local practitioner, or consultant, devoting part 
 time to the work. The ideal should be to give not 
 more than 2,000 or 3,000 children to each doctor, say 
 in five or six schools. This would represent an annual 
 number of 200 or 300 new children for admission. 
 The school doctors would devote one, two, or three 
 school sessions a week to the duties, according to the 
 pressure of the work. They would be responsible for 
 the supervision of the school nurse, for the keeping of 
 health registers and schedules, and for the sanitation 
 and general well-being of the school, and would co- 
 operate with the medical officer of health in case of 
 school outbreaks of infectious disease, and refer cases 
 of intractable verminous conditions to him for further 
 investigation and disinfection at the home. They could 
 also conveniently examine all absentees alleged to be 
 suffering from various diseases. 
 
 The advantage of this system is that it tends to 
 make each school dependent upon a local medical 
 
ORGANIZATION OF SCHOOL HYGIENE 117 
 
 man for routine inspection. It is the plan that has 
 been adopted in German towns for general school 
 hygiene, and in American cities for the prevention of 
 infectious and contagious diseases. It is an improve- 
 ment upon the itinerant inspectorial system, by which 
 an unknown medical man pays occasional visits to the 
 school, possibly to the discomfiture of the children 
 or to the dislocation of school routine. Moreover, 
 a local doctor has a great opportunity of getting into 
 touch with teachers and parents. It should be part 
 of his duty to give lectures to the teachers, and arrange 
 conferences at the school for the parents. By means 
 of these conferences and bv the exercise of tact he should 
 be able to overcome any danger of losing his own 
 patients in the person of aggrieved parents — a danger 
 which might occasionally arise in the case of the parents 
 of verminous or neglected children. 
 
 The appointment of local school doctors for the 
 routine work of medical inspection should only be 
 temporary, say for two or three years, and the duties 
 would occupy only a small portion of each doctor's 
 time. The question of professional jealousy need 
 scarcely be considered in practice, as the majority of 
 local doctors would hold appointments in course of 
 time. Moreover, as their duties are confined to 
 inspection, without any extension to treatment, there 
 would be no opportunity for appropriating patients. 
 All children would be examined in the presence of 
 teachers, and it is difficult to imagine that any 
 school doctor would be likely to attempt to improve 
 
118 MEDICAL INSPECTION OF SCHOOLS 
 
 his position as a private practitioner. Another 
 distinct advantage is that this system affords an 
 opportunity of educating the medical profession itself 
 in a new and important branch of preventive medi- 
 cine. To quote Dr. Lovett, of Boston, ' The chief 
 obstacle to progress is to be found in the general 
 apathy of the average medical practitioner, whose 
 knowledge should be brought up to date in the 
 matter of school hygiene, with special reference to 
 defects of eyes and ears.' To overcome this limited 
 clinical experience on the part of general practitioners 
 in poor districts, and their apathy as to the possibilities 
 of preventive medicine, it should be possible to make 
 the appointment of a local school doctor conditional 
 upon his attendance at one of the recognized post- 
 graduate courses of instruction. 
 
 The preliminary methods adopted in some of the 
 large towns may now be described in detail. In Boston, 
 Massachusetts, a town with a population of 600,000, 
 there are a director of school hygiene and three assist- 
 ants, a medical inspector of special classes, a supervising 
 nurse and assistants, and an instructor of military 
 drill. Provision is also made in the same department, 
 and under the director of school hygiene, for special 
 instructors in physical training and assistants, instruc- 
 tors and supervisors of playgrounds and athletics, and 
 assistants in the sand gardens for infants. The director 
 has general supervision and control of all matters affect- 
 ing the physical welfare of pupils and teachers, as 
 
ORGANIZATION OF SCHOOL HYGIENE 119 
 
 indicated by the multifarious duties of his assistant 
 staff, and in cases of infectious and contagious disease, 
 he co-operates with the Board of Health. In his report 
 for 1907, Dr. Harrington, the director, says, after 
 sixteen years' experience : ' It does not seem possible 
 to conceive a more satisfactory arrangement, or a more 
 effective piece of school machinery, than nurses under 
 school supervision. With a corps of medical inspectors 
 under this same supervision, who would conduct a daily 
 clinic Mn their respective districts, there are no problems 
 connected with the health and efficiency of school 
 children which would not be quickly, rationally, 
 economically and effectually solved. Until such an 
 organization is perfected, in part or in whole, little 
 progress can result from the efforts to promote the 
 health and efficiency of our school children.' 
 
 Paris, with nearly 3,000,000 inhabitants, is divided 
 into twenty districts. In each of these a number of 
 local school doctors are appointed for three years. 
 Thus in the twentieth district there are ten school 
 doctors, each having charge of four or five schools with 
 2,000 to 3,000 school children. Provision, so far, has 
 only been made for systematic health inspection, by 
 means of fortnightly visits by the doctor to each school 
 in his group. There is no supervisory medical officer, 
 or director of school hygiene. As far as medical 
 etiquette is concerned no difficulty has arisen between 
 school doctors and private practitioners. Some of the 
 
 * Weekly or fortnightly visits have been recommended as suflScient 
 throughout this volume. 
 
120 MEDICAL INSPECTION OF SCHOOLS 
 
 school doctors have devoted considerable time to the 
 study and investigation of various problems in the 
 field of school hygiene. 
 
 Berlin, with a population of 2,000,000, began 
 cautiously with the appointment of ten school doctors ; 
 two schools were allotted to each. The number of 
 doctors was increased three years later to thirty-six, 
 each having charge of seven, eight, or nine schools. 
 Now there are forty- two doctors, each having roughly 
 5,000 school children under his care. 
 
 Wiesbaden, with a population of 100,000, was the 
 first town to arrange for the systematic examination 
 and re-examination of children by school doctors, to 
 take practical interest in educational hygiene and to 
 adopt a system of allotting health certificates to all 
 children. The re-examination takes place in the third, 
 fifth, and eighth school years. This scheme, which was 
 recommended by the Prussian Ministry as a model for 
 other towns, depends for its efficiency upon the fact that 
 a large number of local school doctors are appointed 
 to take charge of only a few schools. On an average 
 twenty-five classes, representing a total of about 1,250 
 children, are allotted to each doctor. All problems 
 of school hygiene are dealt with by the school doctors, 
 but there do not appear to be any adequate arrange- 
 ments for uniformity in routine or for supervision and 
 control by a chief medical officer. 
 
 Iiondon. The first steps in the scheme of organiza- 
 tion, still in process of development, in London have 
 been already dealt with from the historical point of 
 
ORGANIZATION OF SCHOOL HYGIENE 121 
 
 view.^ At the present time there is a permanent staff 
 of eleven assistants under the direction of the Medical 
 Officer (Education). Some of these assistants are 
 responsible for certain branches of the work at the 
 head office, such as uniformity in the control of infec- 
 tious disease in school. Others are engaged in the 
 special schools for physically and mentally defective 
 children, in secondary schools, or in the laboratory. 
 For the purpose of routine medical inspection, the 
 London educational area has been divided into sixteen 
 school districts, in charge of which there are sixteen 
 ' school doctors '. Each school doctor already has the 
 services of one or two * assistant school doctors', and 
 the schools in each district are evenly apportioned. 
 There is also a staff of fifty-one school nurses under 
 a superintendent and two assistant superintendents. 
 Eventually, when the complete scheme is in work- 
 ing order, there will be, for the purposes of local medical 
 supervision, sixteen school doctors, fifty-six assistant 
 school doctors giving part of their time, and fifty-one 
 nurses giving the whole of their time to the work. Each 
 doctor will have charge of approximately 8,000 or 
 9,000 children in ten or twelve schools, and each nurse 
 of 13,000 children in twenty schools. Special work, 
 requuing uniformity and exact knowledge of adminis- 
 trative routine is, for the most part, carried out by the 
 permanent staff. But aU school doctors, in addition 
 to their routine duties, are expected to devote part of 
 their time to original research in connexion with the 
 
 ^ See chap, ii, p. 32. 
 
122 MEDICAL INSPECTION OF SCHOOLS 
 
 material problems of school hygiene. Many also have 
 the opportunity of lecturing to teachers upon the theory 
 and practice of school hygiene. Vacancies in the per- 
 manent stafif will be filled by ' school doctors ', and the 
 school doctors themselves will be appointed by selec- 
 tion from assistants when they have gained two or 
 three years' experience. The full staff of the medical 
 department of the London Education Committee will 
 eventually consist of fifty-one school nurses, a superin- 
 tendent, and two assistant superintendents of nurses, 
 seventy- two local school doctors, devoting three school 
 sessions a week to their duties and holding office for 
 only three years (twenty-four retiring each year), 
 a staff of twelve or more permanent officers, aU working 
 together under the guidance and direction of the 
 Medical Officer (Education). 
 
 As far as organization in England is concerned, and 
 if provision is to be made for the broad requirements 
 of school hygiene in accordance with the suggestions of 
 Circular 596,^ the only practicable scheme in a town 
 of, say, 300,000 population, with 50,000 school children, 
 is to appoint a medical superintendent of schools as 
 a whole-time officer of the Education Committee. 
 Under his direction there should be a permanent staff, 
 consisting of at least one whole-time assistant and two 
 half-time assistants, to whom the superintendent would 
 delegate certain duties (such as the supervision of 
 schools for defective and cripple children, or of methods 
 of physical training, or other work), and a service of 
 
 ^ Appendix II, C. 
 
ORGANIZATION OF SCHOOL HYGIENE 123 
 
 ten or fifteen part-time school doctors, each having 
 charge of the routine work in a particular school 
 district. There should also be a nurse attached to each 
 group of schools to work in association with the local 
 school doctor. 
 
 A similar scheme of organization is desirable in all 
 towns and county boroughs, with a population much 
 above 100,000 or with more than 20,000 school children. 
 That is to say, there should be one medical super- 
 intendent of schools, four or five local school doctors, 
 and three or four school nurses, who might perhaps 
 also fulfill the duties of health visitors. In addition 
 there would be the medical officer of health. It is 
 important that the office of medical superintendent 
 of schools should be distinct from that of the medical 
 officer of health, as in towns of this size there is always 
 ample work in the field of public health for the services 
 of a whole-time medical officer who would be able to 
 co-operate with the school medical officer as far as in- 
 fectious diseases and sanitation are concerned. 
 
 The Education Committee in such a town is of suffi- 
 cient importance to require the services of a special 
 medical officer, devoting his whole time to school 
 problems, and should not be satisfied with the second 
 call upon the time of another officer. Moreover, in 
 most cases, a fundamentally wrong principle is enforced 
 if one officer attends the meetings of the Education 
 Committee, while the actual educational work is 
 carried out by a subordinate, who may possibly be 
 some underpaid assistant. 
 
124 MEDICAL INSPECTION OF SCHOOLS 
 
 Small Towns 
 
 In the smaller towns there is no need for special 
 differentiation. Everything is more compact, there is 
 less ground to be covered, and there is generally a more 
 intimate association between the Education and the 
 Sanitary Committees. Moreover, as there is not always 
 sufficient work to occupy the whole time of a medical 
 officer of health, both Committees can employ the 
 services of the same officer, who, by delegating certain 
 duties to an assistant, or to one or two local doctors 
 (required to help in routine health inspection), will 
 be able to maintain control over all branches of the 
 work. Undoubtedly it is difficult for any man to 
 make himself expert in all branches of sanitation and 
 public health as well as of education, in the same 
 way that it is difficult for any man to be proficient 
 in the practice of both medicine and surgery. But the 
 doctor appointed should be able to get thoroughly in 
 touch with all classes of his small community, and 
 should become a 'pervading influence making in the 
 long run for better hygienic conditions in the school 
 and the home '. Such an official would be a truly 
 invaluable asset in a small town. 
 
 Rural Districts 
 
 The organization for county areas and rural districts 
 is more difficult. At the head of the system of Local 
 Government is the County Council, directly responsible 
 among other things for the administration of the laws 
 
ORGANIZATION OF SCHOOL HYGIENE 125 
 
 as to lunacy, rivers pollution, and the regulation of 
 midwives, but having only advisory and supervisory 
 duties as to public health, sanitation, and the Poor Law 
 medical service. Responsibility in these matters is 
 delegated to Urban and Rural District Councils. 
 Educational administration, however, is centralized in 
 the Education Committee of the County Council, except 
 in the case of the larger urban districts, where there 
 may be a separate Education Committee. 
 
 Medical inspection of schools and general school 
 hygiene must be considered in their relation to a 
 school population of, say, 20,000 to 50,000 school 
 children in attendance at 200 to 500 schools, scattered 
 over an area of from 400,000 to 900,000 acres, according 
 to the size of any particular county. There are two 
 great difficulties : one is the absence of travelling 
 facilities from school to school ; the second is the 
 small size of the schools, only a few children needing 
 examination on any particular day. The only imme- 
 diate obligation is for the Education Committee to 
 organize some scheme whereby the children can be 
 medically examined on admission to school and at 
 subsequent periods. Such a scheme presents no diffi- 
 culties in itself, but there is need to consider the future 
 developments of school hygiene and the possibility of 
 combining these with the existing public health ad- 
 ministration in country districts. Four different 
 schemes deserve consideration, and experience alone 
 can decide which should be adopted in practice. 
 
 1. Some County Councils propose to leave the matter 
 
126 MEDICAL INSPECTION OF SCHOOLS 
 
 in the hands of their Education Committees, instructing 
 them to prepare a scheme for the medical examination 
 of the children on admission to school and on subse- 
 quent occasions, as the Board of Education has directed. 
 The Education Committee can then make arrange- 
 ments for a local doctor to be attached to the staff of 
 each school and to attend at the beginning of each 
 school term to carry out the necessary examination. 
 His reports would be sent direct to the Education 
 Committee. In some such way as this the work was 
 begun in Sweden and Switzerland, and it is a method 
 which has many advantages. Very few rural districts 
 or county areas are prepared to meet the expense of 
 introducing a complete scheme of organization. Hence 
 it is advisable to begin slowly and quietly, to carry 
 out statutory obligations and to proceed tentatively 
 with further organization. None of the local doctors 
 so appointed for a special purpose would be permanent 
 officials. They would be paid for examining school 
 children and for filling up schedules, with which their 
 duties would cease. Experience, however, tends to show 
 that many doctors would welcome the opportunity of 
 interesting themselves in education and in school 
 hygiene, and would very shortly become useful in help- 
 ing to perfect a scheme of organization, when the County 
 Council considered it necessary to take further action. 
 The sanitary inspection of schools and the preven- 
 tion of infectious disease now fall within the duties of 
 medical officers of health, and there is no reason why 
 the present arrangement should not continue or be 
 
ORGANIZATION OF SCHOOL HYGIENE 127 
 
 extended. Indeed there would be distinct advantage 
 if the Education Committee were to appoint the 
 local medical officers of health to carry out the routine 
 examination of the children, but such a course need 
 not be essential. In either case the appointment for 
 routine inspection would not be permanent. 
 
 The next step towards progress would be for the 
 Education Committee to appoint a medical officer at 
 head quarters — either part-time or whole-time — to 
 advise them as to future developments and to deal 
 with other problems of school hygiene, but not to 
 carry out routine inspection. 
 
 The great advantage of this first plan lies in the 
 fact that it necessitates very gradual development 
 as the result of local experience and requirements. 
 Furthermore, no difficulties as regards travelling from 
 place to place have to be considered. 
 
 2. The second scheme is for the Education Com- 
 mittee to appoint, according to the size of the county, 
 one, two, three, or more whole-time officers to travel 
 round the country and to examine the children in 
 accordance with statutory obligations. Such officers 
 are expected at the same time to pay attention to other 
 problems of school hygiene. But this work of routine 
 inspection is monotonous to a degree and could not 
 be endured if unreHeved by other work. Besides, a 
 great amount of time and energy must necessarily be 
 expended in travelling. In this case also the prevention 
 of infectious diseases, and perhaps sanitation also, are 
 left to the local medical officers of health. But pro- 
 
128 MEDICAL INSPECTION OF SCHOOLS 
 
 vision is made by the Education Committee for uni- 
 formity and systematic recording of health conditions 
 at head quarters, while one of the officers is appointed 
 as superintendent, and attends all the meetings of 
 the Education Committee for advisory purposes. He 
 also can undertake the examination of scholarship 
 candidates and teachers, as well as of defective children 
 who require special educational methods. 
 
 In the remaining two schemes the conditions are 
 different, for the County Councils, who are ultimately 
 responsible, take into consideration the whole question 
 of medical service. 
 
 3. The County Council appoint a full-time county 
 medical officer, who is made responsible for the super- 
 vision of all problems of public health and for the 
 administration of school hygiene. He attends all 
 Committee meetings and is himself able to undertake 
 many branches of the school work, such as supervision 
 of the mentally and physically defective and their 
 separation into residential schools and the introduction 
 of methods of physical and manual training. He would 
 also be able to supervise and introduce uniform methods 
 for dealing with outbreaks of infectious disease in the 
 schools. He also supervises the administration of the 
 Midwives Act and the work of the local medical officers 
 of health and sanitary inspectors of the various dis- 
 tricts. The actual work of school inspection may either 
 be allotted to the local medical officers of health, or 
 full-time assistant travelling inspectors may be 
 appointed. 
 
ORGANIZATION OF SCHOOL HYGIENE 129 
 
 4. The fourth scheme is merely the outcome and 
 extension of Scheme 3. But it is based upon a complete 
 and efficient system, in which all the medical services 
 of the county are centred in one administrative medical 
 officer, under whom there are a number of full-time 
 deputies in charge of certain areas, working indepen- 
 dently of local influence, but in harmonious co-opera- 
 tion as part of one organization. 
 
 To begin with sanitation : there are a number of 
 sanitary inspectors appointed and paid by the various 
 Urban and Rural District Councils. These have 
 definite duties to perform, and are indirectly under 
 the supervision of the Local Government Board. 
 A great deal of useful work falls within the sphere of 
 their activities, but they require more immediate 
 supervision than is possible at the present time. If 
 a number of these urban and rural districts are grouped 
 into a smaller number of sanitary areas, say four or 
 six for each county, it should be possible to appoint 
 a deputy county medical officer to take charge of the 
 public medical interests and problems of the area. 
 He would be a whole-time official and would be free 
 from the demands of private practice. There would 
 be a great variety of work — sanitation, public health, 
 Poor Law, vaccination, and school inspection. In the 
 smaller areas also he would be made responsible for 
 the charge of the isolation hospital and Poor Law 
 infirmaries, or in the larger districts a junior medical 
 man might be appointed for these purposes. He would 
 be able to get about his district conveniently. These 
 
 HOGARTH K 
 
130 MEDICAL INSPECTION OF SCHOOLS 
 
 deputies would naturally be under the supervision of 
 the chief medical officer. 
 
 At the same time all other branches of State Medicine 
 could gradually be brought under the jurisdiction of 
 the deputy medical officers, such as the duties of 
 certifying factory surgeons, district nursing associa- 
 tions, and the supervision of midwives. Such a scheme 
 is eminently desirable in the interests of harmony, 
 economy, and efficiency, but it is doubtful whether 
 the time is ripe for such a complete unification of the 
 public medical services in a county area. The County 
 Councils have no power to compel District Councils to 
 acquiesce in such a scheme, though it would relieve 
 the District Councils of a considerable amount of 
 responsibility and expense.^ They would still continue 
 to appoint a sanitary inspector and a surveyor. 
 
 If such a scheme were adopted there would be, for 
 administrative purposes, under the supervision of the 
 principal medical officer of a county area, the following 
 institutions : — 
 
 (1) an asylum for mental diseases,^ 
 
 (2) a residential school for mentally defective, 
 
 crippled, and epileptic children, 
 
 (3) a laboratory for chemical and bacteriological 
 
 investigations, 
 
 * For any such scheme fresh legislation under the Local Government 
 Acts would be necessary. 
 
 ' It is not suggested that the medical superintendent of an asylum 
 for mental diseases should work under the direction of a county medical 
 officer — for that would be impracticable. But in the interests of 
 harmony and efficiency, there should be, for administrative purposes, 
 definite co-operation between the two officers. 
 
ORGANIZATION OF SCHOOL HYGIENE 131 
 
 and, in each sanitary area, under the immediate super- 
 vision of the deputy medical officers, 
 
 (4) one or more Poor Law infirmaries, 
 
 (5) one or more isolation hospitals for infectious 
 
 diseases, 
 
 (6) a district nursing association for midwifery as 
 
 well as for general duties and for school work, 
 
 (7) a sanitary inspector for each sub-district. 
 With regard to the more detailed organization of 
 
 school hygiene in county areas, it is useless at present 
 to deal with the matter more fully, or to give examples 
 of what has so far been done in England, as the whole 
 subject of school hygiene has been treated in a some- 
 what haphazard manner. Various schemes have been 
 prepared, but, for the most part, without due apprecia- 
 tion of all the factors of the problem. 
 
 Experience alone will show which of these four 
 schemes suggested in this chapter should be adopted 
 in any particular county area. In the meantime the 
 general advantages and disadvantages of each scheme 
 may be indicated. 
 
 Summary. The main point of the first scheme, a 
 scheme by which local practitioners are placed tempo- 
 rarily in charge of several schools in their respective 
 districts, is that it is tentative, that it fulfils statutory 
 obligations without any great expense, that it is 
 efficient and that it serves the great purpose of edu- 
 cating medical men and teachers in each locality as to 
 the needs and requirements of school hygiene, gradually 
 leading to the institution of an adequate system of 
 
 k2 
 
132 MEDICAL INSPECTION OF SCHOOLS 
 
 lectures for teachers and to closer association with the 
 work of the district nurse. At the same time, under 
 this scheme, an Education Committee is enabled to 
 hold its hand so as to give the whole matter due con- 
 sideration. No difficulties as to travelling from place 
 to place or any great waste of time is likely to be 
 experienced. The scheme has few disadvantages except 
 that it means tardy progress, and that no provision is 
 made for a central authority to co-ordinate results or 
 to insist upon uniformity in administrative routine. 
 Questions of jealousy and friction between local medical 
 practitioners need not be seriously considered, while 
 the difficulties that are likely to arise between aggrieved 
 parents and a conscientious school doctor are more 
 imaginary than real. 
 
 The second scheme, whereby travelling inspectors 
 are appointed, is useful for securing the control of 
 officers and uniformity in administration ; but the 
 personal contact between teacher, parent, and doctor 
 is lost. Moreover, there can be no adequate arrange- 
 ment for systematic lectures to teachers or for the 
 education of local medical men in the problems of 
 school hygiene. There are also great difficulties in 
 travelling over large and sparsely populated areas. 
 
 The third scheme, in which the work is entrusted to 
 district medical officers of health under the supervision 
 of a county medical officer, is sound and practicable, 
 and has been initiated in Surrey, Hertfordshire, and 
 other counties. The chief objection is that some of 
 the local medical officers of health have not sufficient 
 
ORGANIZATION OF SCHOOL HYGIENE 133 
 
 spare time to devote to the additional work. But in 
 such cases other local practitioners might be appointed 
 for the routine work, while the district medical officers 
 of health would be charged, as at present, with all 
 matters relating to infectious disease and sanitation in 
 school. 
 
 The fourth scheme — a scheme for unifying the 
 medical services of a county under one principal 
 medical officer — offers the widest outlook, though at 
 present few areas are prepared for the introduction of 
 such a sweeping reform in methods of administration. 
 Some counties, however, may lay their plans with the 
 broad view in mind, of forming combined sanitary 
 districts and placing them under the charge of deputy 
 medical officers. The advantages are obvious. There 
 would be a uniform scheme of organization and all 
 branches of State Medicine would be under the charge 
 of full-time officers with security of tenure ; while 
 there would be no disarrangement of routine work 
 owing to the exigencies of practice or of local influences. 
 
 Finance 
 
 The financial considerations of medical inspection 
 are intimately bound up with those of local organiza- 
 tion, for the greater part of the expenditure devolves 
 upon local authorities. To secure efficient work, it is 
 essential that some part of the expense should be 
 borne by the National Exchequer. The State's 
 responsibility and the national importance of the work 
 
134 MEDICAL INSPECTION OF SCHOOLS 
 
 have already been emphasized in a previous chapter ; 
 and the report of the Interdepartmental Committee 
 on Physical Deterioration also urges this point of view 
 in the following terms : — * The Committee are em- 
 phatic in recommending that a systematized medical 
 inspection of children at school should be imposed as 
 a public duty on every school authority, and they agree 
 with the Royal Commission on Physical Training 
 (Scotland) that a contribution towards the cost should 
 be made out of the Parliamentary Vote.' 
 
 The cost of medical inspection by itself is infinitesimal 
 as it means little more than the school doctors' salaries. 
 As to this point, the report of the Interdepartmental 
 Committee on Medical Inspection, 1905, says : — 
 
 * Finally we desire to point out how small is the 
 expenditure which inspection involves ; in no urban 
 area does it require more than Yod. rate, generally not 
 so much.'^ 
 
 Expenditure, however, will increase if the doctor's 
 recommendations for improvements and amelioration 
 are carried out and if any form of medical treatment 
 is undertaken. Such expenditure represents merely 
 the cancelling of a national debt bequeathed from 
 a previous generation. And it should be possible by 
 means of carefully considered adjustment of local and 
 national charges to overcome the usual objection to 
 expenditure — ' the phantom of the ratepayer.' 
 
 ^ It must be remarked, however, that much of the work to which the 
 report refers was undertaken by medical officers of heahh who were 
 either not paid at all for their services, or else received only small 
 honorariums. 
 
ORGANIZATION OF SCHOOL HYGIENE 135 
 
 With regard to the details of finance, at one time 
 rough estimates of the total cost of medical inspection 
 to the nation were made on some such basis as 
 a minimum of sixpence, and a maximum of one shilHng, 
 per child per year. That represents approximately, 
 for six million children, an annual expenditure of 
 £150,000 to £300,000. It was further suggested that 
 towards this sum one half — that is £75,000 to £150,000 
 — should be contributed from the National Exchequer 
 as a Parliamentary grant. These estimates, which 
 were of the vaguest kind, were offered only with 
 a view to giving legislators and administrators some 
 idea of the comparative smallness of the cost involved 
 in establishing the necessary machinery for medical 
 inspection. 
 
 The next step was to count the actual cost of providing 
 for each child to be inspected each year in accordance 
 with the terms of the Act and the recommendations 
 of the Board of Education. That is to say, each 
 Education Committee calculated, for its own area and 
 for the first year, the number of children to be admitted 
 and the number leaving. It was then assumed that 
 a medical man should be paid one shilling or half 
 a crown for each child examined. Education Com- 
 mittees thus drew up very rough estimates, added 
 certain grants for travelling, printing of forms, office 
 expenses, &c., and compared these estimates with the 
 salaries of one, two or more whole-time officials. 
 
 As a result, no definite financial standard was ever 
 established. Adequate remuneration has been offered 
 
136 MEDICAL INSPECTION OF SCHOOLS 
 
 only by one or two of the large towns and boroughs, and 
 by a few counties which have appointed whole-time 
 medical officers, partly as health officers and partly 
 to supervise the school work. For the most part, 
 however, grossly inadequate salaries have been offered 
 by local authorities, with the result that the most 
 suitable men have not submitted applications, and in 
 many parts the posts have been filled by medical men 
 scarcely fitted for the work. Some medical journals 
 have even refused to accept advertisements from local 
 authorities not offering adequate salaries. 
 
 It was not until the British Medical Association took 
 up the question of finance that any definite standard 
 was set. Many suggestions were considered, but 
 finally it was resolved to recommend the standard 
 adopted by the London Education Committee. That 
 is to say, every school doctor should be paid not accord- 
 ing to the number of children examined — which is not 
 a fair criterion, for one child requires half an hour and 
 the next child two minutes or less — but according to 
 the time spent in school work. This time should 
 include not only the routine examination of children, 
 but also the advising of teachers, the supervision of 
 the work of the school nurse and other duties that 
 fall to the lot of the school doctor. The salary suggested 
 was £50 per annum for one session per week. Thus 
 a school doctor devoting three school sessions a week to 
 the work in accordance with the practice recommended 
 in previous chapters would receive a yearly salary of 
 £150. In the case of school doctors newly appointed, 
 
ORGANIZATION OF SCHOOL HYGIENE 137 
 
 without any previous experience of the work, it would 
 be sufficient that they should be paid a commencing 
 salary at the rate of £40 a year for one school session 
 per week, that is £120 a year for three school sessions 
 a week. In either case, the salaries of medical women 
 should not be less than those of medical men. 
 
 An experienced whole-time school medical officer 
 should, under no circumstances, receive less than £500 
 a year. There would be no objection, however, to 
 junior men being appointed as assistants early in their 
 professional career at a salary of £250 or £300 per 
 annum. 
 
 Financial considerations as to medical treatment at 
 school and as to the establishment of school clinics 
 are deferred to a subsequent chapter. 
 
CHAPTER X 
 
 THE SCHOOL DOCTOR : HIS DUTIES AND 
 
 QUALIFICATIONS 
 
 School Doctors of Two Kinds : (1) ' School Doctors' Proper, i. e. Practi- 
 tioners of Medicine, (2) 'School Medical Oflacers', i.e. Directors and 
 Administrators.— Duties of a ' School Doctor ' : (a) Official ; (&) Funda 
 mental.— Duties Specified.— Interest in Social Problems Essential- 
 Personal Qualifications.— A Special Mental Attitude.— Obstacles and 
 Hindrances.— Professional Qualifications.— An Additional and Special 
 Training.— Clinical Experience.— Diploma in School Hygiene.— Ex- 
 perience in Social Work.— Pioneer Investigation, Social, Educational, 
 and Medical— Summary of Qualifications and Duties.— Medicine, Psy- 
 chology, and Pedagogy.— The Chief School Medical Officer.— Capacity 
 for Organization and Administration. 
 
 * The function of the school doctor in relation to 
 children in the schools is often mistaken even by 
 medical men. It is no part of his duty to prescribe 
 for, or to treat, any individual case. His work is 
 preventative, and in individual cases only applies to 
 matters involving educational questions. He can call 
 attention to the need of glasses, but he has nothing 
 to do with prescribing them. He may notice the pre- 
 sence of adenoids, but takes no part in their removal. 
 On the other hand, his work should extend far beyond 
 mere investigation of the sanitary state of buildings 
 or the exclusion of unhealthy or diseased children. 
 The methods of education, the requirements of physical 
 exercise, the avoidance— particularly in the very 
 
THE SCHOOL DOCTOR : HIS DUTIES 139 
 
 young — of overstrain from prolonged fatigue or from 
 improper tasks, are all matters in which improvement 
 can only be attained by the efforts of the school doctor. 
 Above all, he must act, not as an authority to shut or 
 close, to disturb or interrupt the proper work of the 
 school, but as a counsellor and adviser with a know- 
 ledge of school routine and of the requirements of 
 health, to assist and collaborate with the teacher and 
 administrator, and it is with this purpose in mind that 
 he should enter any school.' These words are almost 
 as true to-day as when Dr. Kerr discovered their truth 
 in Bradford fifteen years ago. 
 
 School doctors are of two kinds. First there are 
 practitioners of medicine who become attached to the 
 staff of one or two local schools, and who carry out 
 the routine work of inspection and classification, 
 giving only a few hours each week to the work ; 'and 
 secondly there are those who, devoting the whole, or 
 the greater part, of their time to the work, become 
 specialists in one or more branches of it, and act as 
 directors and administrators of school hygiene. The 
 first class will always be many— one doctor to every 
 small group of schools. The second class are few, and 
 are developed from the first by a process of natural 
 selection. 
 
 Duties 
 
 The school doctor was first recognized officially at 
 the Board of Education in the Code of 1908. He is 
 defined as ' a medical officer named by the local educa- 
 
140 MEDICAL INSPECTION OF SCHOOLS 
 
 tion authority and recognised as such by the Board'. 
 Previously the medical officer of health, having certain 
 statutory functions with regard to the prevention of 
 infectious diseases in school, was vaguely referred to as 
 a ' medical authority ' ; and there was also provision 
 for the appointment of medical men to carry out certain 
 powers and duties under the Elementary Education 
 (Blind and Deaf) Act, 1893, and the Elementary 
 Education (Defective and Epileptic) Act, 1899. 
 
 The Code of 1908, however, assigns to the school 
 medical officer the specific functions : 
 
 1. Of reporting on the working and effect of any 
 arrangements made for educating children at open-air 
 schools, school camps, or other places selected with 
 a view to the improvement of the health and physical 
 condition of the children. 
 
 2. Of advising or approving the closure of a school 
 in the case of outbreak of epidemic disease. 
 
 3. Of authorizing the exclusion of certain children 
 from a school on specified grounds for preventing the 
 spread of disease, on account of their uncleanly and 
 verminous condition, or because owing to their state 
 of health or their physical and mental defects, they 
 are incapable of receiving proper benefit from the 
 instruction in the school. 
 
 The first official pronouncement on the organization 
 and future development of a special School Medical 
 Service is contained in Circular 596, which indicates 
 the advisability of centralizing these functions and 
 responsibilities in the department of the chief school 
 
THE SCHOOL DOCTOR : HIS DUTIES 141 
 
 medical officer of each education authority. For the 
 Board of Education has in view ' the desirability of 
 assisting local education authorities to concentrate 
 and organize, in the department of the school medical 
 officer and matters of school hygiene, including medical 
 inspection under the Act of 1907, and they assume 
 that the school medical officer will, in addition to 
 performing the specific functions assigned to him by 
 the Code, also be made responsible by the local educa- 
 tion authority for supervising and controlling the 
 general work of medical inspection '. 
 
 In official regulations and suggestions, however, 
 there is an occasional tendency to confuse statutory 
 and incidental obligations with fundamental general 
 principles. It may be as well to treat the subject in 
 natural sequence, according to its spontaneous growth, 
 and to deal with the duties of the school doctor first, 
 and defer to the end of the chapter any reference to the 
 functions of the chief school medical officer. 
 
 The personal and professional qualifications of a 
 school doctor attached to the staff of every group of 
 schools will be considered later. His duties, which 
 depend for their efficient discharge very largely upon 
 his co-operation with the teaching staff and school 
 managers, may be summarized thus : — 
 
 1. To examine cursorily every child about the time 
 of its admission to an infant school, as to cleanliness, 
 and as to its obvious physical defects. This first 
 examination should be conducted in the presence of 
 parents or guardians. 
 
142 MEDICAL INSPECTION OF SCHOOLS 
 
 2. To examine in detail every child about the time 
 of its transference to the upper school — that is about 
 seven years of age — and to decide what special educa- 
 tional training (if any) is suitable to the child. 
 
 3. To visit and inspect all classes once or twice 
 a year both as regards the general health and physique 
 of the children and also as regards the conditions under 
 which they are working, namely the ventilation, 
 lighting, &c., on the one hand and the amount and 
 kind of work, overpressure, fatigue, physical exercises, 
 manual training, &c., on the other hand. 
 
 4. To make special visits to the boys' and girls' 
 departments once a year for the purpose of examining 
 all children suffering from defective vision and to 
 report upon eye disease generally. The teachers should 
 test the vision of all children once a year, but the 
 doctor's examination can scarcely be undertaken at 
 the time of his visits for other work, except in very 
 small schools. 
 
 5. To supervise the work of nurses with regard to 
 ringworm, vermin, and skin affections, and to visit 
 each school once a week or once a fortnight for the 
 general examination of special children selected by the 
 teacher or nurse. 
 
 6. To advise the Health Committee of each school 
 upon various points of hygiene bearing upon educa- 
 tional matters, and to give definite instructions about 
 the care of the delicate and defective children. 
 
 7. To give lectures to teachers and others upon 
 school hygiene and elementary physiology. 
 
THE SCHOOL DOCTOR : HIS DUTIES 143 
 
 8. To deal with the question of medical certificates 
 of absence given by other practitioners. This duty 
 might be combined with the weekly visit to the schools. 
 
 9. To investigate (if necessary in conjunction with 
 the medical officer of health) all epidemics and out- 
 breaks of infectious disease in the schools and also 
 to take measures to prevent not only the spread of 
 the disease but also the unnecessary closure of the 
 school. 
 
 10. To carry out original investigations and to do 
 research work, especially in the larger towns. 
 
 With regard to these duties the Board of Education 
 has issued the following regulations : ' (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, (h) The convenience of the teaching staff and 
 the circumstances of each school must receive con- 
 sideration, and in these matters and in the actual 
 examination, the medical officer will no doubt exercise 
 sympathy and tact, giving due thought to the per- 
 sonal susceptibilities of those concerned, (c) The facts 
 revealed by inspection must be entered in a register 
 kept at the school, the confidential nature of many 
 of the entries being carefully respected. A copy of 
 the entries should be transmitted with the child to any 
 other school to which he or she may go.' 
 
 The general principles of these duties and the neces- 
 sity for the co-operation of the teachers have already 
 
144 MEDICAL INSPECTION OF SCHOOLS 
 
 been considered in a previous chapter. At present the 
 minimum amount of inspection that is required by the 
 Board of Education under the Act consists in three 
 examinations of each individual child — the first at the 
 time of, or as soon as possible after, admission to school ; 
 the second at about the seventh year of age ; and the 
 third at about the tenth year of age. A further 
 inspection immediately before departure of the child 
 into working life is recommended as desirable. But 
 it is distinctly laid down in an official memorandum 
 that these directions and requirements as to the degree 
 and frequency of inspection ' are not intended to exclude 
 other medical work which the Board trust will be 
 undertaken by local education authorities according 
 to their abilities and opportunities '. 
 
 To summarize the position : — As far as the routine 
 duties of a school doctor are concerned, efficiency 
 demands that — 
 
 1. Each school in his area should be visited as a 
 matter of routine once a week or once a fortnight for 
 general purposes. 
 
 2. Each department (boys and girls) should be visited 
 once a year for vision testing of selected children ; and 
 each department (including infant schools) once a year 
 for dental examination.^ 
 
 3. Each class should be visited once or twice a year 
 for general inspection and for the supervision of special 
 children. 
 
 ^ Dental examination by itself is a large and important subject. 
 Perhaps it might be combined with the ordinary class-room examination. 
 In populous districts special dental surgeons are required. 
 
THE SCHOOL DOCTOR : HIS DUTIES 145 
 
 4. And, lastly, each child should be inspected three or 
 four times, at stated intervals, during its school career. 
 
 Further, the school doctor must supervise the work 
 of the school nurse, investigate outbreaks of epidemic 
 disease, and give lectures to teachers. 
 
 In addition to these definite and practical duties, 
 a school doctor should undertake a personal investi- 
 gation of the social conditions and local influences 
 affecting the mental and physical development of 
 the children under his supervision. He should also 
 lose no opportunity for the diffusion of knowledge 
 among the lay public in general and among educa- 
 tionalists m particular as to the meaning of school 
 hygiene. 
 
 To this end he should arrange to be present at con- 
 ferences of teachers and parents at the school. For 
 instance, once or twice a term, about one hour before 
 the afternoon school session closes, the department 
 should be thrown open to parents. They should come 
 and see their children at play and at work, doing 
 physical exercises and manual work, or singing, draw- 
 ing, reciting, and dancing. The school doctor on such 
 occasions, either by personal conversation with the 
 individual parents, or by a series of short discourses 
 on health, should explain the desirability for the help 
 and co-operation of the parents in the education of 
 their children. This scheme has been practically 
 carried out in certain schools, and might with advantage 
 be extended throughout the country. No financial 
 outlay is involved, and it is likely to ensure more definite 
 
 HOGARTH r. 
 
146 MEDICAL INSPECTION OF SCHOOLS 
 
 results than house to house visitation by a lady health 
 visitor. 
 
 For the same purpose also, namely, that of educating 
 others, the school doctor should attend the meetings 
 of the Health or Care Committee of each school, so 
 as to direct the zeal of lay workers in the right channels. 
 Such a Health Committee for each school should meet 
 once or twice a term after the visits of the school doctor, 
 and its chief functions should be to discover how the 
 doctor's advice as to the treatment of defective children 
 may best be followed. 
 
 So far, only the diagnosis, or rather the detection of 
 disease, has been considered. Nothing has been said 
 as to the question of treatment. The school doctor 
 indicates to the parents, generally through the medium 
 of the teacher, what line of treatment is necessary, 
 and all further responsibility is left in the hands of the 
 parents — which means very often, especially in the 
 poorer districts, that nothing is done. It is for this 
 purpose that Health Committees are recommended for 
 certain schools, and in others the co-operation of 
 Guilds of Help and other voluntary agencies is neces- 
 sary. This aspect of the problem — the medical treat- 
 ment of school children — must be deferred to a later 
 chapter. 
 
 Qualifications 
 
 As every doctor is not fitted to become a surgeon, 
 so every medical man is scarcely fitted to become a 
 school doctor. So far no special code of qualifications 
 
THE SCHOOL DOCTOR : HIS DUTIES 147 
 
 has been drawn up. But these new duties are not 
 to be undertaken lightly, without care or forethought. 
 The work is only in its infancy. All school doctors 
 must therefore educate themselves, and there is great 
 scope for originality, and for the adoption of in- 
 dividual methods in contrast to the official attitude 
 and traditional acquiescence in routine which is so 
 often to be found in other branches of the public 
 service. 
 
 In the practice of medicine, a physician comes into 
 contact with his patients and with one or two members 
 of the patient's family, and occasionally with the 
 medical officer of health, the coroner and other officials. 
 But there, as a private physician, his responsibility 
 ends.^ For the most part, his routine duties are confined 
 to the consideration of his patients and of himself. 
 In the school his sphere is at once extended. His daily 
 work brings him into contact not only with children 
 and parents, but also with many officials — teachers, 
 school managers, nurses, school inspectors, medical 
 officers of health, and a committee of expert education- 
 alists. There are two courses open to him. He may 
 take refuge in the dignity of his legal standing and 
 enforce the requirements of hygiene as an official, 
 thereby nullifying the most essential potentialities 
 of his work. Or he may pursue a course of harmonious 
 co-operation with the school authorities, almost for- 
 getting that he himself has an official role. Teachers 
 
 ^ In this respect all reference to the public appointments held by 
 many practitioners is omitted. 
 
 l2 
 
148 MEDICAL INSPECTION OF SCHOOLS 
 
 and parents want his help and advice, and will be 
 ready to follow it, if given in the right spirit. To this 
 end there is need for a consideration of the school 
 doctor's qualifications and methods. 
 
 Before undertaking the new work, the school doctor 
 should be possessed of many qualifications — both 
 personal and professional. He should be a man of 
 wide experience, of large sympathies, of many interests, 
 and endowed with abundant insight into human nature. 
 Such personal qualities are likely to prove of greater 
 value than the highest professional attainments. 
 
 The school doctor should have a special temperament 
 
 and should possess some of the characteristics, more 
 
 commonly found in women than in men, such as the 
 
 power of attraction, sympathy and a natural love for 
 
 children. He requires also to develop in himself a 
 
 special mental attitude. His manner should be open 
 
 and his speech direct. His task is not easy, and 
 
 children themselves— always difficult enough to manage 
 
 — are especially shy of strange doctors, but experience 
 
 will teach him how impediments may be overcome by 
 
 a little patience and circumvention. The difficulty is 
 
 generally increased when the children are seen in the 
 
 presence of their parents, who often show a certain 
 
 objection to official interference with their natural 
 
 responsibilities, and sometimes put foolish obstacles in 
 
 the way of the doctor. In these cases the doctor's 
 
 word is not accepted as law ; there is no firm bed-rock 
 
 of faith, as is the case in private practice. 
 
 The teachers also are not always easy to approach ; 
 
THE SCHOOL DOCTOR : HIS DUTIES 149 
 
 they have a dread of the inspectorial system, and if 
 they think the doctor enters their school to find fault 
 and to criticize, all kinds of complications may arise. 
 The nurse too is no longer in the private employ of 
 the doctor. She is an official with her duties and 
 responsibilities, not only to the doctor but also to the 
 State. She must be regarded rather as a coadjutor 
 than as a subordinate. The susceptibilities of school 
 managers and of any philanthropists interested in 
 school work must be considered. The school doctor 
 is responsible to his Education Committee and to 
 the State for the efficiency of his official routine. 
 Finally, he will occasionally find himself in conflict 
 with the interests of other medical men, especially as 
 regards the matter of certificates of absence from school. 
 
 Thus, owing to the numerous obstacles and impedi- 
 ments which beset the school doctor's work consider- 
 able discretion must be exercised in the choice of 
 suitable men. 
 
 The school doctor's professional qualifications are 
 also of importance. Generally speaking, he should 
 begin to fill his first school appointment between the 
 ages of 30 and 35, but, for routine work, older men 
 may very reasonably be chosen if they have been 
 engaged in the practice of medicine. Over and above 
 the ordinary training of a medical student, a would-be 
 school doctor should hold an appointment for six 
 months or a year as house physician, or house surgeon, 
 in a general hospital. He should also devote some 
 time after qualification to making himself specially 
 
150 MEDICAL INSPECTION OF SCHOOLS 
 
 acquainted with the practical methods and routine of 
 the special departments concerned with diseases of the 
 eye, ear, nose, throat, and skin, and also with a special 
 study of orthopaedics and of electrical treatment for 
 infantile paralysis. Then he should spend at least six 
 months in the wards and out-patient department of 
 a children's hospital, where he would study the normal 
 and pathological growth and development of the child, 
 and another six months either in a fever hospital, or 
 in an asylum for mental diseases.^ 
 
 That is to say, for two to three years after obtain- 
 ing a qualification to practise medicine, the would-be 
 school doctor devotes his time to attaining some degree 
 of proficiency in all the branches of his profession. 
 At the same time he gains a broad outlook on the field 
 of medicine, and needs only a few years' experience 
 as practitioner, or as assistant, to increase his know- 
 ledge of the world and of human nature. Two or 
 three years of work in private practice should suffice 
 to enlarge his outlook on life, and enable him to under- 
 take the duties of a school doctor with knowledge 
 and understanding. In return for such an additional 
 and special training a medical practitioner may 
 reasonably look for an appointment as local school 
 doctor in charge of a small group of schools in his 
 neighbourhood. The school work would always be full 
 of interest, and would, to a large extent, relieve the 
 monotony of private practice. 
 
 1 Both these appointments are important. A study of psychological 
 medicine should be regarded as essential. 
 
THE SCHOOL DOCTOR : HIS DUTIES 151 
 
 If a man has obtained this kind of practical training 
 in his profession, it matters not what are his actual 
 degrees or diplomas. It is clinical experience which is 
 most likely to develop qualities suitable to a school 
 doctor. 
 
 In addition to all this if the doctor has a natural bent 
 towards administrative work or capacity for organiza- 
 tion, he should certainly spend six months or a year in 
 securing the Diploma in Public Health. For such as 
 intend to confine their attention to school work, this 
 examination should be considerably modified so as to 
 include the study of physical education, of mental 
 development, and of general educational hygiene, and 
 at the same time to omit the routine of the chemical 
 and physical laboratory and other work relating to 
 the control of food and milk supplies and problems of 
 public health and sanitation with which the school 
 doctor can never be primarily concerned.^ 
 
 As soon as the doctor begins his work in the schools, 
 he will find it useful to obtain first-hand knowledge 
 of the social conditions of the people in the district 
 where his schools are situated. It is impossible to 
 appreciate fully the life and home conditions of the 
 children whom he inspects, unless he understands not 
 only the ignorance, the apathy, and the neglect of 
 the parents but also their poverty, and the wretched 
 housing conditions under which they live. 
 
 1 Possibly examining bodies will see their way to dividing this examina- 
 tion into two separate parts, or to issuing a separate diploma of School 
 Hygiene. 
 
152 MEDICAL INSPECTION OF SCHOOLS 
 
 In the poorer quarters of the towns, he meets 
 the neglectful, the criminal, the apathetic parent, as 
 well as the honest, hardworking, underfed labourer, 
 and the thrifty housewife who can scarcely keep her 
 home together. Each of these sends a different type 
 of child to the school, and the doctor must be able to 
 understand and recognize each type. Otherwise he 
 cannot diagnose the case, and each must be treated 
 on its merits. In another part of the town there may 
 be congregated the spoiled, pampered, and neurotic 
 children of different social status. In the rural dis- 
 tricts also he must know the parents and their ways. 
 This first-hand knowledge is not easy to obtain except 
 by living among the people. It is, however, possible to 
 acquire reliable information from the teachers, and the 
 school doctor must not hesitate to instruct himself in 
 this way in the absence of personal knowledge. 
 
 To all these personal and professional qualities, 
 there must be added freshness of mind and ability 
 to undertake pioneer work. There are many problems 
 to be investigated — social, educational, and medical ; 
 and in addition to his routine work, every school 
 doctor should set himself to add something to the 
 store of knowledge. The work is from the first so 
 absorbing and so interesting, that every medical man 
 will feel himself compelled to undertake some kind 
 of research. 
 
 Briefly to summarize the qualifications and duties 
 of a school doctor : He must be observant and recep- 
 tive not only in regard to the children themselves, but 
 
THE SCHOOL DOCTOR : HIS DUTIES 153 
 
 also as to their surroundings and conditions of work. 
 His knowledge must be both sound and extensive ; 
 he may be almost a specialist in all subjects, without 
 being a faddist in any. He must be broad-minded 
 and possessed of a thorough acquaintance with general 
 principles. He must be a rapid facial diagnoser, not 
 necessarily a diagnoser of disease, but a detecter of 
 any abnormal condition. He must also be well 
 acquainted with all the possibilities of treatment, and 
 be certain that benefit will result before he urges the 
 necessity that the children should seek medical advice. 
 He must remember that his very raison cfetre is to 
 correct ignorance ; he must, therefore, not be ignorant 
 himself, and, above all things, must never pretend to 
 knowledge. He must not fence with questions put by 
 teachers : an evasive answer may be the means of 
 perpetuating the very mischief which it is his chief 
 desire to abolish. He must be interested in educational 
 problems, and must understand the aims and general 
 scope of school work in the various standards. He 
 must be interested in child life, and acquainted with 
 the physiological and psychological development of the 
 child. He plays the part, as it were, of a professional 
 pedagogue, not making the children introspective and 
 neurotic, but, in the case of the elder children, im- 
 pressing upon them the object of his visit and the need 
 of their co-operation and good sense. He must show 
 great sympathy and tact ; he has to deal with all sorts 
 and conditions of teachers, of whom some extend 
 a cordial welcome, while others regard him as a merely 
 
154 MEDICAL INSPECTION OF SCHOOLS 
 
 superfluous element in school life. In short, the school 
 doctor's work is partly medical, partly psychological, 
 and partly pedagogic. To quote Dr. Kerr, ' It over- 
 laps the psychologist's field and partly invades the 
 teacher's domain. It is difficult to say where it be- 
 gins or where it ends, and, therefore, all must work 
 together as colleagues towards the common object, 
 the progress of education, and the physical improve- 
 ment of the race.' 
 
 The personal and professional qualifications of a 
 school doctor attached to the staff of every group of 
 schools have now been considered. With regard to 
 the chief school medical officer who is responsible for 
 the organization and administration of the school 
 medical service, little need be said. His functions 
 have already been indicated in a previous chapter.^ 
 They vary greatly according to the size and con- 
 ditions of the area over which he exercises control. 
 In some places his time will be occupied entirely with 
 supervisory and administrative duties ; in other places 
 he may also undertake some work in connexion with 
 special schools, physical training, or other branches of 
 school hygiene. Elsewhere, again, he may combine 
 with his other duties some of the work of the local 
 school doctor. 
 
 There is little to say about his qualifications, as he 
 generally attains his position by a process of natural 
 selection. However, it is almost essential for the proper 
 fulfilment of his duties that he should have gained defi- 
 
 * Chap, ix, p. 115. 
 
THE SCHOOL DOCTOR : HIS DUTIES 155 
 
 nite knowledge of the practical routine in the schools by 
 means of actual first-hand experience. Also, he should 
 gradually have acquired special knowledge in regard 
 to physical training, mental deficiency, infectious 
 diseases in schools, school furniture, school architecture 
 and ventilation. Such special knowledge is not to be 
 obtained from books, but only from special study 
 during the plastic period of mental growth. He 
 should have gained some experience in the examination 
 of scholarship candidates, and of pupil-teachers. 
 
 Above all, the chief school medical officer should 
 possess capacity for administration and organization. 
 In populous districts he will have to organize means 
 for the treatment of school children, and, for this 
 purpose, he must have had considerable clinical ex- 
 perience and be not merely an official administrator. 
 He must of necessity co-operate with other medical 
 officers attached to various branches of the public 
 medical service. 
 
CHAPTER XI 
 THE SCHOOL DOCTOR : HIS METHODS 
 
 First Examination Superficial. — Details of Second Examination. — 
 Preliminary Test of Vision and Hearing. — Estimate of Physical Con- 
 dition : Three Factors. — Anthropometry of Doubtful Value. — Clinical 
 Methods Modified by Special Circumstances. — Examination of Mouth 
 and Neck. — Heart, Lungs and Spine. — Minute Technical Research 
 Unnecessary. — Defects of Speech : Peripheral, Habitual and Develop- 
 mental. — Language of School and Language of Home. — Nerve Signs. — 
 Mental Capacity. — Time Occupied in Examination. — Health Certificate. — 
 Class-room Inspection; a Surprise Visit. — Its Educational value. 
 
 It remains now to consider the methods of the 
 school doctor. The first examination of the children 
 on admission has already been described in sufiicient 
 detail in an earlier chapter.^ The essential point of the 
 first examination is to discover the general fitness of 
 the child for school life at an early age and its previous 
 medical history, and to call the attention of parents 
 to any obvious defects, such as squints, deformities, 
 or ear discharges, and as to conditions of uncleanliness 
 or of parasitic and contagious diseases. Such a medical 
 examination only occupies a few minutes, and should be 
 arranged to take place either on the first two or three 
 days of each term, or on one fixed day once a week 
 or once a month according to the number of children 
 admitted. It is advisable that this examination should 
 be held in the presence of parents in order to obtain 
 accurately the child's previous medical history, and 
 
 ^ Chap, vii, p. 86. 
 
THE SCHOOL DOCTOR : HIS METHODS 157 
 
 for the purpose of calling attention to any conditions 
 that demand immediate remedy. 
 
 With regard to the next examination, which should 
 take place at seven or eight years of age, at the time 
 of transference of the children from the infants' school 
 to the girls' and boys' departments, or, better still, 
 one term later,^ there is need for greater care and 
 accuracy. A preliminary test of vision and hearing 
 may, generally speaking, be undertaken by the head 
 teacher with the help of the school nurse, both of 
 whom can be properly instructed in the necessary 
 routine by the school doctor. Besides the actual 
 saving of time involved by this practice, such a pre- 
 liminary examination has the advantage of interesting 
 teachers in the physical condition of the children, and 
 of impressing upon them the importance of making 
 allowance for those with defects of vision or hearing. 
 The teachers, too, will be able to select at once those 
 children who cannot be expected to read the vision 
 test because they do not know their letters ; and 
 they could be taught how to deal with these children 
 separately. In this way a great deal of time is saved, 
 the doctor only testing again those with actual defects 
 of vision and hearing. 
 
 Each class of thirty or forty children should be 
 examined separately, and, as a rule, in the presence 
 of the class teacher. The children — with bared 
 
 ^ Experience shows that during the first term the children grow 
 accustomed to their surroundings and that the teachers have detected 
 individual peculiarities. Consequently the work of the school doctor 
 is easier. 
 
158 MEDICAL INSPECTION OF SCHOOLS 
 
 shoulders, chest, and back — are brought to the doctor 
 separately by the nurse, and the examination begins. 
 The school doctor first notes any peculiarity or general 
 deviation from the normal, either as to gait, general 
 condition, appearance, size, and shape of head, or as 
 to clothing, foot-gear, and personal cleanliness ; at 
 the same time he estimates the general nutrition and 
 physical condition of the child. This is best calculated 
 in numbers according to the scheme of Koppe : 1 = 
 excellent, 2 = good, 3 = fair or average, 4 = poor, 5 = 
 bad. Unfortunately there is no exact criterion by 
 which a standard of physical condition may be esti- 
 mated, but each doctor must, by experience, for- 
 mulate his own standard which, if expressed as 
 a figure, is in reality the component of three factors — 
 physical stature, general nutrition, and the condition 
 of the circulation. Therefore, if the results are to be 
 of any scientific value, or to be intelligible to any 
 second person, it is necessary to indicate each of the 
 three factors by a separate figure in accordance with 
 the following tables : — 
 
 Stature and growth. 
 
 A healthy giant 1 
 
 Well-grown . . 2 
 
 Average 3 
 
 Stunted 4 
 
 Miserable, de- 
 formed .... 5 
 
 Nutrition. 
 
 Excellent muscular de- 
 velopment 1 bronzed . . 1 
 
 Well nourished, healthy 2 I Healthy pink .... 2 
 
 Medium 3 Average 3 
 
 Circulation and 
 comylexion.^ 
 
 Ruddy and 
 
 bronzed . . 
 
 Thin, or fat and flabby 
 
 tissues 4 
 
 Very thin 5 
 
 Anaemic, sallow 4 
 Pallid 5 
 
 ^ The condition of the circulation, as seen in the superficial mucous 
 membranes, is as a rule a safer guide than the appearance of the child's 
 complexion. 
 
THE SCHOOL DOCTOR : HIS METHODS 159 
 
 Such an estimate will take an experienced observer 
 only a few seconds, and can be expressed in three figures. 
 If on the other hand it is not thought advisable to 
 take the trouble of indicating each of these three 
 factors by a number, a general estimate may be given, 
 and the number qualified by an adjective for the most 
 striking factors : 2, well nourished, somewhat pale ; 
 3, anaemic ; 4, well grown, very thin and pale. The 
 adoption of some such method as this will probably 
 prove more valuable than the pseudo-scientific results 
 that will be evolved from any elaborate anthropometric 
 survey, which must occupy several minutes for each 
 child, and even so may be inaccurate. In any case the 
 actual weighing and measuring of the children should 
 be undertaken by the class teacher as a regular yearly 
 routine wherever weighing-machines are supplied. But 
 the figures will seldom have much medical significance. 
 
 Next, the school doctor undertakes, according to 
 somewhat modified clinical methods, the examination 
 of the various physiological systems in order ; ^ and 
 perhaps the quickest and most systematic method of 
 examination is to begin at the head and gradually 
 work downwards over the body. The examination of 
 the head as to ringworm or verminous conditions and 
 of the ears as to any discharge has already been per- 
 formed by the school nurse, while the acuity of hearing 
 and vision have already been recorded by the teachers. 
 It is only necessary for the doctor to re-test those who 
 
 ^ Cf . Methods of Medical Examination in School : Janele and Moucka. 
 Transactions : 2nd International Congress on School Hygiene, vol. ii, 
 p. 546. 
 
160 MEDICAL INSPECTION OF SCHOOLS 
 
 are found by the teacher to be defective. But in 
 all cases he notes the condition of the eyes, as to 
 squints, opacities and external diseases. The exami- 
 nation of the eyes, though only superficial, should 
 be precise. The doctor must discover if the child 
 shows any objective symptoms, such as watering 
 eyes or sticking of the lids. Irregularity of the cornea 
 may be tested by the reflection of the window-panes 
 to discover the likelihood of astigmatism ; the presence 
 of synechiae or adhesions must be detected and the 
 state of the lens must be examined as far as is prac- 
 ticable in the absence of the ophthalmoscope. In 
 this way it is possible to ascertain if there is any need 
 for the testing of refraction or for further examination 
 by a specially qualified oculist. Such children are 
 referred either to the school clinic, or for appropriate 
 treatment by a specialist. 
 
 The hearing has already been tested, and the nurse 
 has reported as to the presence of any aural discharge. 
 If any abnormalities are discovered, the doctor must 
 investigate the cause. Generally speaking, it should not 
 be necessary to use a speculum or other instruments ; 
 but the doctor should be able to decide as to whether 
 there is need for further examination and treatment. 
 
 Then comes the examination of the mouth. Simple 
 inspection is all that is required. Small wooden 
 spatulas,^ or even the child's own pocket-handkerchief, 
 may be used to depress the tongue. The number of 
 decayed and missing teeth are noted as well as any 
 
 ^ E. g. the ordinary garden plant-labels. 
 
THE SCHOOL DOCTOR : HIS METHODS 161 
 
 oral sepsis or impairment of function; the child la 
 referred for appropriate treatment by the dentist. 
 Where a dental surgeon or assistant is attached to 
 a school, this part of the examination maybe left to him. 
 In any case it is sufficient to ascertain only the above- 
 mentioned particulars. Special classification is un- 
 necessary. The shape of the palate is incidentally noted, 
 though there is little need to record it. Enlarged tonsils 
 can be seen, but the presence or absence of adenoids 
 must be inferred without recourse to digital examina- 
 tion. In this respect great care must be exercised in 
 referring cases for operative treatment. ■■ In the poorer 
 quarters of the towns the majority of the children 
 are mouth-breathers, but only a small percentage have 
 enlarged tonsils or adenoid growths. The school doctor 
 must exercise his judgment. Such habitual mouth- 
 breathing can readily be overcome by the constant use 
 of the pocket-handkerchief and by the frequent prac- 
 tice of breathing exercises. The doctor will indicate 
 this to the class teacher in the case of certain children 
 who will require special attention in this direction. 
 
 The neck is then examined by palpation in order 
 to detect the presence of enlarged submaxillary and 
 cervical glands. These will be discovered in the 
 majority of elementary school children, the sub- 
 maxillary being due to carious teeth and septic absorp- 
 tion, and the posterior cervical to verminous and 
 uncleanly conditions of the scalp. 
 
 The doctor must then take a general survey of the 
 child's chest development, and of the state of the 
 
 HOGARTH ]yj 
 
162 MEDICAL INSPECTION OF SCHOOLS 
 
 heart and lungs and spine. Old rickets and other 
 deformities will be noted ; special care should be taken 
 to detect the earliest sign of lateral curvature of the 
 spine or of tuberculosis and heart disease. There is 
 no need, however, to indicate any special methods 
 for this part of the examination, which should be con- 
 ducted in accordance with the approved clinical 
 methods of inspection, palpation, percussion, and aus- 
 cultation — eyes first and most, hands next and little, 
 tongue not at all, except for the purpose of diverting 
 the child's attention. Any abnormalities should be 
 noted and the teacher's attention directed to them 
 with definite instructions as to any necessary departure 
 from the ordinary curriculum or school routine, such as 
 the necessity for special physical exercises or for being 
 excused attendance from particular classes or games. 
 
 In actual practice the school doctor should, as a rule, 
 be able to detect at a glance whether there is any need 
 for a careful examination or not. It is mere waste of 
 time to percuss and auscultate systematically the lungs 
 and heart of every child. * Minute technical research 
 does not suit the purposes of school hygiene, especially 
 when the use of instruments would be necessary to 
 ascertain all the clinical details.'^ Either nurse or 
 doctor should be required to see the child's bare feet 
 so as to detect any commencing deformity, as well as 
 to insist on the necessity of cleanliness. 
 
 Finally, there is the examination of the child's 
 mental capacity and the general state of the nervous 
 
 ^ Janele and Moucka : loc. cit. 
 
THE SCHOOL DOCTOR : HIS METHODS 163 
 
 system. First of all any defects of speech may be 
 noticed if the child is set to count slowly to 12, or 
 to recite a piece of poetry. The doctor must be able to 
 distinguish three kinds of defects ; (1) Peripheral , due 
 to some local defect of the teeth, palate, or lips : such 
 defects as a cause of defective speech are very un- 
 common and are revealed during the inspection of 
 the mouth, and Central, of which there are two 
 kinds ; (2) Habitual ; and (3) Developmental. 
 
 Habitual defects include any special type or 
 manner of speech which the child affects, often as 
 the result of home education. Defects of this nature 
 are very common, and are due only to habit. The 
 child naturally imitates the language of its parents 
 and associates, and in the poorer districts of the towns 
 the dialect becomes, as it were, a different language — 
 only understood with difficulty by the uninitiated. 
 In these cases, the child has no impediment in speech, 
 and can be taught with ease to speak correctly. Some- 
 times the child adopts two languages — the correct 
 language of the school, and the natural language of 
 the home. In the same category, also, may be placed 
 the habitual lisp or the affected speech of neurotic 
 and spoiled children of another social class. Habitual 
 defects of this kind are diagnosed not only by know- 
 ledge of the type of child and of the social conditions 
 of the neighbourhood, but also by compelling the child 
 to imitate correct speech. Developmental defects of 
 speech are due to imperfect development of the speech- 
 centre in the brain, whereby the child is unable to 
 
 m2 
 
164 MEDICAL INSPECTION OF SCHOOLS 
 
 control and co-ordinate the various muscles which 
 take part in the mechanism of speech. This condition 
 may be diagnosed by the child's total inability to 
 imitate particular combinations of sounds. 
 
 The presence of any of Dr. Warner's classical ' nerve 
 signs ' will have been observed already during the 
 examination ; such are asymmetrical positions seen 
 in the balances and movement of the body, defective 
 expression, vacancy, apathy, grinning, overaction of 
 the frontal muscles, corrugation of the eyebrows, 
 relaxation of the orbicularis oculi, irregular and uncon- 
 trolled movements of the eyeballs, asymmetry in the 
 balance of the head and hands, finger twitches, tremors, 
 and general immobility, or constant spontaneous move- 
 ments ; the presence or absence of any or all of these 
 signs will enable the school doctor to make a rough 
 estimate of the child's nervous and mental stability. 
 
 Then the doctor calls for the class teacher's report 
 and general observations upon the child's intelli- 
 gence or backwardness. Gross mental deficiency will 
 be readily observed, and the child is recommended 
 for admission to, or for further examination with a view 
 to transference to, a special school. Similarly the blind 
 and the deaf, the semi-blind and semi-deaf, as well as 
 the epileptic and crippled, are singled out for further 
 examination, and should not be allowed to continue 
 in school, even if they have been allowed to proceed 
 through all the stages of the infant school. Putting 
 aside all these children, the doctor must estimate each 
 child's mental capacity and decide whether it is of 
 average intelligence and likely to derive benefit from 
 
THE SCHOOL DOCTOR : HIS METHODS 165 
 
 the educational system of an elementary school, or 
 whether the child requires another year in the infant 
 school, or is to be placed for a time in the backward 
 class, or in an intermediate school. Experience alone 
 will teach the school doctor how to decide these points, 
 but he must learn to rely on his own judgment rather 
 than to trust entirely to the teacher. By setting the 
 child to read, or to do mental arithmetic, or by asking 
 one or two of a series of carefully graduated questions 
 which evoke certain definite mental processes before an 
 answer can be given, and by giving fixed marks 
 according to the way in which the questions are 
 answered, the school doctor should be able to place 
 each child in its proper place. The questions must 
 be left to the individuality of the doctor. The following 
 groups of children will be met with at this stage of 
 their educational career (excluding idiots and imbeciles 
 who may be represented numerically as 0) : — 
 
 Classification. 
 
 Mentally defective (low grade) 
 
 „ „ (middle grade) 
 
 „ „ (high grade) 
 
 Very dull 
 
 Dull 
 
 Average 
 
 Quick and bright 
 
 Very intelligent 
 
 Numerical 
 Representa- 
 tion.^ 
 
 1 
 7 
 
 1 
 
 2i 
 3 
 
 4 
 
 5 
 
 Educational 
 Prognosis. 
 
 Permanent custodial 
 treatment. 
 
 Permanent supervision. 
 
 Self-supporting, able to 
 work and to learn re- 
 sponsibility. 
 
 The normal 'hewers of 
 wood and drawers of 
 water', but hkely to 
 benefit from special in- 
 struction. 
 
 * The numerical representation here given is for purposes of definition 
 and of comparison. The Table indicates that the difference between the 
 
166 MEDICAL INSPECTION OF SCHOOLS 
 
 A complete medical examination of this nature 
 cannot occupy, on an average, less than four or five 
 minutes for each child, and if the mental capacities 
 of more than one or two of the children have to be 
 tested, it will be impossible for more than eighteen or 
 twenty children to be seen during a session of two 
 hours. Otherwise apart from any estimates of mental 
 capacity it should be possible to examine thirty 
 children in the same time. 
 
 As a result of each individual examination, the 
 doctor fills up a health certificate or schedule, and 
 issues any necessary instructions both to the teacher 
 and to the parent. The child's schedule is passed on 
 from class to class or from school to school, and is 
 kept for future reference in the actual classroom in 
 which the child is working. Those children who 
 require more frequent supervision should be given 
 a different coloured card marked * under supervision '. 
 The card recommended by the Board of Education is 
 too complicated for ordinary use ; it serves the useful 
 purpose of reminding the doctor that nothing should 
 be forgotten. The issue of a uniform card is desirable, 
 but there should be no crowding of details, and room 
 should be left for notes and additions. Simplicity is 
 essential. There is no need to include many details as 
 to family or previous medical history. A convenient 
 form of card is given on pp. 167-80. 
 
 various grades of mental deficiency and of natural dullness is sometimes 
 very slight, whereas the difference between the average child, the bright 
 child and the highly intelligent child is more marked. 
 
THE SCHOOL DOCTOR : HIS METHODS 167 
 
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THE SCHOOL DOCTOR : HIS METHODS 169 
 
 With regard to other methods in connexion with the 
 additional duties of a school doctor, there is not much 
 to say.^ The weekly or fortnightly visits to each 
 school would be to help the school nurse in the diag- 
 nosis of difficult cases, or for the doctor to examine 
 any children to whom the head teacher wished to 
 direct his attention, such as cases of sore throat, or to 
 see any special cases which were under observation, 
 and to consult and to co-operate with the head 
 teacher as to the school routine and curriculum. 
 This visit should be a regular weekly or fortnightly 
 fixture at each school and at this time the teacher 
 should secure the attendance of any doubtful cases 
 of exclusion during outbreaks of scarlet fever or 
 diphtheria. 
 
 The annual or terminal visit to each class would be 
 a more searching affair, and here there would be 
 ample opportunity for the school doctor to show his 
 special qualities. As far as possible these visits should 
 be unexpected. Children and teachers should be taken 
 by surprise. The doctor would first of all ask for the 
 cards belonging to those children who were under 
 supervision. Immediately on entry he would observe 
 how the children were seated, and how they were 
 working ; he would note the condition of ventilation, 
 heating and lighting and would ask the teachers if 
 
 ^ Various other points are considered in Chapter XIII. The methods 
 of the school doctor with regard to infectious disease in school are 
 dealt with in Chapter XVI (6) under 'Sore Throat'. Methods of 
 research in school hygiene must be left to the individuality of the school 
 doctor. 
 
170 MEDICAL INSPECTION OF SCHOOLS 
 
 they had any complaints to make. He would study 
 the time-table and take note of the amount of play 
 and physical exercises. He would put the children 
 through their breathing and other exercises, and if 
 necessary would demand a handkerchief parade. He 
 would examine the children as to cleanliness and ask 
 about the cleansing of teeth. He would discover the 
 presence of headaches, of aching and watering eyes. 
 For instance, he should question the children as to 
 their reading badly-printed books in dark corners 
 or by the firelight at home. He might investigate 
 their knowledge of the elements of physiology or 
 hygiene. 
 
 In the case of younger girls he might select those 
 with close-cropped hair and commend them to the 
 notice of other children. Such an informal action 
 upon the part of the doctor sometimes has the desired 
 effect of inducing the younger girls, affected with 
 verminous heads, to obtain their parents' consent 
 to the cutting of their hair. His methods and 
 his conduct would naturally be adapted to the age 
 and sex of the children. He would congratulate 
 the teacher on the brightness and intelligence of 
 the children ; or would offer suggestions for improve- 
 ments. All these simple manifestations of interest 
 in the children's life conditions, whether at home 
 or at school, are part of the work of the school 
 doctor, and during these visits there is need for the 
 expression of the various qualities of sympathy and 
 tact, which were set out above as requisite for the 
 
THE SCHOOL DOCTOR : HIS METHODS 171 
 
 ideal school doctor. In this and in many other ways, 
 the school doctor can make his visit to the classroom 
 of great educational and hygienic value, of interest and 
 stimulation to the teacher, as well as an hour of 
 pleasure and happiness to the children. 
 
CHAPTER XII 
 THE SCHOOL NURSE 
 
 School Nurse a New Idea. — Not a ' Nurse' but an Education Officer. — 
 Her Evolution. — Daily Visits. — Want of Guiding Principles. — Pioneer 
 Work in London. — Examples from Cambridge and Wimbledon. — Her 
 Work (1) at the School ; (2) at the Home. — Summary of Duties. — 
 School Nm-se as Attendance Officer. — Her Qualifications. — General 
 and Special Training. — District Work Essential. — Her Personality. — 
 Methods and Routine. — Examination for Vermin, Ringworm, &c. — 
 Extension of Work. — Co-operation with Teachers. 
 
 The school nurse represents as new an idea in the 
 school world as the~school doctor. She is not a nurse 
 in the usual acceptation of the term, but a woman who 
 has had the scientific training of a nurse. On the 
 other hand she is not merely a sanitary inspector or 
 a health visitor. She is an Education Officer employed 
 by an educational authority for certain^routine medical 
 duties in connexion with education. As in the hospital, 
 so in the schooLshe is the doctor's assistant, and works 
 under his direction. 
 
 History 
 
 The evolution of the school nurse is interest- 
 ing. Soon after the institution of Queen Victoria's 
 Jubilee Nursing Association in 1887, nurses began, 
 in certain areas, to visit a few schools almost daily 
 
THE SCHOOL NURSE 173 
 
 for the purpose of ' attending to minor injuries and 
 complaints, following serious or potentially serious 
 cases to their homes and insisting on the children 
 being taken to a doctor '. In one or two populous 
 centres this beginning was followed by extensive 
 developments, but the school nursing service was 
 maintained quite independently of, and unsupple- 
 mented by, any school medical service. 
 
 The report of the Interdepartmental Committee 
 on Medical Inspection of children attending public 
 elementary schools, 1905, says : — 
 
 ' In Liverpool and Birmingham the nurses visit the 
 schools and attend to cases of cuts, small sores, and 
 other petty ailments ; they also, where necessary, 
 visit the homes and instruct the parents as to the daily 
 treatment of children. In Liverpool twenty-one schools 
 were visited, and over 50,000 dressings have been done 
 in the course of the last year. In Birmingham, there 
 have been in four schools over 20,000 dressings in 
 twelve months. It has been found best in these 
 cases that the nurses should only work part time at 
 their school duties, devoting the rest of their time to 
 district nursing. Mr. Williamson, of Liverpool, who 
 gave evidence as to the work done in the schools by 
 the Queen's Nurses throughout the country, said that 
 this was considered the most satisfactory arrangement 
 as school nursing was liable to become monotonous if 
 the nurse did nothing else ; the combination of duties 
 permits her to follow up cases she has seen in school, 
 and enables her to be employed at times when the 
 school is closed. In Fulham, Kensington and other 
 districts of London the Queen's Nurses have visited 
 schools and treated children ; but this has been done 
 independently of the local authority and the nurses 
 appointed by them.' 
 
174 MEDICAL INSPECTION OF SCHOOLS 
 
 At Barry, Widnes, and other places similar work was 
 undertaken ; while at Reading a nurse was employed 
 by the local authority to attend to the heads of vermin- 
 ous children. A somewhat different scheme was 
 adopted at Wimbledon. The school nurse helped the 
 doctor with his work in the school, but undertook no 
 treatment herself at school. At the request of teacher 
 or doctor, however, she visited the homes to offer her 
 services, but always acted under the direction of the 
 medical attendant. She also visited and treated cases 
 at the request of parents. 
 
 So far, however, the work of the school nurse was 
 chiefly the outcome of voluntary effort. The result 
 was that there was not only an absence of any definite 
 guiding principle, but also a want of general finality 
 and completeness in the work. 
 
 The first school nurses in the newer sense of the 
 term were appointed in 1901 by the London School 
 Board. In contradistinction to the vagueness of their 
 functions in the past, definite duties were at once 
 assigned to the nurses. The duties, however, differed 
 essentially from those that have been indicated, in 
 being purely inspectorial and advisory. They were 
 not required to treat cases, but were employed for the 
 systematic detection among school children of uncleanly 
 and verminous conditions. One of their earliest and 
 most important duties was to examine children sys- 
 tematically for ringworm, and to send specimens of 
 hair from suspected cases for microscopic investigation 
 by the medical officer. They were also expected, from 
 
THE SCHOOL NURSE 175 
 
 the first, to advise teachers about difficult and doubtful 
 cases, especially regarding the exclusion of children 
 suspected to be sufiering from infectious or contagious 
 diseases. 
 
 Only in the event of gross neglect or ignorance 
 on the part of parents were the nurses required to 
 follow the children to their homes and to advise the 
 parents. Their original powers for the exclusion of 
 verminous children were severely restricted. They 
 were not allowed to exclude cases for prosecution except 
 on the authority of the school doctor. A definite 
 school district was assigned to each nurse ; and she 
 was instructed to visit systematically under the 
 direction of the educational medical officer all the 
 schools in her district. Each nurse was warned to 
 pay due regard in her work to the necessity for exer- 
 cising discretion and tact in dealing with teachers, 
 parents and children, and to cause as little disturbance 
 as possible of school routine. A similar scheme on 
 a smaller scale was undertaken in Brighton. 
 
 The value of the nurse's services in school work was 
 speedily recognized. So much so that, in 1906, a fully 
 trained nurse, with considerable experience of district 
 work, was appointed at Cambridge to assist the medical 
 officer of health in his duties in the schools. She has 
 proved useful in verifying the teacher's provisional 
 diagnosis of suspected cases of infectious disease as 
 well as of skin affections and of acute eye diseases. 
 'The medical officer of health takes action on her 
 reports ; and, when there is doubt, visits cases himself. 
 
176 MEDICAL INSPECTION OF SCHOOLS 
 
 The nurse visits cases weekly and in some ringworm 
 cases applies ointments as treatment. Before issuing 
 a return certificate, the nurse visits the child and, if 
 necessary, takes material for examination at the 
 Public Health Office. She also tests vision, colour 
 vision, and hearing during the medical inspection of 
 schools, thereby economizing the time of the medical 
 officer of health enormously.'^ 
 
 Although, as is often urged, it may be scarcely 
 desirable that nurses should thus be appointed to 
 usurp the functions of a school doctor, at the same 
 time this report of Dr. Duncan Forbes bears striking 
 testimony to the invaluable work which an efficient 
 nurse can perform in the schools. 
 
 Dr. Hayward, of Wimbledon, has lately extended 
 his original scheme and has suggested ^ that the work 
 of a school nurse lies in two directions. 
 
 1. At the School, where her duties fall into two 
 categories. She can help the doctor in his routine 
 work of medical inspection by writing notes and 
 instructions to parents, by undertaking examination, 
 especially of the girls, as to verminous and uncleanly 
 conditions, and by affording information to the doctor 
 as to home conditions. She would also be ready to 
 receive verbal instructions from the doctor as to the 
 
 ^ ' The work of the School Nurse under the Medical Officer of Health,' 
 by Dr. Duncan Forbes, Transactions Second International Congress of 
 School Hygiene (1907), vol. ii, p. 475. 
 
 2 ' Co-operation of Doctor, Teacher and Nurse in Medical Inspection.' 
 Transactions of Second International Congress of School Hygiene (1907), 
 vol. ii, p. 47.'?. 
 
THE SCHOOL NURSE 177 
 
 needs and future care of individual children. Secondly, 
 it would be her duty to visit each classroom once 
 a week to help the teachers by advice, to make notes 
 in the medical register, to inspect the children as to 
 uncleanliness or other obvious defects and to arrange 
 for home visiting. She should report personally to the 
 doctor the results of her weekly visits, thereby keeping 
 him in touch with the schools in the intervals between 
 his visits of inspection. 
 
 2. At the Home, where, by means of a personal 
 interview, the nurse can emphasize the importance of 
 the doctor's advice, and can demonstrate to the parents 
 the methods of carrying out the treatment of minor 
 ailments and verminous conditions. Her visit, there- 
 fore, becomes an important factor in the education 
 of parents. At the same time * she gains an insight 
 into the home conditions, and can acquire much useful 
 information in particular cases as regards the medical 
 history of a child '. 
 
 Such a scheme forms an admirable model for any 
 small town or urban district. 
 
 In London, which was the first city in any country 
 to establish a school nursing service, the scope of 
 the nurse's duties has recently been enlarged. But 
 the number of schools to be visited and the number 
 of children requiring attention have been so enormous 
 that development has, for the most part, been confined 
 to working out broad general principles. Regular 
 systematic visiting of the schools has been slowly 
 introduced and developed until the head teachers 
 
 HOGARTH jj 
 
178 MEDICAL INSPECTION OF SCHOOLS 
 
 have gradually come to place reliance upon the nurses' 
 work ; and their visits are duly appreciated. At the 
 same time much detailed work has been undertaken 
 in a certain proportion of the schools. In 1907 a super- 
 intendent of nurses was appointed and more recently 
 two assistant superintendents ; and at the present 
 time there is a staff of fifty nurses working in the 
 schools. Their routine duties as to inspection for 
 ringworm and verminous conditions is dealt with in 
 tlie chapter upon administrative routine, and the 
 general principles of their work have already been 
 indicated. 
 
 Duties 
 
 The duties of a school nurse in any large town may 
 be summarized thus : — 
 
 1. To assist the local school doctor at his examina- 
 tions in the schools and to carry out his instructions. 
 
 2. To keep records of progress of individual children 
 between the doctor's visits, making special notes as to 
 what treatment has been obtained. 
 
 3. To hold a preliminary examination of all babies 
 and infants on their first admission to nursery schools 
 or infants' departments as to cleanliness and obvious 
 defects. 
 
 4. To be responsible for the supervision of personal 
 hygiene and cleanliness of all children under the 
 direction of a superintendent of nurses. 
 
 5. To recognize ringworm, favus, scabies and other 
 contagious conditions. 
 
THE SCHOOL NURSE 179 
 
 6. To recognize discharging ears and the commoner 
 external eye diseases, such as corneal ulceration, con- 
 junctivitis, ophthalmia, &c. 
 
 7. To pay regular weekly visits to the schools for 
 these purposes and for advising teachers in regard to 
 the exclusion of doubtful cases of infectious and 
 contagious diseases. 
 
 8. To weigh and take the height and chest measure- 
 ments of children where any system of anthropometry 
 is introduced or to help the teacher in so doing. 
 
 In addition to these specified duties, occasion for 
 home visiting will necessarily arise in the course of 
 a school nurse's work. At the present time it is im- 
 practicable to organize any adequate or satisfactory 
 scheme of home visiting in the populous districts of 
 large towns,^ especially as the scheme would involve 
 enormous expenditure. But the desirability of grad- 
 ually replacing school attendance officers by school 
 nurses has often been suggested, and in process of time 
 the suggestion may eventually be adopted. 
 
 Furthermore, there must be a nurse attached to 
 the stafif of each special school for physically de- 
 fective and debilitated children as well as of each 
 open-air school. In this work her training as a hospital 
 nurse is indispensable ; for she is required to take 
 charge of the crippled, delicate and ailing children 
 between the doctor's visits. She is responsible for 
 their proper conveyance in the ambulance to and 
 
 ^ Cf. chap. V, p. 68, where the inadequacy of any system of home 
 visiting is indicated. 
 
 n2 
 
180 MEDICAL INSPECTION OF SCHOOLS 
 
 from the school. She must also be adequately trained 
 in the principles and practice of physical education, 
 so that, besides helping the teacher to conduct special 
 physical exercises applicable to children suffering from 
 deformities, paralysis or heart disease, she may herself 
 be qualified to undertake courses of massage and of 
 remedial exercises for individual children. 
 
 Finally, if any system of treatment is undertaken by 
 local education authorities, such as the establishment 
 of school clinics for the treatment of the more chronic 
 diseases of childhood, there will be further opportunity 
 for extending her sphere of activity. 
 
 Briefly, then, the work of the school nurse has now 
 become so comprehensive that the time for vague 
 generalities is past. In small towns and in rural areas 
 Education Committees will be able to employ the 
 part-time services of district nurses ; and with this 
 idea in view. County Nursing Associations should be 
 properly organized in every county area, partly for 
 the more efficient conduct of midwifery and general 
 nursing and partly for the adequate development of 
 medical inspection of schools. But in the populous 
 centres and in large urban districts a school nurse's 
 sphere of activity is so wide, and her work so difficult, 
 that she must devote her whole time to her school 
 duties. Nor is there any real monotony in the work. 
 
 In any case, the school nurse is definitely an educa- 
 tion officer, and not merely a district nurse or health 
 visitor employed in the schools. Her first instinct 
 
THE SCHOOL NURSE 181 
 
 and duty must be to promote the efficiency of school 
 routine by increasing the attendance and improving 
 the health of the children as well as by advising the 
 teachers on difficult questions. At the same time her 
 work should be directed towards the education of the 
 children in the principles of cleanliness and of healthy 
 living. She should be interested in the simpler pro- 
 blems of school hygiene and should call the attention 
 of the teachers and children to the necessity of open 
 windows, to the harmfulness of wet clothes and boots 
 and to other similar matters. Incidentally she should 
 take notice of all sickly and ailing children and 
 should endeavour, when necessary, to get medical 
 assistance. Sometimes she may be able to obtain the 
 help of voluntary societies for the purpose of sending 
 a child to hospital or into the country. By these and 
 similar methods she may hope to train the parents, 
 through their children, to aim at a higher standard of 
 health and comfort in the homes. 
 
 On the other hand, the school nurse should not be 
 allowed, as part of her ordinary routine, to attend to 
 sores and bruises, or to bind up cut fingers and chil- 
 blains. Thereby is introduced a scheme which, although 
 at one time advocated by the Board of Education, has 
 been characterized by the British Medical Association 
 as embodying an unsound principle. For any such 
 system tends to waste time, to appeal to benevolent 
 sentimentality, and to undermine parental responsi- 
 bility. 
 
182 MEDICAL INSPECTION OF SCHOOLS 
 
 Qualifications 
 
 For the efficient discharge of these duties the 
 school nurse must have had general and special 
 training and be possessed of certain personal quali- 
 fications. Her general training should have been 
 adequate, consisting, for instance, of three years' work 
 in a large general hospital of not less than 100 beds, 
 or in an infirmary authorised as a training school 
 by the Local Government Board. A period of this 
 hospital training should have been specially devoted 
 either to out-patient work, or to duty in a special 
 department for skin diseases or for orthopaedics. In 
 addition to this general training she requires special 
 training for the further period of at least one year. 
 Six months should be spent in the wards and out- 
 patients' department of a children's hospital, and for 
 three months she should attend the practice of a 
 hospital for skin diseases, and another three months 
 should be devoted to the study of infectious diseases. 
 
 After such a systematic course of training a nurse 
 should be capable of undertaking school duties. But 
 much would be gained if her appointment were 
 postponed until she had devoted a year or two to 
 district work. Later there is little doubt that this 
 part of her training will come to be regarded as the 
 most essential qualification, because it tends to widen 
 her outlook and to develop all the best womanly 
 qualities in contradistinction to the somewhat narrow 
 
THE SCHOOL NURSE 183 
 
 and restricted life of a hospital nurse. Her work will 
 often be harassing and troublesome. Consequently 
 she should be gifted with a large share of human 
 sympathy and true kindliness of heart, combined with 
 good humour and firmness of temper. Her powers of 
 observation should be especially cultivated, for she 
 is brought into touch with a new sphere of life. Above 
 all, tact, personality and strength of character are 
 greatly needed in a school nurse, required as she is to 
 work in co-operation with the school doctor, teachers, 
 children, parents, school managers, attendance officers, 
 the medical officer of health, sanitary inspectors, 
 women health visitors, and district nurses. 
 
 Methods and Routine 
 
 There is no need to discuss the methods or routine 
 of the school nurse in a country district, seeing that 
 the school work will have to be fitted in with other 
 duties. Experience alone will decide the best method 
 
 of procedure. 
 
 In towns a school nurse should visit each school in 
 her district at least once a week and should pay 
 a special visit to each classroom once a month for 
 the purpose of keeping in touch with the teachers 
 and for seeing the children who are * under super- 
 vision ' and for other general duties. 
 
 For carrying out her examination as to the cleanliness 
 and personal hygiene of the children, each nurse ought 
 to carry a bag containing a metal comb, a pointed 
 
184 MEDICAL INSPECTION OF SCHOOLS 
 
 glass rod, ringworm forceps and spirit lamp, as well 
 as permanganate of potash crystals and corrosive 
 sublimate tabloids as disinfectants. For the examina- 
 tion of verminous conditions of the head, she may 
 separate the hair with her metal comb or glass rod, 
 which should be dipped into the disinfectant lotion 
 between each examination. This is rather a tedious 
 and unsatisfactory process, and it is generally pre- 
 ferable for the nurse to use her fingers. There is no 
 occasion for her to wash or disinfect her hands between 
 the examination of each child, as the risk of trans- 
 ferring vermin is more imaginary than real. 
 
 When, in the course of such an examination, the 
 nurse discovers a case of ringworm or of suspicious 
 scurfiness or scaling of the head, she should place the 
 child on one side for later examination. She should 
 thoroughly disinfect her comb or glass rod or, as the 
 case may be, wash her hands with soap and water, 
 before proceeding to the next child. After removing 
 stumps of hair in suspected ringworm cases, the forceps 
 must be sterilized in the flame of the spirit lamp. 
 By such precautions as these any danger of transferring 
 infection from one child to another is prevented. 
 
 In the conduct of this ordinary routine work there 
 is no need for privacy. Each child should be examined 
 in its turn either in the classroom or in the hall, unless 
 special accommodation is provided. Objections to 
 this routine examination of children in front of their 
 classmates is raised only by unreasonable parents or 
 by those whose pride has been wounded. Generally 
 
THE SCHOOL NURSE 185 
 
 speaking, parental pride is more affected by the 
 discovery and tacit exposure of the children's unclean- 
 liness than by the fact itself ; and such parents are 
 disinclined to take any remedial or preventive measures 
 unless their neglect is exposed. ^ 
 
 With regard to the examination of the more un- 
 cleanly children for verminous conditions of body and 
 clothes, some privacy may be necessary. Arrangements 
 for the inspection of such cases must be left to the 
 judgment of the head teacher and nurse. 
 
 Miss Pearse, the superintendent of nurses in London, 
 has recently discovered that verminous conditions of 
 bodies and clothes are more prevalent in the dirtiest 
 schools than is commonly supposed. For instance, she 
 reports as a result of cursory examination, ' that at one 
 school she found 12 out of 55 boys in one class, 10 out 
 of 60 girls and 8 out of 54 infants with verminous 
 clothes ; while in another school there were 43 boys out 
 of 135 in a similar condition. These proportions are 
 fortunately characteristic only of the dirtier schools, 
 but of these there are very many '. 
 
 For the examination of children suffering from sore 
 eyes, discharging ears, skin affections and other simple 
 ailments the nurse should adopt the ordinary clinical 
 methods of inspection. No exact diagnosis is required. 
 But a nurse must be able to recognize the simpler 
 diseases and should know when a child needs medical 
 advice or treatment. She must also be acquainted 
 with the conditions which demand exclusion from 
 
 ^ See footnote, p. 294. 
 
186 MEDICAL INSPECTION OF SCHOOLS 
 
 school so that her advice to the head teacher may be 
 reliable. In the case of infectious and contagious 
 conditions she must advise the immediate exclusion of 
 children in the interests of other children ; and in the 
 absence of medical advice she must be prepared, in 
 cases of obvious overpressure or of commencing 
 chorea to advise temporary exclusion until a medical 
 opinion can be obtained. 
 
 The functions of a school nurse are likely to be ex- 
 tended in many directions ; but, if the teachers are not 
 in harmony with the work, difficulties will inevitably 
 arise. Experience in London, however, has shown 
 that the majority of teachers, so far from objecting to 
 the nurse, have constantly asked for more frequent 
 visits, and have, from the first, taken a pride and 
 interest in the cleanly condition of the children attend- 
 ing their schools. Such co-operation is essential for 
 a satisfactory and efficient school nursing service. 
 
CHAPTER XIII 
 
 ADMINISTRATIVE ROUTINE 
 
 Distinction between Medical Inspection and School Hygiene Artificial. — 
 Routine in London. — General Medical Supervision. — Medical Register 
 in Schools. — Vision Testing. — Regulations as to Infectious Disease. — 
 Scarlet Fever. — Diphtheria. — Measles. — Cleansing Schemes. — Routine of 
 Special Schools. — Medical Certificates. — Scholarship Candidates. — 
 Secondary Schools. — Annual Reports. — ' Medical Room.' 
 
 It is impracticable, and indeed almost superfluous 
 at the present time, to give any account of the adminis- 
 trative routine of medical inspection of schools necessary 
 under the Education (Administrative Provisions) Act, 
 1907. The requirements of the Act and the regulations 
 of the Board of Education have tended to make an 
 artificial distinction, where none should exist, between 
 medical inspection and school hygiene. The result is 
 that, until the fundamental principles of school hygiene 
 have been fully grasped, there is little opportunity for 
 the application of any general system of administrative 
 routine. 
 
 For the time being each local education authority 
 will necessarily make its own administrative arrange- 
 ments in accordance with local conditions and local re- 
 quirements. The routine will differ widely according 
 to the area and according to the particular system of 
 inspection that is adopted. The present chapter, how- 
 
188 MEDICAL INSPECTION OF SCHOOLS 
 
 ever, aims at giving a few general notes upon the 
 administrative routine applicable to large towns — say, 
 with more than 100,000 inhabitants — in which the 
 school medical service is co-ordinated with, not sub- 
 ordinated to, the sanitary service. These notes are 
 modelled upon the scheme which has been in force, 
 since 1902, in London ,i where the main object has been 
 gradually to develop the whole field of school hygiene 
 rather than to devote much time to the systematic 
 and routine examination of large numbers of children. 
 The latter course would have been impracticable with- 
 out an enormous staff of school doctors, and is even, 
 at the present time, of little value until some special 
 provision has been made for the treatment of defective 
 
 children. 
 
 General Medical Inspection. Each school doctor 
 has a certain district allotted to him and is expected 
 to make a systematic visit to each department of every 
 school in his district once in three months. Before 
 making this visit he sends a notice to the head teacher 
 stating that he will visit the department three days 
 hence and asking that the names of all children known 
 to present any conditions likely to affect seriously their 
 education or future life be placed upon a suitable form 
 (No. 21).2 When the doctor visits the school, he deals 
 
 1 The author is indebted to Mr. E. Greer, chief clerk in the Medical 
 Officer's Department of the London County Council (Education Com- 
 mittee), for invaluable help and co-operation in the preparation of this 
 chapter. 
 
 2 This and similar numbers in the text refer to the forms and 
 schedules in Appendix III, p. 330-7. 
 
ADMINISTRATIVE ROUTINE 189 
 
 first with this list of children, makes notes in the column 
 provided for this purpose, and advises the head teacher 
 in special cases. The doctor then goes round the classes 
 and notes any children with external eye diseases, 
 squints, nose and throat affections (enlarged tonsils, 
 adenoids, mouth-breathers, &c.), impetigo, discharging 
 ears, excessive dirt, or other defects. He then turns 
 his attention to the items set out on the form used for 
 his report to the chief medical officer (Education) ; 
 he notes the number present, number examined, the 
 general arrangement of the school (environment, &c.), 
 the general conditions of the school (window and 
 artificial lighting, heating, ventilation, sanitation, 
 desking, &c.) ; the hygiene of school work (hours of 
 work, modes of work, reading, writing, drawing, manual 
 work, recreation, exercise, &c.). After the examina- 
 tion, his report is completed and forw^arded to the 
 head office, where the general conditions of the school 
 are tabulated on a card (No. 62) and the various officers 
 (e. g. architect, supply officer) informed of any defec- 
 tive conditions which require to be remedied. 
 
 The records of all school work should be kept as far 
 as possible on cards, as they are so much more easily 
 handled for statistical purposes in regard to any 
 particular subject. A corner is cut off each card, so 
 that when they are sorted with the cut corners in one 
 direction the same side of all cards is uppermost.^ 
 
 Medical Register. In each department a medical 
 register is kept. This register affords ready means of 
 
 ^ See schedule, chap, xi, p. 167. 
 
190 MEDICAL INSPECTION OF SCHOOLS 
 
 communication between the medical officer (Education) 
 and the managers of the school. The school doctor 
 makes notes in one column of this register in regard to 
 any school conditions, or to the condition of individual 
 children, in which the managers could assist in having 
 rectified. The school nurse is also allowed to enter 
 the names of neglected children where the managers 
 might have them relieved. The managers make 
 notes in the second column and the head teacher 
 states in the third column what action is ultimately 
 taken. This register is submitted to the managers at 
 all their meetings. 
 
 Vision Test. The vision testing is not done at the 
 time of ordinary inspection, but in the summer when 
 there is a good light. The preliminary test is made by 
 the teachers. A communication is addressed to each 
 head teacher asking him to test the vision of the 
 children in his department in accordance with the 
 instructions set out in Article 110 of his Code. The 
 instructions are briefly these : — 
 
 A large test card is fastened to the wall in a good 
 light so that the bottom line is about the level of the 
 child's eyes. The distance of 20 feet ( 6 metres) measured 
 from it on the floor and marked in chalk with a cross 
 gives the distance at which the child to be tested 
 should stand. 
 
 Children having good vision should be able to read 
 the test letters in the bottom row, marked on the 
 card D = 6. If they fail, they should be called upon 
 to read the letters in the second line from the bottom, 
 marked D = 9. Children who cannot read the letters 
 in either of these lines should be requested to read the 
 
ADMINISTRATIVE ROUTINE 191 
 
 letters, beginning from the top of the card, and going 
 downwards until they reach a line they are unable to 
 read. The lowest line read gives the measure of visual 
 acuity. 
 
 Only the names of children in Standards I, II, III, 
 and IV, whose vision is 18 or worse, and of children 
 in Standard V and above, whose vision is 12 or worse, 
 should appear on the teacher's return. 
 
 Each child tested should have the number (6, 9, 12, 
 18, 24, &c.) expressing his visual acuity noted in the 
 column provided for the purpose in the attendance 
 register. 
 
 Children wearing spectacles should be regarded as 
 having the vision they attain when wearing their 
 glasses. 
 
 A supply of forms is forwarded on which the names 
 of all children with defective vision are placed, together 
 with their standard and age. 
 
 Directly the vision test has been completed, this 
 return of children with defective vision should be for- 
 warded to the medical officer (Education). 
 
 The lists are returned to the head office, where a 
 summary form is attached, and these are then sent to 
 the school doctor. The doctor, after due notice to the 
 teacher, visits the school and examines all the children 
 returned by the head teacher and selects those who 
 require further attention or treatment. For each of 
 the children thus selected he gives to the head teacher 
 a red or green card, according to the seriousness 
 of the defect. On the cards are printed instructions 
 and warning to parents and guardians. The head 
 teacher distributes a certain number of these cards 
 each week with a view to limiting the number of 
 children that attend hospital at one time. The presen- 
 
192 MEDICAL INSPECTION OF SCHOOLS 
 
 tation of these cards at a hospital or to an ophthalmic 
 surgeon signifies that the children have been seen by 
 a qualified practitioner. 
 
 The doctor completes the summary form, which 
 affords a comparison between the number of defects 
 reported by the teacher and those selected by the 
 doctor. At the same time he reports on any matter 
 specially affecting the children's vision, and forwards 
 his report to the head office. On receipt of this return, 
 the attention of the medical officer is drawn to any 
 excessive defect of vision, and any conditions affecting 
 the children's vision are made the subject of special 
 investigation. 
 
 As many parents could not afford to purchase the 
 glasses which were prescribed by hospital authorities, 
 an association was formed for obtaining glasses for 
 school children at wholesale prices. Each head teacher 
 is supplied with a copy of the association's circular 
 with a view to his co-operation in the scheme. The 
 association almost immediately effected a great reduc- 
 tion in the price of spectacles as supplied at the hospitals 
 by the leading opticians. 
 
 Infectious Diseases. The Public Health (London) 
 Act, 1891, requires that, so soon as it becomes known 
 that an inmate of a house is suffering from an infectious 
 disease, the medical attendant shall forthwith send 
 a certificate to the medical officer of health for the 
 district ; and, if the patient attends school, or is 
 resident in a house in which there are school children, 
 the medical officer of health is required to forward 
 
ADMINISTRATIVE ROUTINE 
 
 193 
 
 a copy of the certificate to the head teacher of the 
 school concerned within twelve hours. 
 
 The head teacher of the school then acts in accordance 
 with instructions set out in Article 1 1 1 of his Code. 
 
 SUMMARY OF REGULATIONS AS TO EXCLUSION OF 
 CHILDREN FROM SCHOOL FOR INFECTIOUS DISEASES. 
 
 Disease. 
 
 Diphtheria. 
 
 Scarlet Fever. 
 
 Erysipelas and 
 Typhoid Fever. 
 
 Measles. 
 
 Exclusion of children 
 suffering from the disease. 
 
 (1) If the case treated at 
 home until a medical 
 certificate based upon 
 bacteriological exam- 
 ination is furnished. 
 
 (2) Until a fortnight 
 after date of discharge 
 from hospital. 
 
 (1) If the case is treated 
 at home until the 
 medical attendant 
 certifies. 
 
 (2) Until a fortnight 
 after date of discharge 
 from hospital. 
 
 (1) If treated at home 
 until the medical 
 attendant certifies. 
 
 (2) Until after dis- 
 charge from hospital. 
 
 At least one month. 
 
 Exclusion of children 
 
 living in houses where 
 
 the disease exists. 
 
 Until 7 days shall have 
 elapsed after the date 
 of the certificate from 
 the medical officer of 
 health that the house 
 is free from infection. 
 In the event of the 
 head teacher not re- 
 ceiving the certificate, 
 it becomes his duty to 
 send to the offices of 
 the local sanitary au- 
 thority, in order that 
 he may procure it. 
 
 Not to be excluded. At- 
 tendance not enforced 
 if medical officer of 
 health specifically orders 
 exclusion. 
 
 Infants. — To be excluded 
 until Monday following 
 14 days from occurrence 
 of last case. 
 
 Seniors. — If child has had 
 the disease, not to be 
 excluded. If child has 
 not had the disease, 
 exclude until Monday 
 following 14 days from 
 occurrence of first case. 
 
 HOGABTH 
 
 o 
 
194 MEDICAL INSPECTION OF SCHOOLS 
 
 Disease. 
 
 Exclusion of children 
 
 Exclusion of children 
 living in houses where 
 
 
 suffering from the disease. 
 
 the disease exists. 
 
 Whooping-cough 
 
 As long as the cough 
 
 Infants. — All infants to be 
 
 
 continues, but not to 
 
 excluded 2 weeks. 
 
 
 be re-admitted until 
 
 Seniors. — If child has had 
 
 
 at least 5 weeks from 
 
 the disease, not to be 
 
 
 the commencement 
 
 excluded. Otherwise, ex- 
 
 
 of whooping. 
 
 clude 2 weeks. 
 
 Mumps. 
 
 One month. 
 
 Infants. — All infants to be 
 excluded for such time 
 as medical attendant 
 considers necessary. If 
 no medical attendant for 
 3 weeks. 
 
 Seniors. — If child has had 
 the disease, not to be 
 excluded. If child has 
 not had the disease, 
 exclude for the same 
 period as infants. 
 
 Chicken- Pox. 
 
 Two weeks, or until 
 
 Infants. — All infants to be 
 
 
 every scab is off scalp 
 
 excluded 2 weeks. 
 
 
 and body. 
 
 Seniors. — If child has [had 
 the disease, not to be 
 excluded. If child has 
 not had the disease, ex- 
 clude 2 weeks. 
 
 Ringworm, 
 
 Until medical certificate 
 
 Not to be excluded. 
 
 Favus, 
 
 is obtained that the 
 
 
 Ophthalmia 
 
 child is cured. Wher- 
 
 
 (BUght), 
 
 ever certificates are 
 
 
 Trachoma, 
 
 not readily procur- 
 
 
 Scabies (Itch). 
 
 able, teachers to exer- 
 cise their discretion 
 as to re-admission, 
 and, if in doubt, ask 
 school nurse. 
 
 
 Consumption. 
 
 Exclude if the disease 
 is accompanied by 
 coughing or spitting. 
 
 Not to be excluded. 
 
 Note. — If a medical attendant or the medical officer of health should 
 certify, in any special case, that periods of exclusion should be extended, 
 teachers are to observe their instructions and to communicate at once 
 with the medical officer (Education). 
 
ADMINISTRATIVE ROUTINE 195 
 
 On receipt of the notification from the medical 
 officer of health, the head master notes the informa- 
 tion and sends the notification to the other head 
 teachers. Each head teacher concerned then sends 
 a copy of a form to the medical officer (Educa- 
 tion) and to the divisional superintendent, giving 
 particulars of all children in the school coming from 
 the same house. 
 
 In the cases of non-notifiable diseases the first 
 information is generally obtained from the head teacher. 
 As soon as the head teacher receives information that 
 a child is suffering from a non-notifiable disease, or 
 comes from a home in which such a disease exists, he 
 forwards full particulars on a convenient form, not only 
 to the medical officer (Education) and divisional super- 
 intendent, but also to the medical officer of health 
 for the district. When these forms are received at the 
 head office, they are at once entered in a register, 
 a folio of which is devoted to each school. On this 
 folio are noted the name of the school, the electoral 
 area, the sanitary district, the departments of the 
 schools, and day by day the number of cases of the 
 principal diseases affecting school life. When the cases 
 have been entered in this register, each of the diseases 
 receives different treatment. 
 
 Scarlet Pever. When a significant recurrence of 
 cases suggesting the possibility of school infection is 
 noticed, the cases are tabulated on a special form/ 
 according to their class distribution. In this way the 
 
 ^ See Appendix III, p. 333, Form No. 4. 
 
 o 2 
 
196 MEDICAL INSPECTION OF SCHOOLS 
 
 medical officer (Education) is generally able, from 
 his special knowledge of school dissemination, to 
 locate the source of infection and to take action 
 either by investigation at the school or by class 
 closure. 
 
 When two or more cases have occurred in one class- 
 room within a period of three weeks, or when one child, 
 who subsequently develops scarlet fever, has shown 
 definite symptoms of indisposition in school, a special 
 communication is sent to the head teacher instructing 
 him to keep a list of absentees from the affected class- 
 room, and to make careful inquiry on their return as 
 to sore throats. He is also instructed to regard any 
 variety of sore throat with great suspicion. By these 
 means, the possibility for mild and unrecognized cases 
 being allowed to remain in school is reduced to a mini- 
 mum. All cases which are excluded from school on 
 suspicion are immediately reported to the medical 
 officer of health for his information, and in this way 
 he is enabled to discover missed cases. If, however, 
 there is a continued occurrence of cases in one or two 
 classrooms, an assistant medical officer is sent to make 
 a special investigation at the school in accordance with 
 a definite procedure, and he is generally able, without 
 much difficulty, to discover the source of infection and 
 to prevent unnecessary closure of the affected class- 
 room. 
 
 If the Medical Officer (Education) decides on closure, 
 instructions are telegraphed to the head teacher and 
 the medical officer of health is informed by telephone. 
 
ADMINISTRATIVE ROUTINE 197 
 
 The heads of the other departments in the Education 
 Office are also informed, so that evening tenancies and 
 children's meetings may be suspended. 
 
 Diphtheria. The notifications of diphtheria are 
 entered in a special register in which are given the 
 names of all children suffering and excluded for house 
 infection, with the dates, departments, and classrooms. 
 This register is kept under observation by the assistant 
 medical officer, who is responsible for this special 
 disease. When diphtheria appears in a school, the 
 head teacher is instructed to exclude from affected 
 classrooms all children suffering from sore throats, until 
 a certificate, based upon bacteriological examination, 
 is presented, or until further instructions from the 
 head office have been received. A supply of cards 
 (No. 7) for distribution to the parents of affected 
 children accompanies this instruction. The medical 
 officer of health for the district is informed imme- 
 diately. If the disease shows signs of spreading, the 
 assistant medical officer visits the school and takes 
 a culture from the throats of any suspicious children. 
 These cultures are incubated at the head office ; and 
 as soon as the results are known, the head teacher 
 is instructed by telegram to exclude children whose 
 cultures yield diphtheria bacilli or organisms of a sus- 
 picious character. The medical officer of health is 
 immediately informed by telephone, and a notification 
 form is duly forwarded by post. 
 
 Measles. Information as to whether or not a child 
 has had an attack of measles is obtained by the head 
 
198 MEDICAL INSPECTION OF SCHOOLS 
 
 teacher when the child is admitted to the infants' 
 department, and is duly recorded. When, therefore, 
 the head mistress notifies to the head office the occur- 
 rence of a case of measles, she at the same time fur- 
 nishes information as to the number of protected and 
 unprotected children in the affected classroom. At 
 the head office these notifications are entered in the 
 general register, and when the cases suggest the possi- 
 bility of school infection, they are tabulated on a special 
 form,^ according to their class distribution, and sub- 
 mitted to the medical officer or his assistant. Class 
 closure is now seldom resorted to, but the unprotected 
 children are excluded for a certain term of days, when 
 the second crop of the outbreak is expected. The 
 application of this routine requires very careful con- 
 sideration, but, if scientifically applied, it is possible 
 to limit, to a certain extent, the outbreaks at school 
 without undue loss of attendance on the part of the 
 children. In case of class closure the head teacher is 
 communicated with by telegram, and, before the 
 children are sent home, each one receives a card 
 (No. 6) cautioning the parents to keep their children 
 under careful observation, both for their own sakes and 
 for the sake of others ; and also pointing out the serious- 
 ness of the disease. When, however, only the unpro- 
 tected children are sent home, a different card is given 
 to each child. 
 
 School Nurses. The duties and methods of the school 
 nurse, and the examination of children suffering from 
 
 » See Appendix III, p. 333, Form No. 5. 
 
ADMINISTRATIVE ROUTINE 199 
 
 parasitic and contagious diseases, have already been 
 considered in a previous chapter. 
 
 With regard to administrative routine, and in order 
 that the work may be systematically done, the nurse 
 devotes the morning of each day to the schools in 
 rotation, and the afternoon to particular schools. This 
 ensures that every school is visited at least once a 
 month. A notice of the intended visit is sent to the 
 head teacher several days beforehand, so that any 
 doubtful out-of-school cases may be presented to the 
 nurse. At the end of the week each nurse forwards 
 a report to the head office. These reports are gone 
 through and any queries answered. In addition, once 
 a month each nurse goes through her weekly reports 
 and general work with the superintendent of nurses. 
 
 Cleansing Scheme (Heads). Unclean heads are a 
 frequent cause of absence from school, causing serious 
 loss of attendance. The cleansing scheme is applied 
 with a view to remedying this condition. The most 
 unclean school in each district is selected. The head 
 teacher is informed by letter from the head office that 
 the scheme is to be applied. The nurse visits the school 
 and notes all children with unclean heads ; she then 
 supplies the head teacher with a white card for each 
 child whose head requires to be cleansed. This card 
 draws the parents' attention to the state of the child's 
 head and gives directions as to cleansing. The cards 
 are enclosed in sealed envelopes and given to the 
 children to take home. 
 
 At the end of the first week all cases not treated are 
 
200 MEDICAL INSPECTION OF SCHOOLS 
 
 separated from the other children in class, and a red 
 card is served on the parents by the attendance officer 
 warning them that, if the condition is not remedied at 
 the end of a week, the child will be excluded from 
 school and that they will be prosecuted. 
 
 At the end of the second week the superintendent of 
 nurses visits the school and excludes those children 
 who have not been cleansed, and forwards the names 
 to the head office. From the head office the divisional 
 superintendent is instructed to prosecute. During the 
 time which must necessarily elapse between the date 
 of exclusion and the hearing of the summons, any 
 children who are presented at school are readmitted 
 and, if found clean, are allowed to remain, but if still 
 unclean, they are again excluded and the prosecution 
 goes on. About 13 per cent, of excluded cases are 
 fined. 
 
 Cleansing Scheme (Bodies). The mode of procedure 
 is similar to that adopted in regard to cleansing the 
 heads. When the nurse finds children whose clothes 
 and bodies are so verminous as to be unfit for school, 
 she excludes them and forwards the names and ad- 
 dresses to the head office. These names and addresses 
 are forwarded to the medical officer of health for the 
 district, whose inspector delivers a card stating that the 
 children can have a warm bath and have their clothes 
 sterilized free of cost at certain hours on specified 
 days. The London County Council in their General 
 Powers Act, 1907, obtained powers to cleanse children 
 in case of parental default ; but the provision by the 
 
ADMINISTRATIVE ROUTINE 201 
 
 local sanitary authorities of adequate means for 
 cleansing children has proved impracticable. The 
 Children Act, 1908, however, which comes into force 
 in April, 1909, places the responsibility of selecting 
 and cleansing these children upon the education 
 authority. Such a course will have the great 
 advantage of differentiating between the cleansing of 
 children and the cleansing of vagrants and beggars 
 under the Cleansing of Verminous Persons Act. * It is 
 a further step in the direction of trusting all public 
 duties, as to the care of a child as a child, entirely to 
 the one authority which is concerned with his physical 
 and mental development during school life.'^ 
 
 Ringworm. Another part of the nurse's work is the 
 detection of ringworm. With so much experience the 
 nurse's judgment is quite reliable. In most cases, 
 however, stumps removed from affected heads are 
 forwarded in small envelopes to the head office. These 
 stumps are examined microscopically. If found to 
 contain ringworm, the head teacher is instructed to 
 exclude affected children. The divisional superin- 
 tendent and school nurse are also informed. 
 
 In many of these cases doctors have given certificates 
 that the children are free from infection, but in nearly 
 every case the child is found to be suffering from the 
 disease. 
 
 Special Schools (Admission). Under the Elementary 
 Education (Defective, Epileptic, Blind and Deaf) 
 
 ^ Annual Rei^ort (1908) Medical Officer (Education) London County 
 Council. 
 
202 MEDICAL INSPECTION OF SCHOOLS 
 
 Acts certain children may be sent to special schools, if 
 they are certified by a duly qualified medical prac- 
 titioner approved by the Board of Education. 
 
 Children attending ordinary elementary schools are 
 nominated for medical examination under the Acts by 
 school doctors, teachers, divisional superintendents, 
 managers, charitable bodies, and others. Special forms 
 are used for both mentally and physically defective 
 children.^ At the head office an index is kept in which 
 are entered the names of all children who have come 
 under notice. On receipt of a nomination form, reference 
 to the index is made in order to prevent duplication of 
 work. If the child has not been seen on a previous 
 occasion, the form is numbered and allocated to the 
 local examination centre nearest to the child's home. 
 General particulars are transferred to a card. The 
 dates of these local examinations are advertised in an 
 official paper issued weekly to teachers and others. 
 Several days before the examination is due a notice is 
 sent to the head teacher of the school at which the 
 child attends, or to the divisional superintendent, 
 asking them to arrange for the child to be presented. 
 They also inform the parents. In the meantime the 
 nomination form, with full details, the registration 
 card, and all papers connected with the case are sent 
 to the school, addressed to the doctor. No child is 
 examined without a registration card. The lady 
 superintendent of special schools, or one of her assis- 
 tants, attends and helps in the examination, and 
 
 ^ See Appendix III. Forms Nos. 8 and 9. 
 
ADMINISTRATIVE ROUTINE 203 
 
 allocates the children to the most convenient centres. 
 One or other parent, and often one of the teachers, are 
 present. The doctor makes brief notes of each child's 
 mental and physical condition and adds instructions 
 with regard to the need for any special educational 
 routine. He then states on the card the kind of school 
 for which the child is suitable (elementary, physically 
 or mentally defective, imbecile, epileptic colony, open- 
 air, &c.). All cards and papers are then returned to 
 the head office and the officers concerned informed of 
 the results of the examination. Examinations are 
 held twice a year at each centre for mentally defective 
 children (of which there are 85 in London) and once 
 a month at each physically defective centre (of which 
 there are 27 in London). 
 
 Should children come before the doctor with special 
 defects which cannot be dealt with satisfactorily at 
 a local centre, a note to this effect is made on the card 
 and arrangements are made for the cases to be seen 
 by the medical officer (Education) at the head office. 
 This routine appHes especially to bhnd, deaf, and 
 morally defective children. 
 
 Special Schools (Centres). In addition to the admis- 
 sion examination, all children on the roll of special 
 schools are examined once in six months. For this 
 purpose the doctor visits the centre, examines the 
 children, and makes notes in regard to their progress 
 or otherwise in the family history and progress book 
 kept at the centre. If there is any child in the centre 
 who should be transferred elsewhere, or be exempted 
 
204 MEDICAL INSPECTION OF SCHOOLS 
 
 from the special school, a report is made on a special 
 form. This report is sent to the head office and arrange- 
 ments are made for the necessary transfer. 
 
 Medical Certificates. The Board of Education re- 
 quires a medical certificate for each child passed for 
 a mentally or physically defective centre. These cer- 
 tificates are made out from the examination cards. In 
 those cases in which the parents refuse to send their 
 child to a special school, a certificate signed by the 
 examining doctor is supplied for prosecution purposes. 
 
 Examination of Candidates. All candidates for 
 employment in schools are medically examined as to 
 their physical fitness. Many of these candidates come 
 under observation as junior scholars. Before they are 
 granted a scholarship they have to satisfy the medical 
 officer as to their physical fitness. When they are 
 summoned to attend at the head office, a form asking 
 for details as to family history is sent. This form 
 must be filled in by the parent or guardian and returned 
 to the head office. When the form has been received 
 the more important particulars are transferred to a 
 special card which, together with the form, is placed in 
 the hands of the doctor who examines the candidates. 
 If the candidate is satisfactory in all respects, a certifi- 
 cate is forwarded to the Committee concerned. If 
 there is any condition which requires to be remedied, 
 various forms are issued for the instruction of parents 
 or guardians. Defective vision, defective teeth and 
 uncleanliness must be suitably remedied. When the 
 condition has been remedied, the candidate again 
 
ADMINISTRATIVE ROUTINE 205 
 
 attends for re-examination or forwards a certificate 
 from a dentist or an oculist, as the case may be. 
 
 Secondary Schools. The majority of these scholar- 
 ship candidates are kept under observation by the 
 doctors attached to the secondary schools, and, when 
 they are seen, fresh notes are entered on the back of 
 their medical record card. When these candidates are 
 transferred to pupil-teachers' Centres, the record cards 
 are transferred with them ; and when they go from 
 the pupil-teachers' Centres to the Training Colleges, 
 the record cards are also sent. By this method teachers 
 are kept under medical observation during part of 
 their school life and during the whole of their training ; 
 and should any physical condition present itself which 
 would ultimately render the student unfit to take up 
 his profession as a teacher, his course at once comes to 
 an end. In this way not only useless expenditure, but 
 also ultimate disappointment to the student in after 
 life, is avoided. 
 
 Annual Reports. With regard to the writing of 
 reports, the Board of Education has issued some sugges- 
 tions in Circular 596.^ The Board suggests that an 
 annual report of a school medical officer should deal 
 with the following matters : — 
 
 (a) General review of the hygienic conditions of the 
 schools. 
 
 (b) Arrangements for co-relation of school medical 
 service with the public health service. 
 
 (c) General statement as to the extent and scope of 
 
 ^ See Appendix II. C. p. 320. 
 
206 MEDICAL INSPECTION OF SCHOOLS 
 
 medical inspection in the area of each education 
 authority. 
 
 {d) General view of facts disclosed by medical 
 inspection. 
 
 (e) General review of social and industrial conditions 
 in their relation to the health and physical condition 
 of the children. 
 
 (/) Review of methods employed, or available, for 
 treatment, including a record of the school nurse's work. 
 
 (g) Review of action as to infectious disease. 
 
 (h) Review of methods for dealing with blind and 
 deaf children as well as the mentally and physically 
 defective, under the special Education Acts. 
 
 (^) Review as to the methods and results (1) of 
 instruction in temperance and hygiene and (2) of 
 physical exercises ; and as to the arrangements for 
 open-air recovery schools. 
 
 Such a report would include a very broad and com- 
 prehensive statement as to medical inspection of schools 
 in its fullest sense. But, as the Circular itself says, ' it 
 is recognized that in many, and indeed in most cases, 
 such a degree of comprehensiveness will not immediately 
 be attainable '. In one direction, however, the scope of 
 an annual report might be supplemented so as to 
 include some reference to the progress of educational 
 hygiene, under which would be mentioned any work 
 upon the questions of fatigue and upon the physiology 
 and psychology of educational methods. 
 
 A few practical points have been emphasized by 
 Dr. Kerr, who alone of school medical officers has 
 
^WIV Civvy ' 
 
 V, OF 
 
 ADMINISTRATIVE ROUTINE 207 
 
 gained experience in the writing of reports. Dr. Kerr 
 suggests that it is advisable to take up the considera- 
 tion of one subject in each annual report and to deal 
 with it thoroughly and exhaustively. In such a case a 
 brief sketch of other branches of school work is sufficient. 
 With regard to statistical tables for comparative 
 purposes, Dr. Kerr insists upon the observation of the 
 following rules : 
 
 (a) The analysis should be according to the children's 
 age, which should be stated in years and months. The 
 age last birthday is the most convenient form of expres- 
 sion. Occasionally there is value in statistical records 
 relating to a number of children born in certain years. 
 
 (b) The analysis should be according to sex, each of 
 which should be stated separately. During any investi- 
 gations different coloured cards should be used for 
 boys and girls. 
 
 (c) The total number of children (boys and girls) 
 dealt with must be indicated. The number of normal 
 must be given together with the number of abnormal. 
 In the case of percentages, the number of children 
 from whom the deductions are drawn must be stated. 
 
 {d) Some indication of the social status of the children 
 examined, however indefinite it may be, should be given. 
 
 (e) Analysis of results, according to school standards, 
 represents an indefinite basis, though scientifically it 
 affords a more rehable estimate of a child's mental 
 capacity than the teacher's unchallenged judgment. 
 
 Through neglect of these simple rules many of the 
 tables and statistics relating to school children, not 
 
208 MEDICAL INSPECTION OF SCHOOLS 
 
 only in England but also abroad, have been of little 
 value for comparative purposes. 
 
 Medical Room. With regard to the statutory in- 
 spection of the children, the Board of Education requires 
 that ' 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.' 
 These points give rise to a difficult problem. In a large 
 school there is seldom any difficulty in finding a con- 
 venient room that can be placed at the disposal of the 
 school doctor during certain fixed hours every week — 
 when, for instance, one of the classes is absent for 
 manual instruction, or for laundry or cookery work. 
 In some cases it may be necessary to partition off, by 
 means of screens, a corner of the central hall. In 
 infants' schools it is generally possible to make use of 
 the babies' classrooms without any undue disturbance 
 of school routine. At some schools head teachers have 
 placed their private rooms at the disposal of the school 
 doctor, but the adoption of this practice should not be 
 allowed. In small country schools, and in some of the 
 non-provided schools in towns, the doctor has the 
 utmost difficulty in securing a room for his work. In 
 towns the difficulty may be overcome by the estabhsh- 
 ment of special centres for the purposes of medical 
 inspection : but in small country schools, consisting of 
 only one or two rooms, the difficulty will remain 
 unsolved until provision is made in the plans of all 
 future school buildings for an additional room for the 
 use of the school doctor. 
 
CHAPTER XIV 
 MEDICAL TREATMENT AT SCHOOL 
 
 A Serious and Urgent Problem. — Recognized by Parliament. — 
 Medical Treatment the Natural Corollary of Inspection. — Facts and 
 Pictures. — Chronic Disease alone calls for Consideration. — Ringworm. — 
 Favus. — Verminous Conditions. — Defective Teeth. — Defective Vision. — 
 Chi'onic Ear Disease.— Other Chronic Conditions.— Their Effect on 
 Education.— Special Circumstances : Prolonged Absence and Illiteracy ; 
 Injury to Physique and to Prospects in After-life. — Complicated Factors 
 of the Problem.— No Single Root Evil.— Existing Institutions for Treat- 
 ment. — The Family Doctor, Hospitals and Poor Law Dispensaries. — 
 How to Solve the Problem ; Four Schemes.— Laissez-Faire PoHcy.— 
 Hospital Reorganization.— Poor Law Methods.— Municipalisation of 
 Medical Services. — These Schemes Inadequate. 
 
 A FURTHER problem demands immediate consider- 
 ation. Are we to be content with mere inspection of 
 the children's defects, or are we to proceed to some 
 system of remedial treatment ? Parliament has recog- 
 nized the urgency of the question and has empowered 
 local education authorities to make arrangements for 
 attending to the health and physical conditions of the 
 children. The intention of ParHament is supported 
 by an official memorandum (Circular 576) on medical 
 inspection of children in pubHc elementary schools 
 issued by the Board of Education under Section 13 
 of the Education (Administrative Provisions) Act, 
 1907. The memorandum says ' The aim of the Act is 
 practical and it is important that local education 
 
 HOGARTH 
 
21U MEDICAL INSPECTION OF SCHOOLS 
 
 authorities should keep in view the desirabihty of 
 ultimately formulating schemes for the amelioration of 
 the evils revealed by medical inspection '. 
 
 Now medical inspection is only in a very early stage 
 of evolution. Consequently every school doctor goes 
 through the same processes of reflection and self -educa- 
 tion. At first he enters the school as a novice, recognizing 
 that his duty is to inspect, not to treat, that his own 
 position is open to attack on the part of his brother 
 practitioners, that he may be interfering with the 
 rightful responsibilities of parents. He is so absorbed 
 in the new work, the new ideas, so interested in the 
 children, the educational system and the teachers, that, 
 as soon as he has notified parent and teacher that a child 
 is suffering from some particular disease, leaving them 
 to take whatever further action may be necessary, he 
 considers that he has done his part. It is not until he 
 returns a year later, that he realizes how completely 
 his advice has been ignored. Then, he begins to think. 
 
 All school doctors go through the same phase — with 
 the result that in course of time they are to be found in 
 one of two camps. Either they still adhere on theoretical 
 grounds to the old mental attitude ; or, in the ardour 
 of their new enthusiasm, they press for some form of 
 State or municipal treatment for the children's needs. 
 It is the purpose of this chapter to analyse these two 
 disparate points of view. 
 
 It is obvious enough that medical inspection by itself 
 is insufficient, serving, as it does, very little practical 
 purpose unless followed by its natural corollary, treat- 
 
MEDICAL TREATMENT AT SCHOOL 211 
 
 ment. In Switzerland, and it may be in a few other 
 countries, about 90 per cent, of the children discovered 
 to be defective actually seek advice and obtain remedial 
 or palliative treatment for their defects. But this is 
 not the case in England. For instance, in London, 
 where there are innumerable doctors and specialists as 
 well as free dispensaries and hospitals, it has been 
 found that only about one third of the children reported 
 to their parents to be suffering from markedly defective 
 vision seek advice of any sort, and even of these the 
 majority do not obtain any remedial treatment. The 
 same percentage holds good for children suffering from 
 chronic ear disease. With regard to diseases of the 
 skin and scalp, a large proportion of children seek 
 advice, but only a very small number obtain satis- 
 factory and adequate relief. The result is, that in 
 London and other large cities probably not one tenth 
 of the defective children are adequately treated or 
 materially benefited. Hence it is clear that more than 
 half the labour and expense of medical inspection is 
 thrown away. 
 
 What, then, are the best means of ensuring efficient 
 medical treatment ? In considering this momentous 
 question, there is need of some convenient distinction 
 between different diseases. The treatment of acute 
 conditions such as pneumonia or appendicitis, of such 
 minor ailments as bruises, blains and cuts, of all 
 diseases which are readily and rapidly cured, of all 
 accidents and emergencies and of other conditions 
 not necessarily incidental to school life, may be 
 
 p 2 
 
212 MEDICAL INSPECTION OF SCHOOLS 
 
 dismissed from present consideration. For, in the 
 case of such purely accidental conditions, it is not 
 incumbent upon the school authority to interfere 
 with the existing agencies by which they are ordinarily 
 remedied. Thus a child suffering from pneumonia or 
 appendicitis is either treated at home by a general 
 practitioner, or is admitted without any further 
 question to a hospital. Again, any treatment by a 
 public authority of minor ailments, such as cuts and 
 bruises which tend to heal without interference, would 
 obviously justify the charge of ill-considered charitable 
 benevolence,^ which may be largely a matter of senti- 
 ment and statistics, — an objection constantly urged 
 against the work of at any rate one well-known 
 institution. 
 
 But with regard to certain chrom'c affections and 
 diseases which are frequently neglected by general 
 practitioners and only inadequately treated at hospital, 
 the circumstances are totally different. Such con- 
 ditions are comprised in the following category : — 
 
 A. Parasitic and Contagious Conditions and Chronic 
 Diseases of the Skin. 
 
 1. Ringworm. 3. Scabies or Itch. 
 
 2. Favus. 4. Verminous conditions — lice and nits. 
 
 5. Impetigo and Eczema. 
 
 ^ The Board of Education, however, appears to be favourably disposed 
 towards schemes for the treatment of minor ailments by the school 
 nurse. Qrcular 596 says :— ' So far as the school nurse is engaged in 
 treating the minor ailments, or in visiting the children's homes for 
 purposes of advice, her employment would require sanction as an 
 " arrangement " for attending to the health and physical condition of 
 the children. The Board would usually have no difficulty in sanctioning 
 any well considered scheme for this purpose.' 
 
MEDICAL TREATMENT AT SCHOOL 213 
 
 B. Dental Conditions. 
 
 1. Extraction. 
 
 2. Filling of Defective Teeth. 
 
 C. Defective Vision. 
 
 1. Exact examination and diagnosis. 
 
 2. Retinoscopy. 
 
 3. Fitting of Glasses. 
 
 D. Chronic Diseases of the Eye, Ear, and Nose. 
 
 1. Eye. Inflammation of the lids, conjunctivitis, corneal 
 
 ulceration, ophthalmia, &c. 
 
 2. Ear. Otorrhcea or discharging ears. 
 
 3. Nasal obstruction, mouth-breathing. 
 
 E. Other Chronic and Neglected Conditions. 
 
 1. Tubercular Bone Affections. 
 
 2. Infantile Paralysis. 
 
 3. Rickety Deformities. 
 
 For present purposes, consideration may well be 
 limited to these few special conditions, which are all 
 of the utmost importance to the school child and to 
 the school authority. Ringworm plays havoc with 
 the child's attendance at school, dental disease under- 
 mines his physical condition, defective vision may 
 retard his educational progress, crippling — the result 
 of neglected or inadequately- treated bone disease — 
 or deafness may handicap him not only at school but 
 also in after-life, if indeed his term of life is not 
 actually cut short. 
 
 It is useless to discuss the means by which these 
 chronic conditions may be remedied, until the circum- 
 stances under which they arise are clearly understood. 
 Are these conditions accidental, incidental, or the result 
 of neglect ? In other words, is chronic disease an acci- 
 
214 MEDICAL INSPECTION OF SCHOOLS 
 
 dent, an incident, or a crime ? This question, again, 
 can only be answered when the nature of the various 
 diseases has been ascertained. Their cHnical aspect 
 is discussed elsewhere. In this chapter they are 
 treated from the general and from the educational 
 
 point of view. 
 
 Ringworm is a common disease of childhood and 
 exceedingly contagious, being due to a highly resistant 
 vegetable fungus affecting either the scalp or other parts 
 of the skin. It is very tedious and difficult to cure, 
 but is not necessarily the result of dirt or neglect, 
 as children from cleanly homes are also liable to 
 the disease. All affected children must be excluded 
 from school, thereby losing enormously through non- 
 attendance. Although the disease can sometimes be 
 recognized by teachers, exclusion should not be enforced 
 until the child has been seen by the school nurse, and, 
 if necessary, stumps of hair have been examined under 
 the microscope. It might be permissible for children 
 to remain at school if strict precautions were taken, 
 and an adequate covering or cap were constantly worn. 
 Early cases can sometimes be cured as follows : — 
 
 1. Cut the hair short and shave the scalp for at 
 least half an inch round the affected part. 
 
 2. Apply strong ointment or other antiseptic night 
 and morning, washing off the old crusts and the oint- 
 ment with spirit and ether lotion before every fresh 
 application. 
 
 3. Continue this treatment for several weeks. 
 Coster's paint may be used as an alternative. This 
 
MEDICAL TREATMENT AT SCHOOL 215 
 
 is left on for a week and the whole of the affected 
 epidermis peels off with it. 
 
 It is, however, in very few homes that the mother 
 takes the trouble to carry out instructions. Nor are 
 the majority of cases cured under many months, even 
 when receiving constant skilled treatment. The average 
 stay at the Metropolitan Asylums Board Ringworm 
 Schools was a year and seven months, 28 per cent, stayed 
 over two years, and 15 per cent, over three. The net 
 result is that the loss of attendance as far as the children 
 are concerned is enormous, and the loss of grant to the 
 educational authorities correspondingly great. Thus, 
 'twelve schools taken at random in various parts of 
 London lost 26,766 attendances through ringworm — an 
 equivalent of the ordinary attendance of nearly 3,000 
 children earning a total grant of more than £5,600 
 per annum.' ^ 
 
 Quite apart from the neglect and poverty of many 
 families in which the children are affected by ringworm, 
 decent parents find very serious and real difficulty in 
 obtaining satisfactory treatment. The following ex- 
 tracts from parents' letters will make this point clear : — 
 
 * I am writing to ask you if something cannot be 
 done for the children suffering from ringworm, of which 
 there seem to be so many. I have two, a girl and a 
 boy ; in the case of the boy, who will be thirteen in 
 May, it is cruel he should lose so much time from 
 school. He has always been a delicate boy, and will 
 
 * Report of Medical Officer (Education), London Countj^ Council, 
 1907. 
 
216 MEDICAL INSPECTION OF SCHOOLS 
 
 never be able to do hard work ; therefore his education 
 will be everything to him for his future. They are 
 both under a good medical man, but it seems to take 
 such a time. They have already been home about 
 ten months.' 
 
 Another says : — ' I am writing to ask if you could 
 assist me about my little boy ... He is nearly 10 years 
 old, and has suffered from ringworm in the head for 
 the last three years, and has been away from school 
 a great deal in consequence. About a year ago it 
 seemed to get better, and he was able to go back to 
 school, but three months ago it came bad again, and 
 as I have three other children (two girls with long hair) 
 I am anxious in case they also will catch it. So if you 
 could help me in any way, I would feel greatly obliged. 
 I forgot to say that I could afford to pay five shiUings 
 a week for him.' 
 
 Experience has shown that the majority of chronic 
 and almost incurable cases of ringworm can be cured 
 after a single appHcation of the Rontgen rays — or after 
 two or three sittings which may vary from five to tw^enty 
 minutes each — sufficient to ensure complete depilation. 
 This method of treatment, though costly for the 
 few, is relatively inexpensive for general use. It should 
 therefore be made more accessible for the children 
 not only of the poor and neglectful but also of the 
 careful and well-to-do. 
 
 With reference to this matter in an official memoran- 
 dum (Circular 576) the Board of Education says : — ' In 
 controlling ringworm, it has been open to a Committee 
 
MEDICAL TREATMENT AT SCHOOL 217 
 
 (a) to neglect the disease altogether ; (b) to adopt a 
 policy of exclusion from school of affected children ; 
 or (c) to supervise or carry out some method of 
 amelioration. Up to the present many authorities 
 have followed the first course. It is intended that in 
 future they should, according to their abilities, adopt 
 the third.' The reason why education committees 
 have neglected ringworm is that by so doing, they 
 secured a more substantial grant for efficiency from the 
 Board of Education itself, thanks to the aboHtion of 
 the epidemic grant .^ 
 
 On the other hand, during recent years the establish- 
 ment of special ringworm schools has been con- 
 templated. But such an undertaking as the institution 
 of Rontgen rays for treatment would anticipate 
 the necessity for these schools ; at least the classes 
 need only be of a temporary nature during such time 
 as the children were attending a centre for treatment 
 and were awaiting the regrowth of their hair. 
 
 Pavus is also due to a resistant vegetable fungus, 
 but is more chronic and more difficult to cure than 
 ringworm. It is possibly less contagious, and its 
 occurrence is much more limited. It appears chiefly 
 to affect the lowest classes of the alien population whose 
 children live in wretched and overcrowded homes 
 amidst dirty surroundings. In London, for instance, 
 it is for the most part confined to the Jewish quarter 
 in Whitechapel, where it has been possible to establish 
 a special favus school in which eighty children are 
 
 ^ Cf. chap, ii, p. 22. 
 
218 MEDICAL INSPECTION OF SCHOOLS 
 
 kept under sanitary and preventive treatment without 
 losing any educational advantages. It is common also 
 in the poorer districts of Glasgow, and it is not unknown 
 in the rural districts of England. The essential point 
 is that affected children, whether in attendance at 
 special schools or not, should be submitted to a daily 
 sanitary routine of disinfection and also to treatment 
 by the Rontgen rays, and this is only possible at special 
 centres. 
 
 Verminous Conditions are commonly found amongst 
 
 school children of all classes. Those from the poorest 
 
 quarters of large towns are specially infected with 
 
 body lice, but head lice are more common. At least 
 
 one-half of the elementary school population have 
 
 been infected at some time or other — a disgrace to our 
 
 civilization. Nor does it seem credible that any of 
 
 H.M.'s Inspectors could pass a school as satisfactory 
 
 and efficient in which more than half the children were 
 
 verminous. Among boys the problem is not so serious, 
 
 as their hair may be cut short and their heads cleansed 
 
 without much trouble, but in the case of girls there is 
 
 a serious difficulty. This problem has already been 
 
 considered in detail in connexion with the work of 
 
 the school nurse. And though it may be argued that 
 
 it devolves on the parents to cleanse their children's 
 
 heads, and that no expense should be borne by the 
 
 municipality for this object, yet, generally speaking, 
 
 it will be convenient for the education authority to 
 
 make some kind of provision for treating a certain 
 
 number of verminous children with sore heads and 
 
MEDICAL TREATMENT AT SCHOOL 219 
 
 enlarged glands on the same lines as other contagious 
 diseases. Moreover, the Children Act, which comes into 
 force in April, 1909, places upon the education authority 
 the responsibility of detecting and cleansing children 
 suffering from verminous conditions.^ 
 
 Scabies, or Itch, can readily be cured by application 
 of sulphur ointment and by sulphur baths, and can, as 
 a rule, be left to existing agencies, if only parents and 
 doctors are induced to take a serious view of their 
 responsibilities. 
 
 Defective Teeth. The dental condition of children 
 attending elementary schools is altogether unsatis- 
 factory, and the more carefully the children are examined 
 the greater the amount of disease and destruction 
 which becomes apparent. There are no exact figures 
 on a large scale available in England, but the British 
 Dental Association found that out of 10,517 children 
 examined between 1890 and 1897, only 14 per cent, 
 had sound teeth, while the remaining 86 per cent, showed 
 definite signs of decay. Similarly out of 10,000 chil- 
 dren examined in Strasburg, only 4-3 per cent, had sound 
 teeth. The further examination of 150,000 children in 
 Germany showed no better results. These figures have 
 also been confirmed in London by the examination 
 of children in selected schools, and Dr. Kerr reports 
 that at least 50 per cent, have caries to a serious extent, 
 and that nearly half of these (25 per cent.) are in urgent 
 need of treatment, and that 10 per cent, actually showed 
 evidence of alveolar abscesses or of suppuration. In 
 
 ^ Cf. chap, xiii, p. 200. 
 
220 MEDICAL INSPECTION OF SCHOOLS 
 
 other words, about 200,000 children attending the ele- 
 mentary schools in London are in urgent need of active 
 remedial treatment, while examination and preventive 
 treatment should be extended to another 200,000 with 
 as little delay as possible. 
 
 Extensive dental disease of this nature gives rise 
 to a foetid condition of the mouth through constant 
 absorption of poisonous material, and leads to con- 
 sequent impairment of physique and general health. 
 The importance of attending to the milk teeth is not 
 generally recognized, because it is difficult for the 
 general public to realize how a carious milk-tooth 
 influences the growth and development of its successor. 
 But this point is well established, and attention must 
 be directed to improving the dental condition of infants 
 as well as of older children. In fact dental caries is 
 essentially a disease of childhood and adolescence, and 
 if only a child's mouth is set in order while at school 
 there will seldom be urgent necessity for much inter- 
 ference in after life. Children at all ages should be 
 taught the necessity of cleanliness. Their teeth should 
 be examined, and opportunities for treatment should 
 be brought within reach of all so as to check an 
 easily preventable source of misery and inefficiency in 
 later life. 
 
 Regular inspection of the teeth has taken place in 
 Brussels since 1875 and also in Germany at Strasburg, 
 Darmstadt, Wiesbaden, and Miilhausen, and more 
 recently in New York, but experience shows that 
 inspection and instruction are useless unless followed 
 
MEDICAL TREATMENT AT SCHOOL 221 
 
 by practical measures. Most of the children are 
 neglected if left to private enterprise. Practical steps 
 must be taken to enforce the discipline of cleansing 
 the teeth, as has been undertaken at certain schools 
 by the institution of tooth-brush clubs and tooth-brush 
 drills. But arrangements must also be made for 
 remedial treatment which consists partly in extractions 
 and in cleansing the mouth, but more particularly in 
 filling the diseased teeth and in other conservative 
 methods. Cambridge, following the example of Stras- 
 burg, has taken the first step in this direction in 
 England. 
 
 Defective Vision. Statistics relating to defective 
 eyesight among school children have been collected 
 abundantly. The problem has been brought very 
 prominently before the notice of the general pubHc. 
 In 1866-7 Cohn of Breslau was the first to examine 
 the vision of 10,000 school children in Germany. 
 Dr. Kerr reported upon the visual acuity of 50,000 
 children in Bradford in 1894, and two years later 
 Dr. Brudenell Carter conducted an examination in 
 London. In 1898 a series of voluntary investigations 
 were carried out throughout England on behalf of the 
 Board of Education, but the results have been pigeon- 
 holed ever since. The general outcome, however, is that 
 about 20 per cent, of children of school age are known 
 to be suffering from defective vision and to be in need 
 not only of more detailed examination than is possible 
 in the schoolroom but also of remedial treatment. 
 
 The whole matter is so notorious that almost every 
 
222 MEDICAL INSPECTION OF SCHOOLS 
 
 medical officer newly appointed by a local education 
 authority has made it his first duty to go over the 
 same ground and to rediscover the fact that about 
 20 per cent, of the children in his district are suffering 
 from defective vision. Still an overwhelming majority 
 remains untreated. In London and other populous 
 districts not more than one-third of those who are 
 defective, and whose defects are reported to their 
 parents, seek any kind of advice. Fewer still procure 
 the necessary glasses. 
 
 There are also a considerable number of children 
 in the infant schools suffering from squint whose vision 
 may be normal, but who require the use of glasses 
 from an early age in order to prevent disuse of the 
 squinting eye. Very few at present actually obtain 
 glasses. 
 
 The outstanding facts are : — 
 
 1. That less than half the children attending city 
 schools could pass so severe a test as perfect vision 
 with both eyes. 
 
 2. That, to supplement the rough testing of the 
 visual acuity of all children by teachers or school 
 doctors, not less than 20 per cent, require routine 
 examination by a qualified ophthalmic surgeon in a 
 specially equipped room. But such routine examination 
 is tedious and uncongenial to the general practitioner 
 or voluntary hospital worker. 
 
 3. That in a large number of these cases occurrence 
 may be prevented and deterioration avoided by im- 
 proved construction and lighting of schoolrooms, by 
 
MEDICAL TREATMENT AT SCHOOL 223 
 
 improved educational methods, and by more personal 
 instruction and supervision of the children. 
 
 4. That of these children approximately one half 
 (i. e. 10 per cent, of all school children) urgently require 
 spectacles, while in the absence of spectacles a certain 
 proportion are seriously handicapped in their educa- 
 tional progress and in after-life. 
 
 5. That the defects, even when reported to the 
 parents, are actually remedied in only an infinitesimal 
 proportion of the cases. 
 
 6. And that this last fact is due partly to the ignor- 
 ance and apathy of the parents, partly to the incon- 
 venience and difficulty of obtaining treatment, and 
 largely to the expense of procuring glasses. 
 
 It was owing to the excessive cost of spectacles in 
 London that a voluntary association was founded in 
 1906 for the supply of cheaper spectacles to school 
 children, but though this association has undoubtedly 
 brought spectacles within the reach of most of the 
 poorer parents by effecting an enormous reduction in 
 the price, yet it has by no means solved the problem 
 of securing efficient treatment for all those who need it. 
 
 Chronic Diseases of the Eye include such defects as 
 inflamed eyelids, chronic ulceration of the cornea, 
 conjunctivitis and ophthalmia. Many of these are 
 considered by the parents to be trivial complaints 
 until permanent injury has been caused, and although 
 parents are repeatedly urged by the teachers and 
 school doctors to seek advice, nothing is done. More- 
 over, owing to the contagious nature of certain forms 
 
224 MEDICAL INSPECTION OF SCHOOLS 
 
 of purulent conjunctivitis — familiarly known as ' blight ' 
 — and more rarely of trachoma, the children are excluded 
 from school ; and, in consequence of much unnecessary 
 delay in the treatment of these cases, there is consider- 
 able risk of spread of infection as well as loss of atten- 
 dance. Thus these conditions, when untreated, are 
 serious as affecting the physical condition, school 
 attendance and after-life of the child. The majority 
 of such cases should be seen by a medical officer or 
 a trained nurse daily until they are cured, and this 
 seems difficult to attain except by special provision. 
 
 Chronic Ear Disease. The worst example of the in- 
 adequacy of treatment and of neglect by parents is to be 
 found in otorrhoea (discharging ears), which often origin- 
 ates in adenoids and frequently leads to permanent 
 deafness and educational backwardness besides prov- 
 ing a handicap in after-Hfe — to say nothing of the 
 constant danger of extension of the disease to the 
 cranial cavity with risks of meningitis. The percentage 
 of children who urgently require treatment is probably 
 not more than 2 or 3 per cent. But here again either 
 the parents do not seek advice, or the remedial treat- 
 ment undertaken by hospitals and local practitioners is 
 quite inadequate to the requirements of the case. 
 Many cases go on and on for months and years. Some- 
 times the children are excluded from school on account 
 of the offensive nature of discharge. A case of chronic 
 ear discharge requires skilled attention daily, often 
 S3n'inging two or three times a day, which cannot, 
 in most instances, be undertaken in a satisfactory way 
 
MEDICAL TREATMENT AT SCHOOL 225 
 
 by the parents ; and, for obvious reasons, these 
 cases do not receive adequate attention at hospitals 
 or from general practitioners. 
 
 In the same way there seems to be general laxity 
 as regards the treatment of chronic affections of the skin 
 and scalp, such as impetigo and eczema. Often the 
 children become unsightly and lose much school atten- 
 dance for the want of a Httle daily supervision and 
 medical treatment. 
 
 Other Chronic Conditions. Many of the children 
 suffering from old infantile paralysis, from deformities 
 and tuberculosis of bones remain insufficiently treated 
 either through parental neglect or through the imprac- 
 ticability of proper hospital treatment. In fact it is 
 almost impossible for a large proportion of tubercular 
 children among the poor to obtain the prolonged treat- 
 ment necessary for complete recovery, and this not- 
 withstanding the considerable number of cases which 
 are dealt with by the InvaHd Children's Aid Association, 
 and similar organizations.^ 
 
 These, then, are the chronic diseases of childhood which 
 urgently demand immediate treatment. In the future 
 it is to be hoped that prevention instead of cure will 
 be the aim, that being the ideal to keep in view. In 
 the meantime there is to be considered the appalling 
 
 ^ These children, and many of those suffering from heart disease, 
 require prolonged treatment in bed. They are possibly outside the 
 purview of the education authority, unless, owing to the general neglect 
 of these conditions, the latter takes upon itself to establish convalescent 
 schools in the country. 
 
 HOGARTH O 
 
226 MEDICAL INSPECTION OF SCHOOLS 
 
 number of children in the elementary schools of the 
 great cities suffering from remediable conditions, the 
 majority of which remain untreated. Consequently 
 there has been an outcry. The general feeUng is 
 that ' something must be done ', and that child life is 
 too valuable to be thus wantonly sacrificed. It was 
 reasonable to expect that the parents, after receiving 
 notice of their children's defects, would do their part 
 towards treating them. But these expectations have 
 not been realised. The story is repeated on all sides 
 — ' Nothing is done '. What then is the ultimate cause 
 of inaction ? 
 
 It will be well at first to confine attention to the 
 needs of large towns and populous centres. The 
 existing means for securing treatment are : — 
 
 1. The family doctor. He is the obvious agent and 
 the best man to carry out treatment, but unfortunately 
 the family doctor does not exist for the homes of the 
 poor. The doctor's bill does not appear as an item in 
 the ordinary working-man's budget, nor can the neces- 
 sary margin for it be easily provided — when a large 
 family must be kept on 255. a week, with 6s. or more 
 to go for rent. The causes for this may be manifold, 
 but doubtless one may be found in the pauperization 
 of the poor by hospitals and other charitable institu- 
 tions. But consider the case of those who, being placed 
 a little higher in the social scale, prefer the family doctor 
 to the hospital, or at least attend a provident dispensary. 
 What is so inadequately paid a doctor to do for 
 a child with discharging ears or with defective vision ? 
 
MEDICAL TREATMENT AT SCHOOL 227 
 
 He gives advice which, for a multitude of reasons, is 
 not followed. In fact, the majority of general prac- 
 titioners in poor districts make no pretence to cure 
 discharging ears, or to prescribe glasses. It is un- 
 reasonable to expect any one of them to do more for 
 Is. or 6d. than to give a bottle of medicine and advice. 
 He may be admirable in deaUng with acute diseases, 
 but so far as chronic conditions are concerned, he is 
 paid to treat symptoms, and he does so. Anything 
 more is a labour of love, the work of a philanthropist. 
 
 In Switzerland the state of affairs is totally different. 
 Nearly all the working-class families employ a family 
 doctor, who is prepared to treat chronic, as well as 
 acute, diseases, and who has no hesitation in referring 
 special cases to the recognized specialists of the district. 
 The remainder take their children to the dispensaries 
 or polyclinics — which are simply hospital out-patient 
 departments — immediately after receiving advice from 
 the school doctors. But Switzerland has several dis- 
 tinct advantages over this country. The general level 
 of education among the poorer classes is much higher. 
 The populations of the towns and communities are 
 smaller, thereby increasing the communal esprit de 
 corps. There also appears to be Uttle tendency to the 
 pauperization of the poor by charitable relief. 
 
 The result is, that 90 per cent, or more of the children 
 who are reported to have physical defects actually 
 obtain definite and proper medical treatment — except- 
 ing of course as regards teeth, for the treatment of which 
 pubHc provision is now being made. 
 
 Q 2 
 
228 MEDICAL INSPECTION OF SCHOOLS 
 
 2. Secondly, there are the casualty and out-patient 
 departments of the larger pubKc hospitals. These must 
 naturally be regarded as appointed places for securing 
 efficient medical treatment for the children. But, in 
 London at all events, and in New York, and doubtless in 
 other large cities, the majority of the parents do not take 
 their children to the hospitals for the specified chronic 
 complaints ; while many of those that do attend are not 
 satisfactorily treated. Moreover, Education Committees 
 continually receive serious complaints from the hos- 
 pitals and appeals for help. Thus, one hospital reports 
 that ' the examination of these children prevents many 
 patients who require more urgent treatment from being 
 seen by the ophthalmic surgeon '. Another says, ' this 
 difficulty is now becoming very acute '. Another, ' it is 
 really intolerable '. Even one of the children's hospitals 
 complains of the ' large batches of children who attend 
 the out-patient departments '. And yet not half the 
 children have presented themselves for treatment. 
 
 It would appear, therefore, that hospitals are un- 
 suitable for the treatment of the chronic complaints 
 of school children for the following reasons :— 
 
 (a) The number of the children requiring treatment 
 is too overwhelming. 
 
 (b) The cases which have been indicated are of too 
 chronic a character, and the treatment is too tedious 
 for voluntary workers. 
 
 (c) The central hospitals are quite inaccessible to 
 the people living in outlying districts, on account 
 partly of the expense, and partly of the distance. 
 
MEDICAL TREATMENT AT SCHOOL 229 
 
 (d) The inordinate length of time during which out- 
 patients are kept waiting at most of the hospitals is 
 a very serious consideration to those working-class 
 parents who must accompany their children. 
 
 (e) Such gratuitous hospital treatment is an unjust 
 tax on the medical profession. 
 
 If any parents desire to take their children to the 
 hospitals and the hospitals are willing to treat them, 
 the school authorities would make no protest, pro- 
 vided that they are in a position to insist upon efficient 
 treatment of chronic conditions, which is scarcely 
 attainable at the great London hospitals.^ 
 
 3. Poor Law Dispensaries. It is often urged that 
 if parents are too poor to pay for medical attention, 
 and if the hospitals are unwilling to provide treatment, 
 the patients must have recourse, through the relieving 
 officer, to the Poor Law.^ But what provision does 
 the Poor Law make for the cases under considera- 
 tion ? The cases are not suitable for admission to the 
 infirmaries ; they are essentially cases for out-patient 
 treatment. But, for practical purposes, no out-patient 
 
 1 It is generally thought that hospitals exist solely 'for the relief 
 of the sick poor'. But this term has become a mere phrase on which 
 a hospital depends for its appeal to the charity of its supporters. If 
 the bare truth is to be stated, the great hospitals, both in London and in 
 the provinces, with their medical schools, exist : — partly for the treatment 
 of accidents and emergencies, partly for the relief of the sick poor, partly 
 for the relief of the sick who are not poor; but chiefly for the advance- 
 ment of medical education. 
 
 2 Thud a correspondent in The Times writes epigrammatically : ' The 
 medical treatment of school children who need it is the business of the 
 parents when they can pay and of the Poor Law when they are unable 
 to do 80.' See also post, p. 234. 
 
230 MEDICAL INSPECTION OF SCHOOLS 
 
 department exists. The parish doctors attend daily 
 at a dispensary : they admit some patients to the 
 infirmary, they order medicine for others, apply a few 
 dressings and undertake to visit a few patients in their 
 homes. But there is no accommodation or conveni- 
 ence for testing errors of refraction, for the daily 
 syringing of discharging ears, for the appUcation of 
 X-rays to ringworm cases, or for attending to the 
 teeth of the children. 
 
 Every one who has any knowledge of the routine 
 and administration of these institutions will reahze that 
 they are wholly unsuitable for the treatment of school 
 children ; nor is it reasonable that school children should 
 thus be branded with the stigma of pauperism. 
 
 It remains now to consider what steps are to be 
 taken to solve the problem. There is no single root 
 evil ; the problem is highly complex ; and upon analysis 
 may be resolved into the following factors : — 
 
 1. The ignorance, apathy, and neglect of parents. 
 
 2. The inadequacy and inaccessibihty of existing 
 institutions. 
 
 3. The real poverty of the people and their inabihty 
 to pay for efficient treatment. 
 
 4. The tedious nature of the treatment required for 
 the specified chronic cases. 
 
 5. The general standing of the practitioners in poor 
 districts. 
 
 In connexion with the last factor it is remarkable 
 that, in certain matters affecting the public health, many 
 members of the medical profession appear quite devoid 
 
MEDICAL TREATMENT AT SCHOOL 231 
 
 of conscientiousness. They constantly certify children 
 as free from infectious and contagious disease, and as 
 fit to attend school, when they are obviously suffering 
 from ringworm or scabies ; and sometimes even in the 
 case of diphtheria their action is not beyond suspicion. 
 For example, out of 240 certificates of freedom from 
 ringworm, no less than 234 were proved to be in- 
 accurate on microscopic examination of specimens from 
 the affected cases.^ 
 
 In short, from a variety of causes, a decent and 
 respectable parent often has the utmost difficulty in 
 obtaining the cure of his children's chronic complaints. 
 Everything must be undertaken with the maximum 
 amount of trouble and inconvenience, and it is only 
 natural to expect that apathy and neglect should be 
 the rule among the less intelligent of the poor. 
 
 What, then, is to be the solution of the problem ? 
 
 Four separate answers to this question may be 
 distinguished. The first advocates a poHcy of laissez- 
 faire. The second and third consist in alternative 
 schemes for the reorganization either of the hospitals 
 or of the Poor Law system. The fourth urges the 
 municipalization of medical services. 
 
 Briefly to summarize the various positions : — 
 
 {a) The first contention emphasizes the obvious 
 danger of tampering with parental responsibihties by 
 the estabhshment of a system of State-provided medical 
 treatment, and lays special stress on the fact that all 
 
 1 Cf. also chap, ix, p. 118. 
 
232 MEDICAL INSPECTION OF SCHOOLS 
 
 progress and reform are the work of time. The 
 strength of the people Kes in the family. But, it is 
 urged, the tendency of all recent philanthropic effort 
 is to weaken family ties. If compulsory education is 
 to lead by way of medical inspection to compulsory 
 treatment, there is no logical stopping-point. Even 
 now the child looks less and less to his family, and 
 more and more to outside agencies, to provide for his 
 most elementary needs. On the other hand, there is 
 no short cut to social reform. It is mere folly to 
 disregard the part played by lapse of time or by 
 general social evolution. One generation has already 
 passed while parents were becoming famiharized 
 with the idea of compulsory school attendance. In 
 the course of another thirty years they will have 
 realized their responsibility for providing medical treat- 
 ment, and allowance for this item will appear in the 
 budget of every working-class family. During the 
 same interval, hospital administration will have under- 
 gone processes of reform and readjustment. The 
 medical profession will have adapted itself to the 
 altered requirements, and every general practitioner 
 will be ready to prevent the very diseases which the 
 specialist is now only seeking to cure. 
 
 The validity of this position is at least open to 
 question. It would require an army of keen social 
 workers and greatly improved methods of education 
 to effect such a change in any large city. It may be 
 the ideal course, and there is no doubt plausibility in 
 the argument. Short cuts to social reform are always 
 
MEDICAL TREATMENT AT SCHOOL 233 
 
 difficult. But quite apart from sentimentalism, it is 
 false economy to allow these chronic conditions to go 
 untreated for twenty or thirty years for want of 
 a little foresight and some public-spirited policy. 
 
 (b) The second contention admits that at the present 
 time the majority of parents have few facilities for ob- 
 taining treatment. But, the argument continues, if, by 
 careful adjustment and organization between hospitals 
 and school authorities, such faciUties could be arranged, 
 then perhaps neglectful parents might be summoned 
 for not obtaining treatment, and the onus of proving 
 their inabiUty to do so would then devolve upon them. 
 For instance, in provincial towns, by careful reorganiza- 
 tion, it might be possible for the local hospital to 
 arrange special hours for school children to be examined 
 for defective vision, and special hours for the syringing 
 of discharging ears, and for the treatment of ringworm. 
 In London, special inquiry was undertaken with a view 
 to ascertaining the practicability of such a scheme. 
 The general conclusion was that no satisfactory arrange- 
 ments could be made. 
 
 Two plans, however, have been suggested : (1) that 
 the municipality should contribute to the funds of 
 selected hospitals and should have the right to send 
 batches of children at certain hours for specified treat- 
 ment ; or (2) that the hospitals should lease their 
 special accommodation and equipment to the munici- 
 paUty at fixed hours for the treatment of school children 
 by special doctors and nurses paid by the municipality. 
 
234 MEDICAL INSPECTION OF SCHOOLS 
 
 On the contrary it might be urged that neither of 
 these schemes goes to the root of the matter, in 
 that the ultimate arrangements are not under the 
 control of the education authority. The first would, 
 moreover, necessitate complete reorganization of the 
 staff, routine and raison d'etre of the hospitals, and 
 in the second there would be insurmountable difficulties 
 and friction. In other words, as far as the require- 
 ments of large cities are concerned, these schemes are 
 neither practicable nor desirable. 
 
 Schemes of this nature, however, might be adopted 
 in small towns and at hospitals without medical schools, 
 and the idea has already met with official approval 
 in the following terms : ' The Board (of Education) 
 will be prepared to entertain proposals for contributing 
 to the funds of hospitals, dispensaries, and nursing 
 associations on terms of adequate advantage. Such 
 contributions are specially desirable in the case of eye 
 hospitals and cottage hospitals, which are prepared to 
 undertake minor surgical operations.' The principle, 
 however, has been condemned by the British Medical 
 Association. 
 
 (c) The third proposal suggests the possibiHty of 
 inaugurating modern up-to-date dispensaries in con- 
 nexion with the Poor Law Unions. There would be 
 one for each district. The expense would be enormous, 
 and great reorganization and extension of Poor Law 
 methods would be necessitated and special provision 
 would be required for dealing with the problems of 
 
MEDICAL TREATMENT AT SCHOOL 235 
 
 school life. For it is essential that medical relief 
 should be given without any stigma of pauperism : 
 and even if two days a week were set apart for the 
 treatment of school children, the school authorities 
 would not have the necessary and complete control to 
 secure efficiency. Moreover, in all probability many 
 difficulties of administration would arise. 
 
 The neglect to deal specifically with the question of 
 the medical treatment of school children constitutes 
 a serious omission in the Report of the Royal Com- 
 mission on the Poor Laws, 1909. There are recommen- 
 dations for the reorganization of the Poor Law, and for 
 the better administration of educational as well as 
 of public health problems ; but this subject — the 
 medical treatment of school children — stands apart 
 and has so far not been sufficiently recognized. No 
 PubHc Assistance Authority or Committee can provide, 
 out of existing institutions, adequate facilities for the 
 treatment of the specified chronic diseases of school 
 children. 
 
 One of the recommendations of the Minority Report, 
 however, may be regarded as covering the omission. 
 This recommendation is : ' that the local educational 
 authority should be given sole charge of all children 
 in need of any form of public assistance '. 
 
 {d) The final contention is concerned with the com- 
 plete municipalization of the medical services. What- 
 ever the future may have in store, the time is certainly 
 not ripe for the introduction of such a sweeping reform. 
 
236 MEDICAL INSPECTION OF SCHOOLS 
 
 The suggestion is not mthin the scope of practical 
 politics. Any complete system of State or municipal 
 medical service should from the first be satisfactorily 
 organized and should be administered on a sound and 
 systematic basis. It is not sufficient for the State or for 
 the municipality to subsidize, out of public funds, the 
 hospitals and charitable institutions so as to entitle 
 persons or children under the care of the State or of 
 the municipaHty to claim the gratuitous services of 
 hospitals. 
 
 Under any such scheme the general practitioners them- 
 selves must be subsidized and paid out of public funds 
 as, to take an instance, at Bellinzona in Switzerland. 
 There the town was divided into medical districts 
 and the inhabitants paid a small tax for medical service. 
 But shortly after the scheme was instituted, fifty- three 
 out of the fifty-five practitioners ' went out on strike '. 
 
 The inevitable conclusion of this chapter is that, 
 although the principle of estabhshing some means 
 for the medical treatment of the chronic diseases of 
 school children is essential to the physical and educa- 
 tional well-being of the community, yet no one of the 
 suggested schemes is either satisfactory or adequate. 
 
CHAPTER XV 
 THE SCHOOL CLINIC 
 
 The Serious and Urgent Problem Still Unsolved. — The Only Solution. — 
 The School Clinic Defined. — Report of Sub-Committee of London County 
 Coimcil. — General Principles. — Building and Equipment. — An Example 
 from Cambridge. — Staff, Service and Routine. — Proposed Methods. — 
 Treatment of Ringworm by X-rays. — The School Clinic at Bradford. — 
 Cost. — Initial Outlay and Annual Expenditure. — Organization in Towns, 
 Small and Great. — Medical Treatment in Rural Districts. — The ' Flying ' 
 Clinic. — Summary of Advantages and Objections. 
 
 A CONSIDERATION of the facts cited in the previous 
 chapter leads only to one conclusion. There is a serious 
 and urgent problem. More than 50 per cent, of defective 
 children in crowded centres do not receive medical 
 treatment. Nor is there any immediate prospect of 
 getting them treated. None of the suggested remedies 
 is satisfactory or adequate. 
 
 There remains, then, as the only solution, the estab- 
 lishment of central school clinics in populous districts 
 for the treatment of the more chronic complaints of 
 children of school age. Such a clinic should be under 
 the direction and control of the education authority, so 
 that it might be conducted with as little interference 
 as possible with school routine. 
 
 A school clinic in its ideal form is a small building 
 containing five or six rooms used as a centre for the 
 
238 MEDICAL INSPECTION OF SCHOOLS 
 
 medical examination and treatment of school children 
 suffering from certain specified chronic complaints. It 
 should be modelled partly on the lines of the special 
 clinics which have been established at Strasburg, 
 Dresden, Miilhausen, and many other German towns, and 
 at Bale, Lucerne, Zurich, Helsingfors, and Stockholm, 
 for the treatment of teeth, and partly on the lines of the 
 general school ' polyclinics ' which have been estab- 
 lished in Switzerland at Lucerne and La Chaux-de- 
 fonds. These latter exist chiefly as consulting-rooms 
 for the school doctor, and only secondarily for the 
 treatment of a few parasitic and minor affections. 
 
 The movement is only in its infancy. On the con- 
 tinent of Europe there does not appear to be the same 
 urgent need for public medical treatment except in 
 the case of teeth, seeing that there is an adequate 
 number of family doctors, as also in every town 
 specialists for the eye and ear. But in England the 
 circumstances, as it was indicated in the last chapter, 
 are totally different. Therefore, we must not be content 
 with merely following the lead of other countries, but 
 should strike out a path for ourselves as soon as the 
 need is shown to exist. 
 
 This matter has received special consideration in 
 London. A special Sub-Committee of the London 
 County Council Education Committee was appointed 
 in July, 1907, and reported in December, 1908. The 
 committee, which was composed of educationalists, 
 medical practitioners and consultants, governors of 
 hospitals, and representatives of the Charity Organiza- 
 
THE SCHOOL CLINIC 239 
 
 tion Society, and other bodies, was required by its 
 terms of reference to make inquiries upon the following 
 points : 
 
 (i) What is the existing provision for the medical 
 treatment of school children ? 
 
 (ii) To what extent can this provision be rendered 
 more available by the action {a) of the hospitals, 
 (6) of the Council ? 
 
 (iii) What additional provision, if any, is desirable ? 
 
 (iv) How should this provision be suppUed? 
 
 The Committee instituted special inquiries among 
 hospitals, dispensaries. Poor Law institutions, and 
 voluntary associations, and took certain expert evi- 
 dence. The children requiring medical treatment were 
 divided into three groups : — 
 
 A. Those requiring care in an institution and outdoor 
 life, i. e. debihtated children ; children convalescent from 
 tuberculosis treated surgically ; children suffering 
 from subacute or early tubercular disease. 
 
 B. Those requiring operative and in-patient treat- 
 ment. 
 
 C. Those who can be promptly and adequately dealt 
 with in suitably equipped rooms, e. g. children suffering 
 from teeth defects and simple diseases, eye defects 
 and simple diseases, skin diseases (chiefly parasitic, 
 ringworm, scabies, and pediculosis), ear defects and 
 simple diseases. 
 
 Eventually the Committee considered two distinct 
 
 propositions : — 
 
 1. That the Council should make arrangements with 
 the existing hospitals and dispensaries. 
 
240 MEDICAL INSPECTION OF SCHOOLS 
 
 2. That the Council should establish school surgeries 
 or cUnics at which treatment should be provided 
 by its own medical officers. 
 
 On the grounds of efficiency and economy the 
 Committee recommended : — 
 
 {a) That, as the existing provision of private and 
 hospital practice sufficiently meets the requirements 
 in the case of children requiring operative and in- 
 patient treatment (who are thus removed from the 
 direct purview of the educational authority), no further 
 steps be taken in respect of this class. 
 
 (h) That the Council should estabhsh school cUnics 
 at suitable centres in the metropolis for the medical 
 treatment of the defects included in group C. 
 
 A school clinic has other advantages. In addition 
 to being a centre for medical treatment it serves 
 as a convenient place for the examination of children 
 on and after admission, in the absence of a satisfactory 
 room for conducting such an examination in the school. 
 There would be better accommodation for the work 
 of the school nurse in connexion with parasitic and 
 contagious diseases. Moreover, the absences from 
 school of children under medical treatment would be 
 under more systematic control than at the present 
 time. There would be less interference with school 
 routine and greater co-operation would result between 
 the school doctor, the nurse, and the attendance officer. 
 Finally, the general simplicity and uniformity of the 
 system offers peculiar advantages. 
 
 Attendance at the clinic should be entirely voluntary 
 
THE SCHOOL CLINIC 241 
 
 and all treatment gratuitous. Those who prefer may 
 attend a private doctor ; others may go to the hospital : 
 but school authorities must be in a position to insist 
 upon the parents obtaining efficient treatment for their 
 children. So much for general principles. 
 
 Building and Equipment. A model school clinic 
 should consist of five or six rooms, a large central 
 waiting hall and dispensary to accommodate 50 to 
 100 children with teachers or parents, two consult- 
 ing rooms, one being for the use of the surgeon or 
 physician, and one for the dentist, one dark room 
 with special apparatus for examining eyes, ears, throat, 
 &c., one room for dental and other operations, and 
 one private room for the nurse. Hot and cold water 
 should be laid on in all the rooms, and there should 
 be adequate lavatory, w.c. and sink accommodation. 
 
 The rooms should be constructed upon the lines of 
 a miniature, but modern and up-to-date out-patient 
 department at a hospital, and should be airy and well 
 lighted and should communicate one with another. 
 
 The physician's consulting-room would be used for 
 the visiting physician or surgeon to examine all except 
 dental cases, and arrangements would be made for 
 children to be seen in different batches. This room 
 should be equipped with a table or desk, three or four 
 chairs, a couch, washing-basin, sink, screen and cup- 
 boards. There should be cases of instruments for the 
 ophthalmic, aural, and throat surgeons, and also a series 
 of lenses for testing errors of refraction ; and other 
 instruments for general work, such as spatulas, forceps, 
 
 HOGARTH J5, 
 
242 MEDICAL INSPECTION OF SCHOOLS 
 
 &c., a movable dressing stand, dressing basins, and 
 trays. 
 
 The Dentist's Consulting-room should be fitted up 
 in a similar manner with special dental equipment. 
 
 The school dentistry at Cambridge, under the 
 direction of Dr. Cunningham, consists of two rooms — 
 a waiting-room containing rocking-horses, chalks, 
 and blackboard, and other toys for the diversion of 
 the children. The surgery itself is a pleasant room 
 facing an open garden, and few parents have objected 
 to sending their children for treatment. Only nine 
 of the first 700 children treated proved intractable, 
 and only fifteen failed to return when told to do so. 
 Extractions are not performed at the clinic, but at the 
 neighbouring hospital. 
 
 It is estimated that one dentist giving his whole time 
 could treat about 1,000 children in the course of a year. 
 Attendance at the school dentistry counts as school 
 attendance. Three children are sent at nine o'clock 
 and three more at ten o'clock. One surgery maid 
 is suggested as a sufficient help for two dentists. 
 The complete equipment of a room in any ordinary 
 house would prove satisfactory and should not cost 
 more than £40 or £50. 
 
 The Operating-room should be situated between 
 the two consulting-rooms and communicate with both. 
 In addition to the usual equipment there should be 
 a sterihzer in which the instruments might be boiled. 
 This room would be used almost entirely for dental 
 surgery and might possibly be combined with the 
 
THE SCHOOL CLINIC 343 
 
 dentist's consulting-room, so as to economize space, 
 as is the case in the school dentistry at Strasburg. 
 
 But generally two dental operating-rooms would be 
 required if there are to be a large number of assistants. 
 At any rate the dentist would need the service of a 
 second room for the use of the children after operation 
 — a spitting-room (Spiihl Zimmer). 
 
 In addition, a small room, capable of being darkened, 
 must be available for X-ray work for ringworm, 
 retinoscopy, and other examinations. It would be 
 fitted up with electric lamps and other modern con- 
 veniences. 
 
 Any one of the rooms (which was not in use at the 
 time) could be used for the nurse to do her dressings, 
 to examine children for ringworm and skin disease, 
 and to syringe discharging ears, &c. 
 
 The waiting-room should be spacious. Probably 
 in populous centres batches of fifty children would 
 attend at once. In a corner of the waiting-room a 
 small dispensary would be fitted up containing a small 
 stock of simple drugs, lotions, liniments, ointments, 
 dressings, &c., for use in the department. 
 
 Staif, Service and Boutine 
 
 In a large town or city the staff of each cHnic 
 would consist at least of one oculist, one general phy- 
 sician, one dentist, one X-ray specialist. It is probable 
 that even in the smaller towns several assistant dental 
 surgeons would be necessary. 
 
 R 2 
 
244 MEDICAL INSPECTION OF SCHOOLS 
 
 This staff of visiting specialists should, generally 
 speaking, be quite distinct from the staff of school 
 doctors appointed to carry out medical inspection 
 or other work in the schools. But they should for the 
 most part be selected from medical men, either general 
 practitioners or consultants, who had already gained 
 experience as school doctors. Each member of the 
 staff would be appointed for special knowledge of some 
 particular branch of the work, and would only devote 
 a few hours each week to his duties. Thus the appoint- 
 ments would rank as equal, in public esteem and im- 
 portance, to those of physicians or surgeons visiting 
 special hospitals ; and would be even more acceptable 
 to younger men in that adequate salaries would be 
 attached to the posts. The fact that the staff of the 
 school cUnic differed from the staff of school doctors 
 and medical inspectors, ensures a double check and 
 prevents any danger of carelessness on the part of 
 municipal officers. 
 
 A trained nurse should have charge of the whole 
 building and equipment under the direction of the 
 responsible medical officer of the education authority. 
 She would probably require the services of an under- 
 nurse to help with the dressings, instruments, and 
 operations, and with keeping the ledgers and records. 
 One of the nurses would also have to make herself 
 proficient in the use of the X-ray apparatus. One 
 attendant would be necessary for scrubbing and keeping 
 the place clean. 
 
 The exact method of service depends upon local 
 
THE SCHOOL CLINIC 245 
 
 conditions and requirements. There are three methods 
 which may be mentioned here : — 
 
 According to the first, which is sufficient for the 
 smaller towns, the nurse is present early every morning 
 attending to all the children with discharging ears who 
 have been referred by the school doctor, sending them 
 back to their own schools immediately or else directing 
 them to a neighbouring school where a special class 
 has been temporarily arranged for all such children ; 
 they attend again in the evening. Then the nurse 
 proceeds to deal with a similar series of verminous or 
 parasitic children, and so on through the morning. 
 In the afternoon the nurse might visit the schools or 
 the homes so that her routine work should not become 
 too monotonous. 
 
 At the close of afternoon school the visiting physician 
 attends and prescribes treatment for all children bring- 
 ing cards from the school doctor. He either examines 
 them for defective vision, or directs the nurse who is 
 also in attendance, to do what is necessary. In 
 a small country town such work should not occupy 
 more than an hour each day. Meanwhile the dental 
 surgeon has attended to the shghter cases, reserving 
 those cases which require the assistance of a second 
 medical man until the physician is free to come to his 
 aid. Both should finish their work at the end of the 
 second hour. This method might be followed five or 
 six days a week, and scarcely interferes with school 
 routine. Such a system has been adopted at Lucerne — 
 a town with a population of about 30,000 inhabitants. 
 
246 MEDICAL INSPECTION OF SCHOOLS 
 
 According to the second method, the children who 
 require daily treatment by the nurse attend at the 
 commencement of morning school. But later in the 
 morning the oculist arrives and examines a batch of 
 fifteen or twenty children who have been referred on 
 account of defective vision. First he examines them 
 and puts drops of homatropin in all their eyes, then he 
 inspects, for instance, a number of the children who 
 are undergoing X-ray treatment for ringworm or any 
 cases of otorrhoea which the nurse has kept back for 
 advice. Then he returns to the children with defective 
 vision, whose pupils in the meantime will have become 
 dilated, and takes them one by one and does retino- 
 scopy. Subsequently those who require glasses are 
 measured for frames, and the prescription given to an 
 optician. The same batch of children attends a week 
 later to be fitted with glasses, for which cost price 
 should be paid. Experience shows that purely academic 
 corrections of refraction errors by means of expensive 
 glasses are needless, and that for practical purposes 
 school children are equally benefited by this rapid and 
 ready method of treatment, while the economic saving 
 in the price of glasses is enormous } In marked cases 
 of astigmatism, cylindrical glasses would be ordered. 
 These children thus only miss two school sessions, 
 
 * The Association for the Supply of Spectacles in London Elementary 
 Schools has done a great work in effecting a reduction in the price of 
 spectacles. Spherical lenses can now be obtained for L<?. 9d., and 
 cylindrical lenses for 2s. 9d., 3.9. 9d. or 4?. 6d. In Bradford the price 
 is Is. 5d. for sphericals, 2s. for cylinders, and 2s. 9d. for sphero- 
 cylinders. 
 
THE SCHOOL CLINIC 247 
 
 and, if their parents are not altogether poverty-stricken 
 they are fitted with glasses without any further in- 
 convenience or trouble to the families. 
 
 A second oculist attends in the afternoon to deal with 
 another batch of twenty children from a different school 
 
 Meanwhile in another part of the building the dentist 
 and his assistants have been attending to one or two 
 batches of children with defective teeth. These have 
 previously been examined in the school by the school 
 doctor or by one of the assistant dentists, and referred 
 to the cHnic for treatment. They are treated either 
 by extraction or by conservative methods, and after 
 two or three visits are finished with for the time, 
 and need not be seen again until sent by the school 
 doctor. Similarly with the next batch. 
 
 The X-ray specialist possibly visits on two or three 
 days a week and treats all the ringworm cases in turn, 
 who are collected together and are in attendance at 
 a special class in a neighbouring school. 
 
 With regard to the treatment of ringworm by the 
 X-rays, there are several points to be borne in mind. 
 Each installation of the apparatus costs about £100 
 or less. It can readily be worked by an attendant 
 under the supervision of a medical man. The expense 
 of outlay is relatively great for the treatment of 
 a few individual cases, but when the apparatus is in 
 constant use, the cost of each treatment is relatively 
 small. Economy would also be effected by the in- 
 stallation of two apparatus, both of which could be 
 used simultaneously under the supervision of one 
 
248 MEDICAL INSPECTION OF SCHOOLS 
 
 medical man. Each application of the rays for the 
 treatment of ringworm occupies on an average five 
 to twenty minutes, and if the whole head requires 
 treatment, as is commonly the case in young children, 
 approximately eight such applications are necessary. 
 Such prolonged treatment should not, as a rule, be 
 undertaken at a single sitting. Generally speaking, 
 one application causes complete depilation of the part 
 treated and effects a cure. The children, however, 
 should be subsequently kept under medical super- 
 vision. And as they are unable to return to school 
 until their hair has grown again — often a period of 
 several months — they should be in attendance at 
 a special class of ringworm cases in the neighbourhood 
 of the cHnic. 
 
 In the case of the large towns, or where the pressure 
 of cases is very heavy, a throat or an aural surgeon may 
 be examining in another room all the children who 
 have been referred for adenoids or mouth-breathing. 
 An exact examination can be made, minor methods of 
 treatment may be adopted, and the children instructed 
 in the correct use of the pocket-handkerchief and in 
 the importance of nasal breathing. But in the case of 
 all children requiring surgical operation, such as 
 tonsillotomy, removal of adenoids, or mastoid opera- 
 tions, the parents should be interviewed and instructed 
 as to the necessity for operation, and the children 
 should be referred with a letter to a hospital or a private 
 practitioner.^ The actual number of cases requiring 
 
 ^ It is inadvisable that the municipality should undertake any re- 
 
THE SCHOOL CLINIC 249 
 
 operation for these conditions is not so large as might 
 be concluded from the statistics which have been col- 
 lected about mouth-breathing and adenoids. Great 
 care should be exercised by any doctor who refers cases 
 for operation without digital exploration. 
 
 Meanwhile the nurse and her assistant would have 
 been present giving necessary assistance, or continuing 
 their own work of cleansing heads or syringing dis- 
 charging ears. 
 
 The third method is merely a modification of the 
 second to suit local conditions. According to this, 
 a smaller staff with less ample accommodation could 
 attend two days of the week for the eyes, two days a 
 week for the teeth, and once a week for ears, throats, and 
 general conditions, while the nurse was in attendance 
 every day as in the other methods. 
 
 Such a scheme has been adopted in Bradford with 
 its population of 300,000 inhabitants. Dr. Crowley, 
 the medical superintendent of schools, writes : — 
 
 ' The clinic was established at the offices of the 
 education committee, the members of the committee 
 being good enough to give up their '' members' room " 
 for the purpose. One or two other rooms also were 
 available, and one of these is now being adapted for 
 the installation of an X-ray apparatus for the treatment 
 of ringworm. 
 
 ' The clinic is open as follows : — Wednesday and 
 
 sponsibiliuy as to operative treatment or as to the administration of 
 anaesthetics. This opinion is endorsed by the experience of New York, 
 where, after eighty-four children had been operated on in the space of 
 two hours, certain compUcations occurred. 
 
250 MEDICAL INSPECTION OF SCHOOLS 
 
 Saturday mornings, 9 a.m., for general purposes, 
 especially for the drug treatment of ringworm, the 
 treatment of sores, and of various skin diseases. 
 Tuesday and Thursday afternoon, 2 p.m., for examina- 
 tion of vision and prescription of spectacles. Monday 
 afternoon, 2 p.m., for the examination and treatment 
 of cases of running ears, and children with this condi- 
 tion attend also every day at 9 a.m. or 4.30 p.m., for 
 treatment by the school nurse. In addition, at least 
 two afternoons per week will shortly be given to the 
 X-ray treatment of ringworm, and it seems likely that 
 an additional afternoon will be needed for ear cases. 
 At the commencement of next year the committee 
 will have under consideration the estabhshment of 
 a dental clinic. It may be added that the clinic is 
 used also for purposes of further medical examination, 
 and children seen in the schools or who are not attending 
 school, and who require such examination, attend any 
 morning at 9 a.m.' 
 
 Treatment at the Bradford Clinic is undertaken by 
 Dr. Crowley and his permanent assistants and not by 
 specially appointed practitioners and consultants. 
 Complicated cases are referred to the hospitals for special 
 treatment. 
 
 The nurse, in addition to the duties which have been 
 indicated, would be responsible for the care of instru- 
 ments and equipment and would take charge of all 
 cases referred to her by the various doctors. 
 
 Cost. It is impossible to make an exact estimate of 
 the probable cost of school clinics, as examples from 
 
THE SCHOOL CLINIC 
 
 251 
 
 the similar institutions in Germany and Switzerland 
 would be misleading. Such estimates afford only a very 
 rough guide. But the following figures from Dr. Jessen's 
 experience in establishing the pioneer school dentistry, 
 founded in 1902 at Strasburg, are useful as an indication 
 of the vast amount of invaluable work which can be 
 undertaken for a trifling outlay in a town of 150,000 
 inhabitants : — 
 
 Number of 
 
 Children in 
 
 Schools. 
 
 Number 
 examined. 
 
 Number 
 treated. 
 
 Fillings. 
 
 Extractions. 
 
 Cost. 
 
 17,119 
 17,054 
 18,073 
 
 18,607 
 
 5,343 
 
 6,900 
 
 4,372 
 
 834 
 
 2,666 
 4,967 
 6,828 
 7,491 
 
 699 
 4,832 
 7,065 
 8,340 
 
 2,912 
 6,530 
 7,985 
 8,552 
 
 £ s. d. 
 137 10 
 271 10 
 335 
 427 10 
 
 For the year 1907 the cost was raised to £450. But 
 the salaries are so very low that they could not be 
 quoted for England. Thus the director and responsible 
 medical officer himself receives no salary at all. About 
 4,000 children or more are treated each year by two 
 dentists, devoting their whole time, morning and after- 
 noon, to the work. 
 
 Professor Jessen estimates the ultimate cost to be 
 about one mark per child treated. Higher estimates 
 he considers to be erroneous and based solely on 
 theoretical calculations. 
 
 Many new school dentistries have been founded in 
 Germany during the last two years, but no exact 
 statistics as to their cost are available. In Dresden the 
 clinic consists of four operating-rooms with a continuous 
 
252 MEDICAL INSPECTION OF SCHOOLS 
 
 service of ten dental surgeons. In addition there are 
 laboratories, photograph and X-ray rooms. In Ziirich, 
 a dental clinic was estabHshed in 1908 and one dentist 
 appointed. Properly equipped rooms and a caretaker 
 were also provided by the municipality. In Lucerne, 
 with a population of only 30,000 inhabitants, the 
 authorities have combined the school dentistry with 
 a small polyclinic, and the routine is conducted on the 
 lines indicated in the first method, though there is no 
 nurse. 
 
 The initial outlay for such a general school clinic as 
 we have indicated would be considerable, but the 
 current expenses beyond the salaries of the staff would 
 be so small as to be almost negligible. The most 
 satisfactory basis for the estimation of the doctors' 
 salaries should be on the scale of £1 for a haK-day 
 session of three hours — that is £50 a year for an assistant 
 who attends one morning or one afternoon a week. It 
 would probably be better not to employ any assistant 
 more than three half-days a week. On this basis the 
 cost might be worked out thus : — 
 
 COST OF A FULLY EQUIPPED SCHOOL CLINIC FOR A TOWN 
 
 OF 200,000 POPULATION. 
 
 Initial Outlay. 
 
 Cost of Building £1,000 
 
 Cost of equipment including X-Ray installation . . 500 
 
 £1,500 
 
 Annual Expenditure : — Salaries : 
 
 Organizer and Responsible Medical Officer (adviser of Educa- 
 tion Committee) additional salary . . . . £100 
 Oculists (6 giving 3 hours a week each) at £50 per annum 300 
 Dental Surgeon (chief) ....... 100 
 
THE SCHOOL CLINIC 253 
 
 Dental Surgeon, 12 assistants (giving 3 hours a week each) 
 
 at £50 per annum ...... 600 
 
 X-Ray and skin specialist, aural surgeon, general physicians 
 
 (6 giving 3 hours a week each) at £50 per annum . 300 
 
 Matron ......... 150 
 
 Assistant Nurse . . . . . . . .100 
 
 Attendant ......... 50 
 
 Lighting, heating, general upkeep and other expenses . 300 
 
 Total annual expenditure £2,000 
 
 In England it would appear that every town with 
 20,000 children, that is, with a population of more 
 than 100,000, requires such a school clinic as a hygienic 
 and economic necessity. It is not unreasonable to 
 assume that 15,000 children would require attention 
 for their teeth, 10,000 for verminous conditions, 4,000 
 for defective vision, 2,000 for mouth-breathing, deaf- 
 ness, and discharging ears, and 1,000 for sore heads, 
 chronic eczema, ringworm, &c. One small general 
 clinic with the four or five rooms would be sufficient. 
 
 Smaller towns, with less than 100,000 population, 
 could probably manage on a much smaller scale. They 
 could follow the example of Lucerne and Neuchatel in 
 Switzerland, obtain the use of two or three rooms and 
 convert them into a convenient place for the school 
 doctor and dentist to attend to the children after school 
 hours, while the nurse attends in the morning for her 
 various duties. Faihng this, it might be possible for the 
 Education Committee to come to satisfactory terms 
 with the local hospital and district nurse with a view 
 to arranging for the treatment of children before 
 
254 MEDICAL INSPECTION OF SCHOOLS 
 
 and after school hours.^ But in any case other arrange- 
 ments for dental conditions would necessarily have to 
 be made, and small towns would do well to follow the 
 example of Cambridge, where a municipal dental clinic 
 for school children has been recently instituted. 
 
 As for the larger towns, twice the number of clinics 
 would not be necessary for twice the population. 
 Probably a town of 300,000 population, with 50,000 or 
 60,000 children, could manage with two clinics in dif- 
 ferent quarters of the town. Possibly some overlapping 
 of the staffs might also be arranged. 
 
 Four clinics would be required for 200,000 school 
 children, while in such a city as London, with its 
 800,000 children, it is probable that not less than 
 twelve would be found to be eventually necessary. 
 In all these cases, however, it would be well to begin 
 with one experimental clinic and gradually to build 
 up a scheme in accordance with local requirements. 
 
 With regard to rural districts, the establishment of 
 school chnics is out of the question. At his visits to 
 the school the medical inspector, be he local practi- 
 tioner or travelling inspector, has advised the parents 
 either verbally or by letter to consult their own 
 doctor and obtain treatment or to attend a hospital, 
 should there be one in the neighbourhood. When lapse 
 of time shows that facihties for obtaining treatment 
 do not exist in any particular district, then it will be 
 necessary to adopt one of the two following schemes. 
 But, in either case, there are many practical difficulties. 
 
 ' See Board of Education's Circular 59G, Api)endix II. C, p. 325. 
 
THE SCHOOL CLINIC 255 
 
 (a) Local practitioners, district nursing associations, 
 or the village dispensary may be subsidized by the 
 education authority for the purpose of attending to 
 the needs of school children. Payment should be 
 granted on a definite scale per caput, that is, for testing 
 errors of refraction, for attending to discharging ears as 
 well as for ringworm cases or other parasitic conditions. 
 Those children who are in need of constant supervision 
 might be transferred to a central residential school. 
 For the time being, however, there is little prospect 
 by this method of making arrangements in rural 
 districts for the dental care of children. 
 
 (b) The other method involves the institution of 
 ' fljdng clinics ' — a scheme to which Professor Osier 
 has alluded : ' Are we to look forward in each district 
 to travelHng specialists, before whom the children will 
 be lined up — Monday the eyes, Tuesday the ears, 
 Wednesday the teeth and so on ? ' This method has 
 been established in some of the country districts in 
 Germany for the treatment of defective teeth. In 
 England some modification would be necessary. 
 About a month after the school doctor's visit for the 
 purpose of inspection, another medical man should 
 go the round of country schools with a view to attending 
 to the eyes, ears, and teeth of all those children who 
 had not in the meantime obtained treatment. The 
 doctor would necessarily carry in his bag all the 
 apparatus for dental treatment, for vision testing 
 and for fitting children with glasses. The district 
 nurse should also be in attendance, and the doctor 
 
256 MEDICAL INSPECTION OF SCHOOIS 
 
 would refer to her certain chronic cases such as otorrhoea 
 and parasitic conditions for further treatment. 
 
 So much for the main principles underlying the 
 establishment of the school clinic and for the actual 
 details of routine, service, and cost. The chief advantages 
 have been incidentally indicated. They consist in the 
 certainty of getting the children treated and thereby 
 raising the general level of knowledge as to health matters 
 among the public, and especially among the poorer 
 classes, in preventing much disease, illiteracy, and 
 unemployment, and generally in improving the physical 
 condition and raising the standard of living. All these 
 advantages are secured at the cost of little interference 
 with school routine, because the arrangements are in 
 the hands of the education authority and of a medical 
 officer specially appointed for educational purposes. 
 There would be no wholesale exclusion of the children 
 from school, such as might be undertaken by an 
 energetic sanitary authority, but an earnest attempt 
 to make defective children healthy. The general out- 
 come must be obvious (even to the lay mind) without 
 more words. 
 
 The chief objections to this practical scheme of 
 affording efficient medical treatment for all defective 
 school children are purely theoretical. They are of 
 two kinds and are based on economic and academic 
 grounds. With regard to the first kind it has been well 
 said, ' Behind everything stalks the phantom of the 
 ratepayer '. We have, however, shown that there is 
 
THE SCHOOL CLINIC 257 
 
 an enormous economic advantage in the treatment of 
 these children suffering from chronic disease — much 
 greater than in the education of feeble-minded children. 
 To take one illustration alone : the municipality will 
 increase its revenue from the Treasury by obtaining 
 increased grants owing to improved attendance and 
 greater educational efficiency. Dr. J. J. Cronin, of 
 New York, has established this point of view by 
 exposing the short-sighted policy of administrators in 
 neglecting the rational care and treatment of children 
 during school life — only to provide for their custodial 
 treatment in Poor Law infirmaries, prisons, and other 
 institutions during after life.^ 
 
 With regard to the more theoretical objections, these 
 appear to show a lack of appreciation of the factors of 
 the problem. To begin with, family doctors and general 
 practitioners have proved themselves unequal to the 
 task of keeping the children in good health. The fault 
 lies partly with the doctors themselves and partly with 
 existing social conditions. At all events, here is a de- 
 finite and a practical reason why the municipaUty should 
 interfere and should undertake the solution of a 
 neglected problem. 
 
 Again, it may be reasonably urged that the system 
 of free treatment is liable to abuse, but this objection 
 is equally true of every other system that has ever been 
 suggested. And, after all, what is the nature of the 
 abuse ? A parent who cannot afford the doctor's fee 
 
 ^ Report showing the economic waste from neglect of the physical welfare 
 of school children. Cf. also chap, i, p. 7. 
 
 HOGARTH S 
 
258 MEDICAL INSPECTION OF SCHOOLS 
 
 of 2s. Qd. or 55. is enabled to have his children's vision 
 tested at the expense of the municipality (to which he 
 already contributes according to his means) ; every 
 child is provided gratuitously with efficient dental treat- 
 ment, whereas at present there are not sufficient dentists 
 for the population ; and the expensive X-ray installa- 
 tion is brought within the reach of all by a system of 
 co-operation. 
 
 Finally, some objection may be raised by voluntary 
 associations and charities, local guilds of help, and by 
 that army of keen social workers who, in many places, 
 have done so much to touch the fringe of a great 
 national problem, but who have naturally failed to 
 bring the issue to its logical conclusion. If these 
 societies and associations have any grasp of the situa- 
 tion, they will fall into line (no matter what the original 
 motive for their formation may have been), and they 
 will urge all municipal authorities to take immediate 
 steps to remedy the defects of their school children. 
 
 On the other side are more compelling considerations. 
 To secure an improved physical condition for the next 
 generation, to obtain a higher standard both of 
 school attendance and of education, to give a fair chance 
 in life to thousands who are now hopelessly handicapped 
 before the race is well begun, are aims which cannot be 
 Ughtly set aside. Without the school clinic the whole 
 system of medical inspection becomes practically 
 fruitless. With it, there is opened up the possibihty of 
 incalculable benefit to the future citizens of the State. 
 
CHAPTER XVI 
 
 COMMON DISEASES AFFECTING SCHOOL LIFE 
 
 (a) General Diseases. — (6) Symptomatic or Local Diseases. — 
 (c) Chronic Contagious Diseases, necessitating exclusion from School. 
 
 This chapter is written partly for teachers and 
 educationahsts and partly for school doctors. It 
 seeks to emphasize the school aspect of a few common 
 chronic diseases. A disease must not be regarded as 
 one of many diseases taken from a catalogue, but only 
 as a disease in relation to its surroundings. So that in 
 the present case each disease is considered not so much 
 from the clinical and medical, as from the educational, 
 point of view. It is on this common ground that the 
 doctor meets the educationaUst. Hence the following 
 notes may be of some value to teachers and members 
 of Education Committees, while some of the remarks 
 may not be without interest to medical men and school 
 doctors in that the traditional textbook method of 
 dealing with diseases has not been adopted. For 
 instance, the classification of sore throats and the 
 notes upon malnutrition, hysteria, mouth-breathing, &c. 
 as well as most of the paragraphs on school life, are the 
 outcome of personal experience in school work. 
 
 The main purpose of the chapter is to enable teachers 
 
 82 
 
260 MEDICAL INSPECTION OF SCHOOLS 
 
 and school doctors to arrive at an early recognition 
 of important conditions affecting school life, and to 
 suggest certain practical lines of educational and 
 hygienic treatment at school. For many simple but 
 essential rules of health are unknown to teachers and 
 are commonly ignored in practice by medical men. 
 At the same time teachers and educationalists are 
 warned of the danger of certain neglected conditions. 
 
 A. GENERAL DISEASES 
 
 Malnutrition — an abnormal or disordered growth in 
 the development of the tissues and organs of a child's 
 body, not necessarily synonymous with under-feeding. 
 
 Causes. Unhealthy surroundings and conditions of 
 life ; improper feeding from birth and later, under- 
 feeding, over-feeding ; bad housing conditions, over- 
 crowding ; insufficient sleep, want of exercise, and 
 proper recreation ; rickets ; acute infectious or other 
 debilitating diseases ; nervous diseases, especially the 
 neurotic temperament ; gastro-intestinal disorders. 
 
 Symptoms. Anaemia, pallor ; weakness, general 
 debility ; immobiUty of face muscles, dark rings round 
 the eyes ; external eye diseases ; squints ; lassitude, 
 listlessness, apathy ; inattention, backwardness or 
 mental dullness. 
 
 Results. Anaemia ; stunted growth and delayed 
 mental and physical development ; deformities and 
 curvature of spine ; liability to infectious diseases and 
 tuberculosis. 
 
DISEASES AFFECTING SCHOOL LIFE 261 
 
 School Life, Malnutrition is at once the most com- 
 mon and, until recently, the least observed of all the 
 unrecognized diseases and affections among children 
 attending elementary schools. It interferes not only 
 with the child's physical development, but also with 
 its educational progress in school. The causes, as 
 indicated above, are many. The greater proportion of 
 cases do not result from insufficient food, though the 
 tendency has been to assign undue prominence to this 
 factor as a cause. Cases of privation and starvation, 
 however serious in themselves, form only a small part 
 of the greater problem of general debility and mal- 
 nutrition. It is difficult, to obtain statistics ; for no exact 
 standard of what constitutes a sufficient or an insuffi- 
 cient diet has been established. There is no doubt, 
 however, that a large amount of general debility and 
 malnutrition is caused by improper feeding, extending 
 over a long period of time and dating from early infancy. 
 A similar condition may be induced or increased by 
 injudicious pampering of the children, thereby causing 
 a reaction on their nervous system and leading to 
 degeneration of the tissues, over-development of fat 
 and generally impaired nutrition. 
 
 The whole problem of feeding and under-feeding 
 will require careful analysis in the light of future 
 research. At the present time, owing to a want of 
 knowledge of all the factors of the problem, social 
 effort is frequently misdirected. 
 
 Treatment should lie, first, in the provision of whole- 
 some food ; and, secondly, in the amelioration of the 
 
262 MEDICAL INSPECTION OF SCHOOLS 
 
 surroundings and conditions of life. For all classes of 
 children— the underfed, the improperly fed, the starved, 
 the pampered, and especially for those of a neurotic 
 temperament — these conditions can be fulfilled during 
 six months' treatment at an open-air recovery school, 
 though, in the case of the underfed, the root problem 
 still remains unsolved. 
 
 Rickets — also a disease of nutrition, beginning as 
 a disorder of the alimentary canal and liable to affect 
 all organs and tissues of the body. 
 
 Causes. Unhygienic conditions before the school 
 period, especially insufficient or improper feeding, 
 aggravated by other causes. 
 
 Symptoms. Indigestion, anaemia ; excessive sweat- 
 ing, especially about the head and during sleep ; soft 
 bones, delayed appearance of teeth, backwardness in 
 use of Hmbs ; child-crowing (laryngismus stridulus) 
 and convulsions. 
 
 Results. Impaired physique, stunted growth ; bony 
 deformities, misshapen head and chest, bowlegs, knock- 
 knees, curved spine ; bad teeth ; predisposition to 
 bronchial catarrh and tuberculosis ; delayed mental 
 and physical development. 
 
 School Life. Rickets is the commonest chronic 
 disease of the infant school ; and, by reason of the 
 resulting bony deformities, as well as of impaired 
 physique and nutrition, it is especially important. 
 Being a disease of early infancy, its occurrence cannot 
 be prevented in the schools. But if infants from the 
 poorest quarters of urban districts are admitted, at an 
 
DISEASES AFFECTING SCHOOL LIFE 263 
 
 early age, to Nursery Schools (as recommended by 
 the Consultative Committee of the Board of Educa- 
 tion), ample opportunity will be afforded for the school 
 * doctor and the school nurse to indicate necessary 
 remedial measures with a view to preventing the usual 
 occurrence of serious deformities and of excessive 
 malnutrition. Preventive and remedial treatment 
 should He in the direction of securing for the child an 
 adequate supply of direct sunlight and fresh air and 
 a liberal diet including milk and fat. Special regard 
 must be paid in school to the posture and habits of 
 rickety children as well as to their teeth. The pre- 
 disposition of rickety children to bronchial attacks 
 and tuberculosis must also be pointed out to parents 
 and teachers. 
 
 Rheumatism is not merely an affection of the joints 
 but a general disease which may attack the joints, 
 heart, brain, or other tissues. It is essentially a heredi- 
 tary disease, that is to say, children of rheumatic 
 parentage are very susceptible to attacks of the disease 
 in one or other of its many forms. 
 
 Causes. Probably caused by the entrance of specific 
 germs into the body, possibly through the tonsils, as 
 rheumatic subjects are liable to attacks of tonsilHtis. 
 Susceptibility to the disease is an important factor in its 
 causation. Chorea, which is a symptom of rheumatism, 
 may be caused by shock or fright in a neurotic child 
 of rheumatic parentage. 
 
 Symptoms : (a) of predisposition : sHght pains in 
 muscles or joints, ' growing pains ' ; abnormahties of 
 
264 MEDICAL INSPECTION OF SCHOOLS 
 
 nervous system and of nutrition, anaemia, nervous 
 excitability, night terrors. 
 
 (b) Of general rheumatism : frequent attacks of ton- 
 sillitis; fibrous nodules under the skin, especially at 
 the knuckles, elbows and knees ; eruptions (erythema 
 nodosum, purpura), and other symptoms of pre- 
 disposition. 
 
 (c) Of joint affections : pains, redness, and swelUng 
 of joints ; symptoms fly rapidly from joint to joint. 
 In sub-acute cases symptoms are less pronounced. 
 
 {d) Of brain affection, which is chorea, or St. Vitus' 
 dance. Unstable nervous condition, inability to sit 
 still, ' fidgets ' ; muscular weakness, irritability, involun- 
 tary twitching of fingers and face muscles, developing 
 later into irregular, unco-ordinated and purposeless 
 movements of arms, head, and lower limbs ; awkw^ard, 
 jerky gait. 
 
 (e) Of heart disease : generally very insidious in its 
 onset : slight palpitation, shortness of breath, pallor ; 
 in advanced cases, when the heart muscle has begun 
 to give way, blueness of the lips, face, and hands ; 
 difficulty in breathing ; swelling of the feet. 
 
 School life. Rheumatism is particularly a disease 
 of school life. It seldom occurs before three or four 
 years of age, and the first attack is seldom postponed 
 after fifteen or sixteen years. The disease is insidious 
 in its onset, obstinate in its persistence, and especially 
 prone to recurrence. The most essential point is for 
 the school doctor and for the teacher to discover early 
 the children of rheumatic parentage and tendency and 
 
DISEASES AFFECTING SCHOOL LIFE 265 
 
 to prevent them from acquiring the disease. The 
 symptoms of hereditary predisposition have been indi- 
 cated. Each one of these symptoms occurring in 
 a school child requires careful consideration. When 
 the rheumatic tendency has been diagnosed, the doctor 
 should prescribe a modified school curriculum, that is 
 to say, avoidance of long hours and overpressure. 
 Moreover, he should indicate to the parent the special 
 need for careful attention to diet and clothing as well 
 as for an abundance of fresh air, sunshine, and for the 
 prevention of any evil results consequent upon damp- 
 ness or chills. Ten or twenty children of this kind 
 will be found in every large school, and these, together 
 with those suffering from general debility and mal- 
 nutrition, should be grouped together for a somewhat 
 modified curriculum. The first signs of an attack, 
 whether of rheumatic fever, chorea, or heart disease, 
 should be sufficient for the child to cease attendance 
 at school. 
 
 In the case of chorea, absolute quiet and rest in bed 
 are essential from the outset. After an attack, which 
 usually lasts from one to two months, the child, still 
 being susceptible to rheumatism and heart disease, 
 should not return to school immediately, but should 
 be treated as an invalid for six months. Overpressure 
 and undue excitement should be avoided, and there 
 should be no unnecessary exposure to adverse con- 
 ditions of weather. 
 
 All children suffering from heart disease, whether in 
 the early or in the more advanced stages, should, if 
 
266 MEDICAL INSPECTION OF SCHOOIS 
 
 possible, be transferred to special schools for physically 
 defective children. 
 
 Dr. F. J. Poynton, in summarizing a paper ^ upon 
 rheumatism and school attendance, emphasizes four 
 main considerations : (1) the excitable nature of the 
 child of rheumatic parentage ; (2) the danger of active 
 rheumatism when untreated by rest ; (3) the stubborn 
 and relapsing character of the disease ; (4) the delicacy 
 of children left with chronic heart disease. 
 
 Tuberculosis — a disease caused by the entrance of 
 the tubercle bacillus into the body, may affect any 
 organ — glands, lungs, joints, especially those which 
 have been exposed to injury or infection. In children 
 the bony structures are more often affected than the 
 lungs : hence the greater frequency of hip-disease and 
 other bone affections. Healthy, normally developed, 
 children are seldom affected : the so-called strumous 
 type of child who may have inherited or acquired 
 predisposition to the disease is always susceptible. 
 
 Symptoms. Tuberculosis of the lungs is phthisis or 
 consumption ; persistent cough, blood-spitting, wast- 
 ing and anaemia are symptoms. 
 
 Affection of bones or joints gives rise to persistent 
 pain, chronic swelling and deformity. Hip-disease is the 
 commonest form, of which persistent limp is often the 
 earliest sign ; the knees and ankles are also frequently 
 affected. 
 
 1 The Problems of Ill-health and School Attendance. F. J. Poynton, 
 Transactions Second International Congress on School Hygiene, vol. ii, 
 p. 605. 
 
DISEASES AFFECTING SCHOOL LIFE 267 
 
 Tuberculosis of the spine is known as Pott's disease ; 
 spinal rigidity and persistent pain are the first signs. 
 
 Tuberculosis of glands is very insidious ; it leads to 
 local swelling and inflammation, ansemia, general de- 
 bility, and malnutrition, and may predispose to the 
 disease attacking other organs. The local swelHng 
 sometimes results in abscess formation. 
 
 When the disease attacks the skin of the face it is 
 known as lupus — now readily treated by the Rontgen 
 rays or by the Finsen light treatment. 
 
 Precocity or an abnormal degree of intelligence is 
 often a characteristic sign of tuberculosis. 
 
 Tubercular meningitis is a fatal form of the disease 
 in which the membranes of the brain are attacked. 
 
 It is seldom met with at school, as even in its earhest 
 stages the child is too iU to remain in attendance. 
 The disease begins with irritabihty, fretfulness and 
 other signs of an altered temperament. It is always 
 fatal. 
 
 Results. Chronic invalidism ; impaired health and 
 physique ; deformity of bones, chest, and joints, per- 
 manent crippling ; prolonged absence from school, great 
 educational loss to the child; liability to recurrence. 
 Complete recovery often is the result of persistent and 
 prolonged treatment. 
 
 School Life. Three forms of the disease require 
 special consideration in regard to school life : — 
 
 1. Of the glands. 
 
 2. Of the hip and spine. 
 
 3. Of the lungs. 
 
268 MEDICAL INSPECTION OF SCHOOLS 
 
 They have one point in common, namely, that early 
 diagnosis, continuous treatment, and prolonged con- 
 valescence are essential. 
 
 1. Tuberculosis of the glands is possibly the least 
 disastrous form of the disease, but at the same time it 
 is the most insidious, and frequently is unobserved. 
 Being a constant focus of danger, it predisposes to the 
 infection of other organs, especially the lungs. After 
 an attack of measles or whooping-cough, the bronchial 
 glands frequently become the seat of tubercular affec- 
 tion which cannot be discovered. It is often impossible 
 to decide whether chronic glandular enlargement is 
 tubercular or not. Therefore, the only safe rule is to 
 treat all children of the well-known strumous or scrofu- 
 lous constitution — that is to say, all children of a weakly, 
 debihtated appearance, with flaxen hair, long silken 
 eyelashes, smooth' skin, as well as children with en- 
 larged glands, or those constantly suffering from coughs 
 and cold — as if they had an unrevealed form of tuber- 
 culosis. In this way the disease can be cured in its 
 earliest stage. A child thus affected attends school 
 with fair regularity, but is thought to be ' delicate ', is 
 excused attendance on wet or foggy days, and is often 
 injudiciously pampered at home. 
 
 2. Tubercular disease is a very common cause of 
 bony deformity in the school child. Owing to its 
 chronic character a child may remain for years in hos- 
 pital or nursing home. Absence from school is pro- 
 longed and results, in addition to the permanent 
 crippling, in great educational loss to the child. Such 
 
DISEASES AEFECTING SCHOOL LIFE 269 
 
 children, however, are often abnormally intelligent 
 and precocious. There is a crying necessity for the 
 establishment of a large number of small residen- 
 tial convalescent schools for these children. On their 
 complete recovery and return to school life, they still 
 require special educational treatment, both mentally 
 and physically, such as is given at the special schools 
 for physically defective and crippled children. 
 
 3. In comparison to the other forms of the disease, 
 pulmonary tuberculosis or consumption is relatively 
 uncommon in school life. It is, however, more serious 
 in its results, and is often fatal. It is probable that 
 the disease in its early stages, or before it is revealed, 
 often escapes detection. All cases of pleurisy should be 
 treated as if of tubercular origin . Children suffering from 
 active symptoms — cough, expectoration, and wasting 
 — should be excluded from school for immediate treat- 
 ment, and partly also to prevent the possibility of 
 other susceptible children being affected by too close 
 personal contact. Early diagnosis is essential. Children 
 suffering from this form of disease should certainly be 
 placed in hygienic surroundings and should be sent for 
 sanatorium treatment until the disease is cured. On 
 their return they should be kept under medical super- 
 vision. 
 
 Bronchitis is a catarrh or inflammation of the bron- 
 chial tubes. It has no particular importance with 
 regard to school life except that it is commonly asso- 
 ciated with rickets and frequently occurs as an after- 
 result of measles, whooping-cough, and other infectious 
 
270 MEDICAL INSPECTION OF SCHOOLS 
 
 diseases of childhood. Children, on their return after 
 these diseases, especially those coming from poor homes, 
 should be kept under careful supervision by the school 
 nurse or doctor, and the parents should be warned and 
 instructed. Children suffering from an acute attack 
 of course remain away from school, but many children 
 subject to chronic bronchitis attend school and need 
 medical supervision. The liability to tubercular infec- 
 tion should be borne in mind. Great care should be 
 exercised to prevent the present day tendency towards 
 the coddHng and pampering of the children. 
 
 Nervous Diseases of Childhood. The neurotic tem- 
 perament is only in part an outcome of modern civiliza- 
 tion. It means ' a disposition in which the emotions 
 are easily kindled, strongly felt, and restrained or con- 
 trolled with difficulty '} It is especially important in 
 school life, because, apart from marked cases, the first 
 obvious signs of the disposition are commonly expressed 
 soon after the child leaves the infant school. All 
 children by nature suffer from nervous instability ; 
 but, in addition to the instability common to their kind, 
 certain children, either from heredity or from un- 
 natural conditions of life, definitely acquire an ' indi- 
 vidual instability ' — a neurotic temperament — towards 
 the end of the first decade of life. Their future life can, 
 as a rule, be either marred or made during their pro- 
 gress through the elementary school. * The emotional 
 
 ' Functional Nervous Disorders in Childhood, Dr. Leonard G. Guthrie, 
 Oxford Medical Publications — a valuable work that has been freely 
 consulted in the preparation of these notes upon nervous diseases. 
 
DISEASES AFFECTING SCHOOL LIFE 271 
 
 temperament may be modified, though it cannot be 
 eliminated, by training and environment.' 
 
 Overpressure is a convenient term used to signify 
 educational overstrain. 
 
 Causes. Preparation for scholarships and competi- 
 tive examinations involving concentration upon only 
 one or two subjects ; excessive homework, especially in 
 a child of a neurotic temperament, or if the overstrain is 
 aggravated by ansemia, malnutrition, or by other un- 
 hygienic conditions at home or in the school, such as 
 long hours of work, too little play and sleep. ' Educa- 
 tional overstrain is more frequently due to fact cram- 
 ming than to imparting general information.' 
 
 Symptoms. Inattention, lapses of memory, mental 
 dullness, incapacity for concentration and for pro- 
 longed mental effort ; headaches, absence of mind, ' le 
 petit mal,' drowsiness. On the other hand, there 
 may be undue restlessness, nervous excitability, irrita- 
 bility, night terrors and screaming, and hysteria. ' The 
 symptoms and physical signs of mental overstrain in 
 adults and in children are much alike — although the 
 child seldom draws attention to them.' 
 
 Results. Physical and mental prostration, brain 
 exhaustion. If continued, it leads to neurasthenia and 
 chronic invahdism. 
 
 Neurasthenia represents a condition of chronic 
 nervous instability. * It is the outcome or result of 
 the neurotic temperament when subjected to unfavour- 
 able conditions and surroundings.' 
 
 Causes. Hereditary predisposition — the neurotic 
 
272 MEDICAL INSPECTION OF SCHOOLS 
 
 temperament — or it is the result of injudicious up- 
 bringing or of overpressure. 
 
 Symptoms. The familiar symptoms of neurasthenia, 
 so commonly met with in adult life, are seldom seen in 
 childhood. But recurring attacks of moodiness, irrita- 
 bility and depression, or of hysteria and other neurotic 
 affections, are, even in the child, definite symptoms of 
 neurasthenia. There may also be subjective symptoms 
 such as constant pains, muscular weakness, h3rper- 
 sensitiveness to pain. These symptoms are the result 
 of personal sensations and psychic effects, or of 
 imaginary evils rather than of any definite organic 
 disease. 
 
 Results. Physical and mental helplessness and ineffi- 
 ciency ; chronic invalidism ; hysteria and other neurotic 
 diseases. 
 
 School Life. A special regime is necessary for all 
 children suSering from overpressure and nervous dis- 
 orders. They should be grouped, for modified educational 
 treatment, with children suffering from chronic rheuma- 
 tism, malnutrition, general debility, and the after-efEects 
 of depressing infectious diseases. 
 
 During the summer and early autumn months, a 
 period of five or six months at an open-air recovery 
 school should be sufficient to restore them to health. 
 At the same time there is need to secure the co-opera- 
 tion of the parents in adapting the home conditions to 
 the requirements of the children. By some such proce- 
 dure as this, it should be possible to fit many of the 
 neurotic and overpressed children to take their place 
 
DISEASES AFFECTING SCHOOL LIFE 273 
 
 again in the ordinary school under the supervision of 
 a sympathetic teacher. 
 
 Hysteria is an uncommon affection of school 
 children. There is, however, a condition known as 
 school or class hysteria — more common in Russia and 
 Germany and other continental countries than in 
 Great Britain. It is characterized by an explosive 
 excitability of the higher nervous centres which may 
 be expressed in sensory or motor paralysis and in 
 deficient emotional control. An example will make 
 this clear. At a school situated in a well-to-do district 
 in London a little girl, who was afflicted with infantile 
 palsy of the left arm, broke her right arm, and was 
 absent from school for several weeks. Within a few 
 days after her return, three children had lost the use 
 of their left arms, and a fourth, being of a rheumatic 
 disposition, had such severe pains in her left arm that 
 she held it to her side and could not be persuaded to 
 use it. All the children were of a neurotic tempera- 
 ment. Two were of Polish extraction : one was very 
 ill-developed, one very affected in manner and speech, 
 and another was supposed to have heart disease. By 
 suggestion, the children were induced to move their 
 arms freely and the head mistress was instructed to 
 see that they did not become paralysed again. The 
 outbreak ended. 
 
 Epilepsy is a disorder of the nervous system charac- 
 terized by loss of consciousness, with or without con- 
 vulsions. It represents an unstable or an explosive 
 condition of certain nerve cells. In the majority of 
 
 HOGARTH rp 
 
274 MEDICAL INSPECTION OF SCHOOLS 
 
 cases the first attack occurs before the age of 
 puberty. 
 
 Causes. The cause of epilepsy is, generally speaking, 
 unknown. In a few cases, especially in neurotic chil- 
 dren, some definite source of local irritation (e. g. indi- 
 gestion, worms, painful dentition) is believed to be the 
 exciting cause of an attack ; but similar sources of 
 irritation do not produce epilepsy in normal children. 
 There is no doubt that heredity plays an important 
 part in causation — if not in the disease itself, at least 
 in the predisposition to it. Epilepsy commonly occurs 
 in children of insane, eccentric, hysterical, neurasthenic, 
 
 or of alcoholic parents. 
 
 Symptoms : (a) Of latent epilepsy (in predisposed 
 children) : inattention, forgetfulness, dreamy mental 
 states ; marked irritability and sudden passions ; head- 
 aches, migraine, disturbed sleep ; night terrors ; incon- 
 tinence of urine ; spasms, involuntary movements. 
 
 (b) Of * petit mal ' ; this condition simulates a 
 fainting attack, and is accompanied by sudden pallor 
 associated with an absent or a dazed appearance and 
 momentary loss of consciousness. The child may 
 suddenly stop speaking, or whatever it may be doing, 
 and stares fixedly without repljdng to questions. 
 
 (c) Of ' grand mal ' or convulsions. The symptoms of 
 an epileptic fit are too familiar to require detailed 
 description. The child is generally warned of an im- 
 pending seizure by some localized sensation of indi- 
 gestion, or of sight or hearing, or by some psychical 
 disturbance, then suddenly loses consciousness and 
 
DISEASES AFFECTING SCHOOL LIFE 275 
 
 falls to the ground. The hands are clenched, the teeth 
 become fixed, often biting the tongue ; the muscles 
 are rigid and the patient frequently foams at the 
 mouth. This stage is soon followed by sHght or by 
 violent movements of the muscles. Relaxation follows 
 and the child falls into a profound sleep. On waking, the 
 child may be to all appearances normal, suffering only 
 from headache or from a confused state of mind. Some- 
 times a trance-like condition follows an attack, in which 
 the patient may unconsciously perform certain auto- 
 matic actions, such as undressing. 
 
 {d) Of chronic epilepsy. The frequent recurrence of 
 epileptic fits leads to impairment of physique and of 
 mental capacity. The child becomes anaemic and often 
 acquires a defective appearance. Chronic epilepsy is 
 commonly associated with congenital mental deficiency. 
 
 School Life. As far as school Hfe is concerned, 
 epileptics must be divided into three classes : — (1) Those 
 who suffer only from ' petit mal ' or from sHght fits in 
 bed at night-time or on waking. Such children should 
 be allowed to attend the ordinary schools or they might 
 be separated with other dehcate and neurotic children 
 into special classes for educational treatment ; and 
 during the summer months at least they should be 
 sent to open-air recovery schools. (2) Those who suffer 
 from infrequent attacks of ' grand mal ' without any 
 other bad symptoms, and are otherwise normal in 
 intellectual attainments. Such children should be 
 excluded from ordinary schools, as an epileptic seizure 
 in a classroom, even once a month, is disturbing to the 
 
 T 2 
 
276 MEDICAL INSPECTION OF SCHOOLS 
 
 children and distressing to the teacher. They should 
 be transferred to special epileptic schools and should 
 be under constant medical supervision and treatment. 
 (3) Those who, on account of the frequency or the 
 severity of their seizures, or on account of special 
 eccentricities or resulting impairment of mental capacity 
 are suited only for detention at epileptic colonies. 
 
 In deaUngwith this subject, Dr. Pojniton has drawn 
 attention to two main problems which require con- 
 sideration in every case of epilepsy : — (a) The frequency 
 and character of the actual fits, and (b) the mental state 
 of the affected children. No hard and fast set of rules 
 can be drawn up for the educational treatment of these 
 three groups of epileptic children, but each case must 
 be considered on its individual merits. 
 
 Mental Deficiency. It is impracticable to deal in 
 a few Hnes with the causes and symptoms, or even 
 with the school aspect, of mental deficiency. The 
 methods of examination, as well as a practical classifi- 
 cation of mentally defective children, according to their 
 educational requirements, have already been indicated 
 briefly.^ Cases of 'word-blindness', 'word-deafness', 
 and of cretinism are occasionally met with. 
 
 Special provision is made by Acts of ParHament for 
 the educational treatment of all grades of mental defect 
 between imbecility and natural dullness or backward- 
 ness, as well as for blind and deaf children. It rests 
 with local education authorities to fulfil their responsi- 
 biUties ; and, as has been suggested, the estabUshment 
 
 ^ Cf. chap, xi, p. 164; also chap, xiii, p. 202. 
 
DISEASES AFFECTING SCHOOL LIFE 277 
 
 of intermediate or lower grade schools in large towns, 
 and of special classes in smaller towns, is essential for the 
 educational treatment of dull and backward children. 
 
 Blind and Deaf Children. Special schools have 
 been established in London for these children — nine 
 for the bhnd and thirteen for the deaf. There are also 
 institutions in other parts of England. Nearly half 
 the cases of ' educational bUndness ' are the result of 
 neglect and specific infection during the first week of 
 life ; others are suffering from high myopia, congenital 
 cataract, or from scarring of the cornea. There is, 
 however, a still greater need for the provision of special 
 educational treatment for semi-bhnd children suffering 
 from chronic eye affections. Such children should be 
 prevented from doing any fine or close work, such as 
 sewing or writing and drawing with pens and pencils 
 on paper or on slates. Similarly for a large group of 
 semi-deaf children special educational facihties are 
 needed. With regard to the ' educationally deaf ', there 
 is Httle certain knowledge ; nor are the various com- 
 binations of mental deficiency with defects of special 
 senses properly understood. An attack of cerebro- 
 spinal meningitis in infancy is responsible for a large 
 proportion of blind and deaf cases, whether or not 
 associated with mental deficiency. All children attend- 
 ing blind and deaf schools should be under constant 
 medical supervision. 
 
 Stammering. Speech defects have already been 
 considered at some length.^ But no special reference 
 
 ^ See chap, xi, p. 163. 
 
278 MEDICAL INSPECTION OF SCHOOLS 
 
 to stammering or stuttering was made. Stammering 
 results from spasm of the respiratory muscles in the 
 act of speech ; the spasm may also be associated with 
 inco-ordination between the articulatory and the respira- 
 tory muscles. ' Stammering is a spasmodic arrest of 
 utterance. ' * Stuttering consists in spasmodic repetition 
 of initial syllables of words ', and, being almost entirely 
 due to imperfect breathing, is more amenable than 
 stammering to treatment by respiratory exercises. 
 Children suffering from speech defects should be trans- 
 ferred to special classes or special schools for temporary 
 educational treatment. 
 
 For a detailed account of this subject Dr. Leonard 
 Guthrie's book on functional nervous disorders in 
 childhood should be consulted. 
 
 B. SYMPTOMATIC OH LOCAL DISEASES 
 
 Anaemia implies an impoverished state of the 
 blood system due to a reduction in the amount of 
 blood as a whole or of its constituents, especially of 
 the red corpuscles or of their contained haemoglobin. 
 During school life it is seldom a separate entity, but, 
 for the most part, only a symptom of some local or 
 general disease. 
 
 Causes. Frequent haemorrhages or losses of blood ; 
 malnutrition and general debility, aggravated by bad 
 housing conditions, want of fresh air, improper food or 
 insufficient sleep ; rickets ; the rheumatic tendency ; 
 tuberculosis ; hereditary syphilis ; Bright's disease, 
 
DISEASES AFFECTING SCHOOL LIFE 279 
 
 especially following scarlet fever ; digestive disturb- 
 ances. 
 
 School Life. Anaemia is important because it is 
 commonly neglected. Its cause should, if possible, be 
 discovered by the school doctor, before the parents are 
 instructed to seek advice. In most cases a child 
 suffering from anaemia should continue in attendance 
 at school, but for a large number some modification 
 of the school curriculum is required. Many are 
 especially suited for transference, for a time, to open- 
 air recovery schools. For those suffering from rheu- 
 matism or tuberculosis the appropriate treatment has 
 already been indicated. All cases should be treated, 
 in accordance with common-sense principles, by means 
 of improved hygienic conditions as to sun, fresh air 
 and better food rather than by medicinal treatment in 
 the form of arsenic or iron. 
 
 Towards the close of school life anaemia may be 
 a sign — especially in girls — of physiological changes at 
 puberty. 
 
 Headaches. Headache is a symptom of great im- 
 portance in relation to school Hfe. It is essential 
 that the cause of the trouble should be discovered as 
 early as possible. 
 
 Causes. Apart from being an early symptom of an 
 acute illness, headaches may either be occasional or 
 habitual. Occasional or temporary headaches in school 
 are due to overheated rooms (temperature above 
 62° or 63°), to want of adequate ventilation, fresh air 
 or of exercise, to temporary overwork, or to nasal 
 
280 MEDICAL INSPECTION OF SCHOOLS 
 
 catarrh. Frequent or habitual headaches may be due 
 to any of the above causes if persistent ; but more 
 generally to eye-strain or defective vision, to anaemia, 
 decayed teeth or digestive disturbance, to over- 
 pressure, to an epileptic or other neurotic predis- 
 position. 
 
 All these causes except those due to overpressure, 
 migraine, and the neurotic temperament can be 
 removed instantly. The headache of the overpressed 
 neurotic child is more difficult to deal with. In the 
 past the poHcy has often been to keep the child from 
 school, to treat him as delicate, to pamper him inju- 
 diciously with extra clothes, extra food and extra 
 attention. The policy of the future should be to keep 
 the child at school under improved surroundings, to 
 impress upon the parents the necessity for altered con- 
 ditions of life and to send the worst cases for educa- 
 tional treatment at open-air recovery schools. 
 
 Sore throat is a condition to which much attention 
 must be paid in school. Many children are subject to 
 sore throat, especially mouth-breathers and those who 
 suffer from chronic pharyngitis, enlarged tonsils and 
 adenoids, or the rheumatic tendency. Nearly all sore 
 throats are the result of infection from a previous case 
 or of so-called ' contact infection '} Therefore they 
 must always be regarded with suspicion. From the 
 school point of view and until such time as a scientific 
 classification, based on bacteriological examination, can 
 
 ' Contact infection implies the transference of quite fresh infectious 
 matter by means of pencils, sweets, &c. 
 
DISEASES AFFECTING SCHOOL LIFE 281 
 
 be prepared, sore throats may be divided for practical 
 purposes into two kinds : — 
 
 1. Severe: sufficient to keep the child away from 
 school and giving rise to general symptoms. 
 
 2. Slight: not involving the child's absence from 
 school for more than a day or two, if at all. 
 
 This classification, depending as it does on the 
 attendance or non-attendance of a child at school, is 
 based on incontrovertible fact, and is unaffected by 
 the varying standard of severity adopted by careful 
 and by neglectful parents. 
 
 Sore throat of the first type is of little account, so 
 far as the spread of infectious disease in school is con- 
 cerned, and may be due to : — 
 
 (1) Diphtheria. 
 
 (2) Scarlet fever. 
 
 (3) Follicular tonsillitis or epidemic sore throat. 
 
 (4) Influenza. 
 
 (5) Acute pharyngitis or laryngitis. 
 
 Under this heading sore throats are only of import- 
 ance before the absence and after the return of the 
 children to school ; and experience shows that, com- 
 paratively speaking, few secondary cases are contracted 
 in school from these severe sore throats. 
 
 Sore throat of the second type may be due to : — 
 
 A. Specific Infectious Diseases. 
 
 (1) Diphtheria. 
 
 (2) Scarlet fever. 
 
 (3) Follicular tonsillitis or epidemic sore throat. 
 
282 MEDICAL INSPECTION OF SCHOOLS 
 B. Other conditions not generally regarded 
 
 AS INFECTIOUS. 
 
 (1) Influenza or severe cold. 
 
 (2) Nasal catarrh (especially when associated with 
 
 adenoids). 
 
 (3) Rheumatism. 
 
 (4) Chronic tonsillitis. 
 
 (5) Pharyngitis and laryngitis. 
 
 This subdivision of slight sore throats into two 
 groups — the specific infections of diphtheria, scarlet 
 fever and follicular tonsillitis and the remainder is 
 important. 
 
 With regard to the second category, children should 
 be excluded from school till all symptoms are abated. 
 No special precautions need be taken to prevent spread 
 of cases in school. 
 
 The first group, being infectious, are of special 
 importance when definite cases of these diseases 
 have previously been reported from the same class- 
 room or from the same houses or streets in which the 
 affected children live. In such circumstances all sore 
 throats should be treated as guilty until proved 
 innocent. 
 
 With the object of discovering mild or missed cases 
 of these conditions in school, the following routine may 
 be found valuable. When two or more cases of sore 
 throat, whether due to scarlet fever, diphtheria or 
 epidemic sore throat, have occurred in one classroom, 
 the teacher should be instructed to keep a list of all 
 children absent for a whole day or more, especially if it 
 
DISEASES AFFECTING SCHOOL LIFE 283 
 
 be a Friday or a Monday.^ On their return the 
 children or the parents should be questioned as to 
 whether the absence has been due to indisposition. 
 If indisposition is admitted, they should be cross- 
 questioned as to the presence of sore throat. If sore 
 throat has occurred, no child should be readmitted 
 except on medical authority. In the case of diphtheria 
 bacteriological examination is essential. In the case 
 of scarlet fever the presence of headache and 
 vomiting synchronous with the appearance of sore 
 throat should be considered as sufficient evidence to 
 treat the case with suspicion for two to three weeks 
 in order to watch for desquamation or for nasal excoria- 
 tion. The rash of a mild case of scarlet fever is often 
 so evanescent that its alleged absence may be regarded 
 as evidence of little value. 
 
 With regard to follicular tonsillitis or epidemic sore 
 throat, the children should not be re-admitted until one 
 week after all signs and symptoms of sore throat have 
 subsided. 
 
 In the case of sore throat, medical certificates of 
 freedom from infectious disease are of httle value 
 unless the doctor, before certifying, has realized that 
 the child has been exposed to the infection of scarlet 
 fever, or unless in the case of diphtheria he bases his 
 certificate upon bacteriological examination. 
 
 By some such procedure as this, it will be possible to 
 
 ^ Absence on a Friday or a Monday implies that the child has not 
 been under observation for three whole days, quite long enough a period 
 for a mild attack of scarlet fever. 
 
284 MEDICAL INSPECTION OF SCHOOLS 
 
 prevent the spread of infection in school — which cannot 
 be as readily arrested by the daily visit of a school 
 doctor as by faithful co-operation on the part of head 
 teachers. 
 
 Sore throats at the beginning of an attack of influ- 
 enza or of a severe cold present the greatest difificulty. 
 If there have been any cases of scarlet fever or diph- 
 theria in the same classroom or many such cases in 
 the district they should be regarded with suspicion. 
 If not, they may be allowed to return to school in the 
 ordinary course, when all symptoms have disappeared. 
 
 Mouth-breathing is a very common symptom 
 among school children of all ages. Professor Osier has 
 suggested that there are more mouth-breathers per acre 
 in England than in any other country in the world, 
 and has indicated the possibihty of chmatic influence 
 as a factor in its causation. At all events, it appears 
 to be equally common among town and country 
 children. Many years ago Kit CatHn published a 
 pamphlet entitled ' Shut your mouth and save your 
 Life ', but the importance of the subject has only 
 recently attracted attention. The pamphlet was well 
 illustrated to show the difference between mouth- 
 breathing and nasal breathing and their effect upon the 
 appearance, physique and character of the children. 
 
 Mouth-breathing is of two kinds : (1) Habitual, due 
 to an acquired habit; (2) Obstructive, due to some 
 definite obstruction in the nasal or respiratory passages. 
 Habitual mouth-breathing arises from careless up- 
 bringing and disuse of a pocket-handkerchief. The 
 
DISEASES AFFECTING SCHOOL LIFE 285 
 
 habit of mouth-breathing by day and of snoring by 
 night is acquired because the nasal passages are 
 allowed to become blocked with mucus. Mouth- 
 breathing gives the impression of stupidity, and 
 there is little doubt that mouth-breathers are more 
 disposed to nasal catarrh and diseases of the respiratory 
 tract. The good effect of nasal breathing can be 
 demonstrated by providing pocket-handkerchiefs to 
 the infants' department of certain schools and by 
 contrasting the appearance of the children after three 
 to six months' practice in their use. When mouth- 
 breathing is due to obstruction, adenoid growths in the 
 naso-pharynx are by far the commonest cause. Other 
 causes, such as nasal polypi, chronic nasal catarrh, 
 enlarged turbinal bones, deviated septum, need only 
 be mentioned. 
 
 The remedy and prevention is very simple and can 
 be carried out even in the poorest quarters of populous 
 centres. The daily practice of breathing exercises 
 should not^ be undertaken until the nasal passages have 
 been adequately cleared by the proper use of the 
 pocket-handkerchief — an elementary principle of com- 
 mon sense often disregarded in practice. 
 
 Adenoids is a convenient term used to signify the 
 abnormal or excessive growth of lymphoid tissue in 
 the post-nasal or naso-pharyngeal space. As a result 
 of this abnormal growth, the posterior nares are 
 partially blocked and nasal breathing is difficult. 
 This difficulty breeds habit. The adenoids continue 
 to grow ; and, as a result, a vicious circle is established. 
 
286 MEDICAL INSPECTION OF SCHOOLS 
 
 Their exact causation has not been determined. Some 
 authorities regard their presence as an expression of 
 disease following measles, whooping-cough or influenza ; 
 other authorities as due simply to an unexplained 
 overgrowth of lymphoid tissue — possibly as a result 
 of the mucous membrane and nasal passages not being 
 properly cooled by the intake of cold air. It is impos- 
 sible to say whether nasal catarrh is due to the presence 
 of adenoids and the nasal obstruction or whether the 
 adenoids are the result of nasal catarrh. The tjrpical 
 appearance of a child suffering from adenoids is too 
 well known to require description. The evil results, 
 however, are not always fully appreciated and may be 
 given in tabular form : — 
 
 1. Nasal catarrh ; liability to colds and bronchitis. 
 
 2. Deafness and ear discharges. 
 
 3. Sore throat ; susceptibility to infectious disease 
 and tuberculosis. 
 
 4. Enlarged glands in neck. 
 
 5. Lowered mental capacity ; dullness, spurious 
 f eeble-mindedness . 
 
 6. Impairment of general nutrition and physique ; 
 lowered vitality ; predisposition to chest disease and 
 tuberculosis. 
 
 7. Deformity of nasal passages and also of chest. 
 When the presence of adenoids has been definitely 
 
 ascertained, they should be removed by a surgical 
 operation. In spite of their removal they commonly 
 recur, though this tendency may possibly be overcome 
 by the practice of suitable breathing exercises. 
 
DISEASES AFFECTING SCHOOL LIFE 287 
 
 Enlarged tonsils represent an overgrowth of tissue 
 normally present. The cause of this overgrowth has 
 not been definitely ascertained, but it may result from 
 frequent attacks of inflammation. It undoubtedly 
 occurs very commonly in children of rheumatic ten- 
 dency ; and, as Dr. George Stewart has pointed out, 
 the condition is associated with a septic state of the 
 mouth due to defective and carious teeth with enlarged 
 submaxillary and cervical glands. In school life 
 enlarged tonsils are important because, like adenoids, 
 they obstruct respiration and are a potential source of 
 danger when exposed to the infections of diphtheria, 
 scarlet fever, rheumatism or influenza. For these 
 reasons their removal should be advised. 
 
 Otorrhoea (or discharging ears) signifies a catarrhal 
 condition of the ear passages and is often the result of 
 chronic inflammation following scarlet fever or measles. 
 Sometimes the condition may merely be due to the 
 presence of a foreign body, such as a pea or a bead, 
 or to an excessive accumulation of wax. Otorrhoea 
 is frequently associated with, or secondary to, the 
 presence of adenoid growths or enlarged tonsils. An 
 ear discharge may signify a more serious condition, 
 such as acute inflammation of the middle ear with the 
 constant risk of extension of the disease to the cranial 
 cavity leading to meningitis. As far as school hfe is 
 concerned, otorrhoea frequently causes permanent 
 deafness and results in marked educational backward- 
 ness. Occasionally also the discharge becomes offen- 
 sive, necessitating exclusion of the affected child from 
 
288 MEDICAL INSPECTION OF SCHOOLS 
 
 school. The condition is generally very chronic. 
 Many cases go on for months and months. They 
 require skilled attention daily, often syringing two or 
 three times a day, which cannot in most instances be 
 satisfactorily undertaken by the parents. 
 
 Foreign Bodies. In the case of a foreign body 
 being impacted in the ear or nose the child should be 
 referred for medical treatment. There should never be 
 any amateur attempt on the part of teachers to remove 
 such things as impacted peas or beads from a nose 
 or ear. In the case of a small piece of grit or dust 
 getting into the eye and causing irritation, it will be 
 well for the teachers to learn how to evert the upper 
 and lower eyelids with a view to removing the foreign 
 body by means of a clean pocket-handkerchief. 
 
 Accidents. These are dealt with fully in manuals 
 and textbooks on first aid to the injured, and are not 
 met with so commonly at school as at home. 
 
 Enlarged Glands in the neck are very common 
 but are frequently unobserved. They are the secondary 
 result of definite infection which may be either general 
 or local. General infection, usually associated with 
 anaemia, debility or malnutrition, occurs in the strumous 
 type of child and is often an insidious form of tuber- 
 culosis. Other glands in the body are usually affected 
 at the same time. Infection, however, is more com- 
 monly of local origin and, in the case of glands in the 
 neck, may be due to temporary affections such as 
 inflamed throat, tonsillitis, and to sore places and 
 eruptions on the scalp or face such as impetigo and 
 
DISEASES AFFECTING SCHOOL LIFE 289 
 
 eczema, or still more generally to chronic conditions, 
 such as a verminous condition of the head or decayed 
 teeth, which cause enlargement of the glands under the 
 jaw. 
 
 The condition of tubercular or of general infection 
 of these glands may be aggravated by a superimposed 
 condition of local origin or vice versa. The glands 
 slowly increase in size and, if the cause is not removed, 
 lead to abscess formation. Treatment must therefore 
 be directed not only to removing the cause of the 
 condition but also to improving the general nutrition 
 and environment of the children. 
 
 Defective Teeth have already been dealt with at 
 considerable length in the chapters on medical treat- 
 ment.^ 
 
 Visual Defects in their relation to school life fall 
 under three heads: (1) External eye diseases ; (2) 
 Internal Eye diseases ; (3) Errors of refraction and 
 squints. 
 
 External Eye Diseases are commonly associated with 
 general debiHty or with malnutrition of local tissues 
 from various causes. The following varieties require 
 special consideration with regard to school children : — 
 
 1. Phlyctenular conjunctivitis is extremely common 
 in neurotic and strumous children, and may be an 
 indication of tuberculosis. Chronic cases can scarcely 
 be dealt with effectively unless a complete change in 
 environment and conditions of Hfe is secured. 
 
 2. Keratitis (inflammation of the cornea) may be 
 
 * Chap, xiv, p. 219, and Chap, xv, pp. 242 and 251. 
 
 HOGARTH XJ 
 
290 MEDICAL INSPECTION OF SCHOOLS 
 
 associated with phlyctenular conjunctivitis or may be 
 due to corneal ulceration which leads to permanent 
 scarring and impairment of vision. Otherwise it is 
 often interstitial in character without any ulceration 
 and is due to inherited syphihs. This variety generally 
 is observed only in the upper standards of the school. 
 Association of Hutchinson's teeth in the affected indi- 
 vidual, or in brothers or sisters, renders the diagnosis 
 clear. 
 
 3. Blepharitis (sore eyes) is either an indication of 
 neglect or of an error in refraction. It is commonly 
 associated with the presence of adenoids and other 
 catarrhal conditions of neglected children. A frequent 
 recurrence of styes indicates a similar tendency. 
 Hypermetropia commonly predisposes to these affec- 
 tions. Dr. Jonathan Hutchinson, many years ago, 
 called attention to the enormous importance of the 
 more common use of ' golden ointment ', as being 
 likely to confer an inestimable benefit on the national 
 well-being. 
 
 4. Contagious affections of the eye will be considered 
 later. 
 
 Internal Diseases of the Eye. Of these, the com- 
 monest affection in school children is disseminated 
 choroiditis, as a result of which a permanently damaged 
 retina is left, often interfering seriously with the visual 
 field. More rarely cases of iritis, due to rheumatism 
 or syphilis, are seen. The eye may be obviously 
 inflamed ; the iris itself has a muddy appearance, and 
 the surrounding blood vessels are injected. To pre- 
 
DISEASES AFFECTING SCHOOL LIFE 291 
 
 vent adhesions to the lens, it is essential that the 
 pupil should be dilated by means of a mydriatic. 
 
 Errors of Befraction. All varieties of defect are 
 commonly met with in school children — short sight, 
 long sight, and astigmatism. It is unnecessary to give 
 an account of errors of refraction, though two or 
 three points, not commonly recognized, must be men- 
 tioned. In all matters deahng with children's eye- 
 sight, the most important factor for consideration is 
 the enormous power of accommodation in the young 
 child — a power which steadily decreases during school 
 life. It is only in neurotic children, with a view to 
 preventing headaches, that a very accurate correction 
 in the error of refraction is required. But no child 
 should be permitted to wear glasses until the refrac- 
 tion has been determined after dilatation of the pupil 
 by means of a mydriatic. As a general rule the 
 strongest convex or the weakest concave glasses are 
 the most suitable for school children. 
 
 Squints in the school child indicate a want of mus- 
 cular balance. A squint frequently appears as the 
 result of general debility and malnutrition, usually 
 following an acute infectious disease or other debili- 
 tating conditions. Habitual squints require immediate 
 attention. If very pronounced at an early age, opera- 
 tive treatment is necessary. If the squint comes on 
 gradually during school life, it is probably the result 
 of excessive convergence associated with hypermetropia 
 and with debiHty or malnutrition, and the defect may 
 be remedied by the use of glasses. An external squint, 
 
 u 2 
 
292 MEDICAL INSPECTION OF SCHOOLS 
 
 associated with short sight, is seldom seen in child- 
 hood. 
 
 Deformities in the school child are of two kinds, 
 (1) congenital ; (2) acquired. Congenital deformities, 
 such as club feet, hare lip, cleft palate, and dislocation 
 of the hip, should have been attended to before school 
 life. Acquired deformities are the result of infantile 
 paralysis, tubercular bone disease, rickets, accidents, 
 or of malnutrition. Most of these have already been 
 considered from the school point of view under their 
 respective headings. There are, however, a few im- 
 portant points in regard to infantile paralysis and 
 lateral curvature of the spine. 
 
 Infantile paralysis is an acute disease of early infancy 
 and leaves its mark in the form of one or more partially 
 or completely paralysed limbs. The acute attack over, 
 prolonged and careful treatment in the form of extra 
 nourishment, massage, and electricity is necessary, but 
 is seldom obtained. The worst cases, requiring either 
 operative treatment or the use of some mechanical 
 apparatus to correct the deformity or to support the 
 limb, should be grouped together for educational pur- 
 poses in special schools for crippled and physically 
 defective children. A nurse capable of giving instruc- 
 tion in remedial exercises should be in attendance. 
 At the same time, these paralytics should be trained 
 to follow trades or occupations suitable to their con- 
 ditions. 
 
 There is another kind of paralysis — generally caused 
 by ha3niorrhage or disease of the brain either at birth 
 
DISEASES AFFECTING SCHOOL LIFE 293 
 
 or shortly after. In these cases, the paralysis is asso- 
 ciated with rigidity and spasm, and with some degree of 
 mental defect. Frequently these children are imbeciles 
 or idiots, and are quite ineducable. 
 
 Scoliosis, or lateral curvature of the spine, is often 
 the result of rickets, but it is primarily associated with 
 debihty and malnutrition. It is common in anaemic 
 girls. Incorrect positions at school are responsible for 
 a large number of cases. The first sign is inequality 
 in the level of the shoulders, or some awkwardness in 
 gait. Slight cases can be treated at home, but children 
 with marked deformity should be sent to special schools 
 for a course of educational treatment by means of 
 remedial exercises and movements. 
 
 C. CEKONIC CONTAGIOUS DISEASES 
 
 NECESSITATING EXCLUSION FROM SCHOOL 
 
 Ringworm is an affection almost peculiar to school 
 life. It is exceeding contagious and is due to a highly 
 resistant vegetable fungus which may affect either the 
 scalp or the skin generally. 
 
 Appearance : on the skin, a round, reddish, scaly 
 patch which causes itching and irritation. The patches 
 tend to clear up in the middle and to spread as an 
 inflamed edge of raised skin. On the scalp, ringworm 
 tends to spread rapidly and to form several bald, 
 scurfy patches on which may be seen the broken 
 stumps of hair, characteristic of the disease. So long 
 as the patches remain scurfy, the disease is active and 
 
294 MEDICAL INSPECTION OF SCHOOLS 
 
 contagious. The serious effects of ringworm upon 
 school Hfe and its treatment have akeady been con- 
 sidered in a previous chapter.^ 
 
 Pavus, a rare disease, is for the most part confined 
 to the alien population in East London, and to the 
 poorest quarters of other towns, Like ringworm, it 
 is due to a highly resistant vegetable fungus. It may 
 be recognized by the yellow, honeycombed and thickly- 
 crusted condition of the scalp. It is exceedingly 
 chronic, and difficult to cure. 
 
 Verminous Conditions. More than half the elemen- 
 tary school population have been affected in some 
 degree with verminous conditions. Not only dirty 
 children but also those who come from what appear to 
 be cleanly homes are affected.^ Head lice are the 
 commonest. Their eggs, generally known as * nits ', 
 are cemented to the hair, and, therefore, are removed 
 with great difficulty. Nits under favourable condi- 
 tions develop into lice in seven or eight days. Boys' 
 hair can be close cropped and their heads cleansed 
 without trouble. The worst obstacle to cleanliness is 
 the imaginary disgrace which girls associate with short 
 hair. As soon as fashion dictates short hair for girls 
 under 12, the problem of verminous heads will be 
 solved. Body lice lay their eggs in the clothes. They 
 are more common in school children than is usually 
 supposed ; but they are only found in the most 
 
 * Chap, xiv, p. 214. 
 
 ' It has been well said : — ' No i^erson should be blamed for having 
 lice, — only for keeping them.' Children are commonly infected by 
 wearing each others' hats and caps, or from combs and brushes. 
 
DISEASES AFFECTING SCHOOL LIFE 295 
 
 neglected children coming from the dirtiest homes.^ 
 With a view to the cleansing of verminous children, 
 new powers and responsibilities have been given to 
 education authorities by the Children Act, 1908. ^ 
 
 Scabies, or itch, is a contagious disease caused by 
 a small parasite which burrows into the skin and lays 
 its eggs. Infection is conveyed from a previous case, 
 generally by means of close personal contact, or by 
 clothes and towels. The thin skin between the fingers 
 and on the back of the wrist and forearm is generally 
 attacked first. The itching, which is usually worse at 
 night, and the characteristic appearance of the burrows 
 accompanied by signs of scratching should lead to an 
 early diagnosis of the case. Affected children must 
 be excluded from school. A hot bath with the free 
 use of soap followed by the application of sulphur 
 ointment for two or three days is a certain remedy. 
 All infected clothes should be thoroughly disinfected 
 by the local sanitary authority before being worn again. 
 
 Impetigo, or infectious sores, frequently attacks dirty 
 and neglected children and spreads rapidly from child 
 to child. It is highly contagious and is often conveyed 
 from one part of the body to another by picking or 
 scratching. Except in very slight cases, aU affected 
 children should be excluded from school. On the 
 scalp it is commonly seen in grossly neglected cases of 
 verminous or other parasitic conditions. It has been 
 observed to occur commonly in classrooms where 
 
 ^ Cf. Chap, xii, p. 185. 
 
 ^ See Appendix II, D. p. 327. 
 
296 MEDICAL INSPECTION OF SCHOOLS 
 
 several of the children have been suffering from sore 
 throat, and sometimes it appears to be associated with 
 outbreaks of scarlet fever and diphtheria. 
 
 Contagious Eye Diseases, usually known as ' bUght ', 
 are common in school. Conjunctivitis as a school 
 epidemic is usually met with as ' pink-eye ' in which 
 a rosy blush of the conjunctiva may be observed. 
 There is an infectious muco-purulent discharge due to 
 the Koch-Weeks bacillus. Outbreaks due to other 
 infections occasionally occur. Constant blinking and 
 dread of light associated with a red and swollen con- 
 junctiva and a muco-purulent discharge are the most 
 obvious signs of the disease. 
 
 Chronic conjunctivitis with ' granular lids ' in un- 
 healthy strumous children must be carefully distin- 
 guished from the more serious but uncommon disease — 
 trachoma. Cases of long standing should certainly 
 suggest a suspicion of trachoma which, in advanced 
 stages, gives rise in the child to a sleepy appearance 
 with half -shut eyes, and with dark rings round the 
 eye. Trachoma cannot be diagnosed with certainty 
 until the lids have been everted. Doubtful cases 
 should always be treated as trachoma. All these cases 
 of conjunctivitis are contagious, and affected children 
 should be excluded from school. Great care should 
 be taken to prevent the common use of handkerchiefs 
 and towels by affected children. 
 
 After-effects of Infectious Diseases. There is no need 
 to give any account of the acute infectious diseases. 
 But, from the school point of view as well as from 
 
DISEASES AFFECTING SCHOOL LIFE 297 
 
 that of the pubHc health, the after-effects of measles, 
 whooping-cough, and other childish ailments are of 
 the utmost importance. Many of these diseases follow 
 one another in rapid succession, and, if the child is 
 in a neglected or debihtated condition, serious com- 
 plications nearly always supervene. After measles, 
 whooping-cough and influenza, pulmonary compHca- 
 tions are common and, as a result the damaged mucous 
 membranes and the enlarged bronchial glands offer 
 a suitable soil for the deposit and growth of the tubercle 
 bacillus. An attack of scarlet fever, if neglected dur- 
 ing convalescence, frequently leads to discharging 
 ears or to inflammation of the kidneys. All children, 
 on their return to school after an attack of any infec- 
 tious disease, should be brought to the notice of the 
 school doctor, and should be examined again from 
 time to time. 
 
APPENDIX I 
 
 BIBLIOGRAPHY OF RECENT LITERATURE 
 IN GREAT BRITAIN 
 
 A. — Medical Inspection of Schools. 
 
 (a) Books. 
 
 Mackenzie, W. Leslie, M.A., M.D., The Medical Inspection of 
 
 School Children. Edinburgh and Glasgow, William Hodge 
 
 & Co., 1904, pp. 455. Price 10s. 6d. 
 Dukes, Clement, M.D., Health at School considered in its Mental, 
 
 Moral, and Physical Aspects. Rivingtons, 1905, pp. 606. 
 
 Price 10s. 6d. 
 
 (b) Reports and Papers. 
 
 ' Report of the Interdepartmental Committee on Medical 
 Inspection and Feeding of Children attending Public 
 Elementary Schools.' Vol. i, Report and Appendices. 
 Vol. ii, Minutes of Evidence. Blue Book, price 4s. 3d. 
 London, Wymans, Fetter Lane, E.C. 
 
 ' Report of the Interdepartmental Committee on Physical 
 Deterioration.' Blue Book, vol. i, Cd. 2175, Is. 2d. 
 
 ' Report of the Royal Commission on Physical Training (Scot- 
 land). Vols, i and ii. London, Eyre «fe Spottiswoode. 
 
 Board of Education Pamphlet. School Doctors in Germany. 
 Wyman & Sons, 1906. 
 
 Chalmers, A. K., M.D., ' Physical Inspection of School Children 
 in Relation to PubUc Health Administration.' Journal of 
 Sanitary Institute, vol. xxvi. 
 
 McMurchy, Helen, M.D., " Medical Inspection of School 
 Children.' British Medical Journal, 1906, ii, p. 675. 
 
 Richards, H. M., ' Organized Medical Inspection in Schools.' 
 Public Health, November, 1906. 
 
BIBLIOGRAPHY 299 
 
 Jones, T. Henry, ' Medical Supervision of Schools.' British 
 Medical Journal, 1906, i, 391. 
 
 Martin, J. Myddleton, ' Keport to Gloucester Education Com- 
 mittee on the Organization of School Hygiene.' Public 
 Health, No. 10, vol. xvi, July, 1904. 
 
 B. — School Hygiene.^ 
 (a) Official Documents. 
 
 Board of Education Pamphlet. The Organization of Physical 
 Training in Sweden. Wyman & Sons, 1907. 
 
 Board of Education. S'pecial Report on School Excursions and 
 Vacation Schools. Wyman & Sons. Price 5Jd. 
 
 Board of Education. Report of the Consultative Committee upon 
 the school attendance of children below the age of five. Cd. 
 4259. Price Is. 5d. Wyman & Sons, 1908. 
 
 Report of the Royal Commission on the Care and Control of 
 the Feebleminded. Vols, i-viii. Wyman & Sons, 1908. 
 
 Report of Interdepartmental Committee on Physical Exercises. 
 
 Board of Education, Whitehall. Rules to be observed in Plan- 
 ning and Fitting up of Public Elementary Schools. Eyre & 
 Spottiswoode, Fleet Street, E.C., 1904. Price 2d. 
 
 Educational Department. Reports on Children under Five 
 Years of Age in Elementary Schools by Women Inspectors 
 of the Board of Education, pp. 155. London, Wyman & 
 Sons. Price 8Jd. 
 
 Board of Education. Suggestions for Teachers. London, 
 Wyman & Sons. Price 8d. 
 
 {b) Reports. 
 
 Kerr, James, M.D., Annual Report of Medical Officer of the 
 late School Board for London for the years 1902-1904. P. S. 
 King & Son, Victoria Street, Westminster, S.W., pp. 42. 
 Price Is. 6d. 
 
 Kerr, James, M.D. Annual Reports to Education Committee 
 
 ^ Contributions to weekly and monthly journals are not included. 
 Complete bibliographies for the years 1904-7, with a brief description 
 of each book, report and article, have been prepared by Dr. C. J. Thomas, 
 Assistant Medical Officer (Education), London County Council, and are 
 published by Wilhelm Engelmann, Leipzig. 
 
300 MEDICAL INSPECTION OF SCHOOLS 
 
 of London County Council, for years 1904-8. P. S. King 
 
 & Sons. Price Is. 6d. each. 
 Salford Education Committee. Report of Drs. Tatteisall and 
 
 Butterworth, Physique of Salford Children. 
 Report of Dundee Social IJnion. Part 1, Physical Condition 
 
 of School Children. John Long, 186 Fleet Street, London. 
 
 Price Is. 
 Ritchie, Brown, M.D., Report of Manchester Education Com- 
 mittee for year ending October, 1907. 
 Kerr, James, and White WalHs, E. Transactions of Second 
 
 International Congress on School Hygiene. Three vols. Price 
 
 5s. each. Royal Sanitary Institute, London, 1908. 
 Reid, George, M.D., ' The Planning of Schools with Special 
 
 Reference to their Ventilation.' Public Health, November, 
 
 1907. 
 
 (c) Handbooks for Teachers. 
 
 Elkington, J. S., M.D., Health in the School. Blackie & Sons, 
 
 Ltd., London, 1907, pp. 180. Price 2s. 
 Wilhamson, R. T., M.D., School Hygiene. Sheratt & Hughes, 
 
 Manchester, 1904. Price 3d. 
 Jones, Herbert, D.P.H., School Hygiene — A Handbook for 
 
 Teachers and School Managers. Dent & Co., London, 1907, 
 
 pp. 148. Price 2s. 
 Porter, Chas., M.D., School Hygiene and the Laws of Health, 
 
 Longmans, Green & Co., 1906, pp. 313. Price 3s. 6d. 
 Newsholme, A., and Pakes, W. C. C. School Hygiene. Tenth 
 
 edition, 1904. Swan, Sonnenschein & Co. 
 Lyster, Robert A. School Hygiene. University Tutorial Press, 
 
 1908. 
 Douglas, Carstairs C. The Laws of Health. Blackie & Son, 
 
 London and Glasgow, 1907. 
 Shaw, E. School Hygiene. Price 4s. 6d. The Macmillan Coy., 
 
 1902. 
 
 (d) Mental and Physical Defects 
 
 Kerr, James, M.D., ' Ingleby Lectures on Mentally Defective 
 Children.' Birmingham Medical Review, May and June, 
 1905. Percival Jones, Ltd. 
 
BIBLIOGRAPHY 301 
 
 Clouston, T. S., M.D., Hygiene of Mind. Methuen & Co., 1906, 
 pp. 271. Price 7s. 6d. 
 
 Shuttleworth, G. E., M.D. Mentally Deficient Children. Lon- 
 don. H. K. Lewis, 1895 (new edition 1909). 
 
 Tredgold, A. F. Mentally Defectives. London, 1908. 
 
 Ban, Martin W. Mental Defectives. London. Pebman, Ltd., 
 
 1904. 
 
 Thomas, C. J. Some forms of Congenital Aphasia in their 
 Educational Aspects. Leipzig. William Engelmann, 1905. 
 
 Surrey Education Committee. Report on Defective and Epi- 
 leptic Children. Surrey Education Office, Kingston-on- 
 Thames, pp. 220. Price Is. 
 
 Ashby, Henry, M.D., ' The Education of Crippled and Mentally 
 Defective Children.' Lancet, 1906, i. 980. Also British 
 Medical Journal, 1906, i, 1167. 
 
 (e) Anthropometry. 
 
 Shrubsall, Frank, M.A., M.D., ' Aims and Functions of 
 Anthropometry in Kelation to Schools.' Report of British 
 Association for Advancement of Science, 1907, pp. 704 et 
 sequitur. 
 
 Meyrick, E., B.A., F.R.S. ' On the Medical Difficulties m 
 Obtaining Measurements of Growth.' Ibid., pp. 704 et 
 sequitur. 
 
 Garson, J. G., and Read, C. H. Notes and Queries on Anthro- 
 pology. Ibid., 1899. The Anthropological Institute, London. 
 
 (/) General. 
 
 Kerr, James. School Hygiene in its Mental, Moral, and Physi- 
 cal Aspects. Journal of Royal Statistical Society, September, 
 
 1897. 
 
 Pedley, R. Denison. The Diseases of Children's Teeth. Segg 
 & Co., 289, Regent Street, London. 
 
 Cohn, Hermann. Hygiene of the Eye. Translated by W. Turn- 
 bull. Birmingham Educational Co. 
 
 Snell, Simeon. Eyesight and School Life. John Wright & Co. 
 
 Carter, Brudenell and Cheatle. Sight and Hearing in Child- 
 hood. Scientific Press. 
 
 Snedden and Allen. School Reports and School Efficiency. 
 Price 6s. 6d. The Macmillan Company. 
 
302 MEDICAL INSPECTION OF SCHOOLS 
 
 Guthrie, Leonard G. Functional Nervous Disorders in Child- 
 hood. Oxford Medical Publications, 1907. 
 
 James, William. Talks to Teachers on Psychology. Longmans, 
 Green & Co., 1907. 
 
 {g) A jew valuable Foreign Publications. 
 
 Axel Key's Schulhygienische Untersuchungen. Edited by 
 
 Dr. L. Burgerstein, 1889. Voss. 
 Burgerstein, Dr. Leo, and Netolitsky, Dr. August. Handbuch 
 
 der Schulhygiene, 1902. Fischer. Jena. 
 U.S.A. Bureau of Education. Annual Reports of the Commis- 
 sioner of Education. Washington. 
 Gulick, L. H., and Ayres, L. P. Medical Inspection of Schools. 
 
 New York. Charities' Publication Committee, 1908. 
 Zeitschrift fur Schulgesundheitspflege. Hamburg. Leopold 
 
 Voss. 
 International Archives of School Hygiene. Leipzig. Wilhelm 
 
 Engelmann. 
 Eos : a quarterly journal on feebleminded, blind, and deaf 
 
 children. Pichlers, Vienna and Leipzig. 
 Poelchau, Dr. med Gustav. Anleitung fur die schulcirztliche 
 
 Tdtigkeit. Hamburg. Leopold Voss, 1908. 
 Massachusetts Board of Education. Suggestions to Teachers 
 
 and School Physicians. Wright and Potter, Boston, 1908. 
 
APPENDIX II 
 
 EXTRACTS FROM OFFICIAL DOCUMENTS AND 
 MEMORANDA CONCERNING MEDICAL IN- 
 SPECTION OF CHILDREN IN PUBLIC 
 ELEMENTARY SCHOOLS ^ 
 
 A 
 
 MEMORANDUM ON MEDICAL INSPECTION 
 OF CHILDREN IN PUBLIC ELEMENTARY 
 SCHOOLS 
 
 Board of Education. Circular 576. 
 
 The Board of Education desire 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 but 
 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. 
 
 2. The section of the Education (Administrative Provisions) 
 
 ^ In deference to the wishes of the publishers these official documents 
 and memoranda have not been reprinted in full. They may be obtained 
 from Messrs. Wyman & Sons, Ltd., Fetter Lane, E.G. Price One Penny 
 or Twopence each. 
 
304 MEDICAL INSPECTION OF SCHOOLS 
 
 Act, 1907, which concerns medical inspection of school children 
 (section 13) is as follows : — 
 
 ' 13. — (1) The powers and duties of a Local Education 
 Authority under Part III of the Education Act, 1902, shall 
 include — 
 
 [{a) Power to provide for children attending pubUc 
 elementary schools, vacation schools, vacation 
 classes, play centres, &c.] 
 (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 associa- 
 tions for the purpose. 
 
 (2) This section shall come into operation on the first 
 day of January nineteen hundred and eight. . . . 
 The present Act is not intended to supersede the powers 
 which have long been exercised by Sanitary Authorities under 
 various Public Health Acts, but is meant to serve rather as 
 an ampHfication and a natural development of previous 
 legislation. . . . 
 
 ■'&' 
 
 Organization 
 
 4. The respective functions of the Board of Education and 
 the Local Education Authorities are clearly defined by the 
 Act. The duties thrown upon the Board consist in advising 
 Local Education Authorities as to the manner in which they 
 should carry out the provisions of the Act, and in supervising 
 the work they are called upon to undertake ; in giving such 
 directions as may be necessary regarding the frequency and 
 method of inspection in particular areas ; and in considering 
 and sanctioning such arrangements for attending to the health 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 305 
 
 and physical condition of the children as may be submitted 
 to them by individual Authorities. The Board will also collate 
 the records and reports made by the Authorities and will 
 present an annual report to Parliament. 
 
 The duty of carrying out the annual inspection has neces- 
 sarily been entrusted by Parliament to the Local Education 
 Authorities and not to the Board. Each Authority must 
 therefore in due course appoint such Medical Officers or 
 additional medical assistance as may be required for the 
 purpose. ... 
 
 5. In view of the varied influences which affect, directly or 
 indirectly, the health of the children of the nation, it is mani- 
 festly of the highest importance that the administration of 
 this Act should rest upon a broad basis of pubHc health, and 
 should not only secure for Local Education Authorities as 
 much freedom as is consistent with adequate uniformity in 
 the presentation of results for comparative purposes, but 
 should also use to the utmost extent the existing machinery 
 of Medical and Sanitary Administration, developing and 
 supplementing it as required, rather than supplanting it by 
 bringing into existence new agencies, partially redundant and 
 possibly competing. 
 
 The Board view the entire subject of school hygiene not 
 as a speciality or as a group of specialities existing by and of 
 themselves, but as an integral factor in the health of the 
 nation. The application of this principle requires that the 
 work of medical inspection should be carried out in intimate 
 conjunction with the Public Health Authorities and under the 
 direct supervision of the Medical Officer of Health. The 
 advantages of such unification of the PubHc Health services 
 have already been recognized by the Interdepartmental 
 Committee on Medical Inspection and the Feeding of School 
 Children, and also by the Local Government Board, who 
 specifically require every Medical Officer of Health to report 
 officially upon matters relating to the sanitary condition of 
 all schools, including the ' action taken (by the Sanitary 
 Authority) in relation to the health of the scholars and for 
 preventing the spread of infectious disease.' . . . 
 
 School hygiene cannot be divorced from home hygiene, and 
 this in turn is intimately bound up with the hygienic conditions 
 of the community. Efficiency and economy require, therefore, 
 
 HOGARTH X 
 
306 MEDICAL INSPECTION OF SCHOOLS 
 
 an organic relationship between the daily work of the school 
 authority and of the authority responsible for the administra- 
 tion of the wider branches of public health, including the 
 supervision of water and milk supplies, food, housing and 
 sanitation, inquiries into matters affecting infant mortaHty 
 (including ante-natal influences), home visiting by men and 
 women inspectors, sanitary and bacteriological investigations, 
 the provision of hospital accommodation, disinfection, the 
 cleansing of verminous persons, the notification of the preva- 
 lence or otherwise of diseases, such as phthisis, affecting the 
 adult population, and the consideration of social factors, such 
 as the occupation of the parents, or the health, habits, and 
 physical conditions of the family, all of which have a bearing, 
 direct or indirect, upon the children's health. . . . 
 
 Generally speaking, the work of inspection should be super- 
 vised by the Medical Officer of Health of the Authority which 
 appoints the Education Committee ; and when the work is 
 obviously more than he can undertake unaided, it should be 
 entrusted to one or more medical officers working under his 
 supervision. In some districts it will be found convenient 
 for such officers to be local Medical Officers of Health holding 
 office within the county ; in others, they may be registered 
 medical practitioners specially appointed for this purpose. 
 Provided that the principle of co-ordination of the medical 
 services is secured in practice, and that the requisite personal 
 and professional qualifications for the new work are present, 
 it is clear that the functions of the school medical officer may 
 be exercised by a medical officer of health, a Poor Law medical 
 officer, a private practitioner, or, as occasion requires, a skilled 
 specialist. When it is necessary to appoint officers for the 
 purpose of the Act it is extremely important that persons of 
 suitable qualifications and experience should be selected, even 
 though they may not be called upon to give the whole of their 
 time to these duties and it should be noted that there are 
 many cases in which women are likely to be specially suitable. 
 In making such appointments preference should be given to 
 medical men and women who (1) have had adequate training 
 in State Medicine or hold a Diploma in Public Health, (2) have 
 had some definite experience of school hygiene, and (3) have 
 enjoyed special opportunities for the study of diseases in 
 children. . . , 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 307 
 
 Subsidiary Agencies 
 
 8. The Board are convinced that the work of medical 
 inspection cannot be properly accomplished by medical men 
 without assistance. The teacher, the school nurse (where 
 Buch exists) and the parents or guardians of the child must 
 heartily co-operate with the school medical officer. In what- 
 ever way the system be organized, its success will depend, 
 immediately and ultimately, upon the cordial sympathy and 
 assistance of the teachers. . . . 
 
 The increased work undertaken by the State for the indi- 
 vidual will mean that the parents have not to do less for 
 themselves and their children, but more. It is in the home, 
 in fact, that both the seed and the fruit of public health are 
 to be found. All-round co-operation between school medical 
 officer, teacher, nurse, health visitor, and parent will prove both 
 effective and economical, and the full utility of the Act will not 
 be secured unless, in advising Local Education Authorities, the 
 medical officer pays careful attention to considerations of 
 expenditure and to the relative urgency of the reforms he 
 proposes to undertake. 
 
 Character and Degree of Medical Inspection 
 
 9. From what has been said it will be clear that the funda- 
 mental principle of section 13 of the new Act is the medical 
 examination and supervision not only of children known, or 
 suspected, to be weakly or ailing, but of all children in the 
 elementary schools, with a view to adapting and modifying 
 the system of education to the needs and capacities of the 
 child, securing the early detection of unsuspected defects, 
 checking incipient maladies at their onset, and furnishing the 
 facts which will guide Education Authorities in relation to 
 physical and mental development during school life. . . . 
 
 10. The directions given in this circular as to the degree and 
 frequency of inspection refer only to the minimum medical 
 inspection, the effectiveness of which will in future be one of 
 the elements to be considered in determining the efficiency 
 of each school as a grant-aided school. They are not intended 
 to exclude other medical work, which the Board trust will be 
 undertaken by Local Education Authorities according to 
 
 X 2 
 
308 MEDICAL INSPECTION OF SCHOOLS 
 
 their abilities and opportunities. For example, the re-testing 
 of the eyesight of every child periodically would be most 
 valuable ; an annual measurement of height and weight ; the 
 more frequent examination of particular children, especially 
 of those suspected to be suffering from deficient nutrition or 
 found to be defective at former inspections ; careful anthropo- 
 metric surveys or special inspections at various ages of school 
 life ; and similar investigations of a special nature undertaken 
 in particular districts, come within the category of additional 
 medical work wholly desirable where practicable, and calcu- 
 lated to advance school hygiene. Such work, however useful, 
 should be looked upon as subsidiary to the main purpose of 
 the Act. . . . 
 
 Kegulations 
 
 12. The Board have decided under section 13 of the Act 
 that not less than three inspections during the school life of 
 the child will be necessary to secure the results desired.^ The 
 first inspection should take place at the time of, or as soon 
 as possible after, admission to school ; the second at or about 
 the third year (say, the seventh year of age) ; and the third 
 at or about the sixth year of school life (say, the tenth year 
 of age). A further inspection immediately before the depar- 
 ture of the child into working life would be desirable where 
 practicable, and in some areas it may be best for this to take 
 the place of the third inspection. Certain adjustments will be 
 necessary in working out any standard in practice, as it will 
 at once be evident that without such adjustment the first 
 year (1908) would be unduly burdened with the inspection of 
 the children newly admitted and of all the children already 
 in school. 
 
 Provision should be made by each Authority, when the 
 Act has been sufficiently long in operation to be in normal 
 working, for the inspection in each year of {a) the children 
 
 ^ There will be special areas where the Board may from time to 
 time require that the inspection should be at shorter intervals and of a 
 more searching character, and also areas in which, owing to largeness 
 of size or population, some exception may have to be made in the early 
 years by way of reduction of the burden per annum. 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 309 
 
 newly admitted ; (6) the children in the school who in that 
 year had matured for their second inspection ; (c) those who 
 had matured for their third inspection ; and where practicable 
 {d) those about to leave school might also be inspected. But 
 in the first year (1908) it may prove impracticable to attempt 
 more than the inspection of the children newly admitted and 
 those leaving school ; and in the second year (1909) the Board 
 will be satisfied with the inspection of those newly admitted 
 and those leaving, with the addition of children who have 
 matured for their second inspection (which is perhaps the 
 occasion of all others requiring the most thorough examina- 
 tion). Some such adjustment would tend to equalize the 
 burden over successive years. It will be understood that the 
 precise way in which the children are grouped in the school for 
 medical inspection will vary according to the internal organiza- 
 tion and circumstances of each school. It may be most con- 
 venient, for instance, to carry out the inspection on an age basis 
 rather than on a basis of period of school life. In subsequent 
 years the Board may issue notice modifying the age periods 
 for inspection in order to obtain facts respecting child physique 
 at ages other than those included above. . . . 
 
 13. The following further regulations should be observed : 
 (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 circum- 
 stances of each school must receive consideration, 
 and in these matters and in the actual examina- 
 tion the medical officer will no doubt exercise 
 sympathy and tact, giving due thought to the 
 personal susceptibilities of those concerned. 
 
 (c) The facts revealed by inspection must be entered in 
 
 a register kept at the school, the confidential 
 nature of many of the entries being carefully 
 respected. A copy of the entries should be trans- 
 mitted with the child to any other school to w^hich 
 he or she may go. 
 
 (d) Every School Medical Officer should make an annual 
 
 report to the Local Education Authority on the 
 
310 MEDICAL INSPECTION OF SCHOOIS 
 
 schools and children under his superintendence, 
 which should be printed for facihty of reference 
 and in order that a supply of copies may be avail- 
 able for distribution among the members of the 
 Authority and other persons interested. The 
 Authority should send two copies of the report 
 to the Board of Education as soon as possible 
 after the end of the year under review. 
 
 (e) In order to secure effective bases for comparison of 
 the work done in different parts of the country, 
 one uniform year must be taken, the year to be 
 adopted being in all cases the calendar year, in 
 order to correspond with the annual period fixed 
 for the closely related report of the Medical Officer 
 of Health. 
 
 (/) The report should be concerned chiefly with the con- 
 ditions and circumstances affecting the health of 
 the children in the Elementary Schools of the 
 district. 
 
 (g) It should also contain statistical records of the num- 
 ber of children examined and of those re-examined 
 or under medical supervision ; the nature and 
 results of the examination ; the number of visits 
 paid to classes ; the number and character of the 
 diseased conditions found at certain age periods ; 
 particulars as to blind, deaf, defective and epileptic 
 children ; the medical advice given both as to the 
 prevention of conditions inimical to health and 
 the remedy of diseased conditions that may be 
 discovered, action taken, and so forth. 
 
 {h) In addition to such records it will be well, as far as 
 practicable, to make systematic comparisons of 
 the individual and collective measurements and 
 characteristics of the children in each school with 
 standard and local records, both as a means of 
 determining the condition of health of particular 
 children or classes, for guidance in future action, 
 and as part of the anthropometric survey to which 
 this Act should contribute in due time. This 
 part of the work, however, must be kept in 
 a secondary position while so much remains to be 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 311 
 
 done in the elementary essentials of school hygiene. 
 It is to those essentials, and the manner and degree 
 in which they have been dealt with in his district, 
 that each school medical officer should devote the 
 major portion of his report. 
 
 Amelioration and Physical Improvement 
 
 14. The aim of this Act is practical and it is important that 
 Local Education Authorities should keep in view the desir- 
 ability of ultimately formulating and submitting to the Board, 
 for their approval under section 13 (1) (b) of the Act, schemes 
 for the amelioration of the evils revealed by medical inspec- 
 tion, including, in centres where it appears desirable, the 
 estabHshment of school surgeries or clinics, such as exist in 
 some cities of Europe, for further medical examination, or 
 the specialized treatment of ringworm, dental caries, or 
 diseases of the eye, the ear, or the skin. It is clear that to 
 point out the presence of uncleanliness, defect, or disease does 
 not absolve an Authority from the consequent duty of so 
 applying its statutory powers as to secure their amelioration 
 and to prevent, as far as possible, their future recurrence or 
 development. The subject of specific medical treatment is, 
 however, one which will require subsequent consideration in 
 the light of the findings of medical inspection and the collateral 
 issues raised thereby, and it is clear that, speaking generally, 
 and subject to the observations in the following paragraphs. 
 Local Education Authorities will be unable to formulate and 
 submit for the Board's sanction any comprehensive scheme 
 for the furtherance of this object until they have considered 
 the results of their medical inspection in various directions. 
 
 15. In the meantime the Authorities should take measures 
 without delay, for dealing, through such agencies as are 
 conveniently available, with what are commonly, though in a 
 sense erroneously, regarded as minor ailments. To such ail- 
 ments, measures of amelioration should immediately be 
 applied. In a broad sense all such amehoration is ' treatment '. 
 Indeed, properly administered, the Act must become some- 
 thing more than a mere record of disabilities and defects. It 
 opens the way to new means of education and lays upon 
 
312 MEDICAL INSPECTION OF SCHOOLS 
 
 Education Committees duties involving ' treatment ' in a 
 broad conception of the term. A few instances will make the 
 matter clear. Thus in controlling ringworm it has been open 
 to a Committee (a) to neglect the disease altogether ; (6) to 
 adopt a policy of exclusion from school of afiected children ; 
 or (c) to supervise or carry out some method of amelioration. 
 Up to the present many Authorities have followed the first 
 course. It is intended that in future they should, according 
 to their abilities, adopt the third. Verminous heads and 
 bodies form another illustration of a common condition in 
 which amelioration can be secured by school nurses. Further, 
 a careful survey should be taken of all available facilities for 
 the promotion of the bodily cleanhness of school children. 
 Wherever such facilities exist they should be utilized to the 
 utmost, and where they are absent, the desirability, particu- 
 larly in the more congested areas, of providing them, either 
 in the schools themselves or at convenient centres, should be 
 clearly recognized. It is of the utmost importance to remem- 
 ber that baths with the necessary accompaniments of soap, 
 sponges, towels, &c., should be utiHzed, not merely for the 
 immediate and obvious purpose of cleansing the bodies of the 
 children, but also as a humanizing influence and as the means 
 of inducing habits and instincts of cleanliness and of incul- 
 cating practical lessons in the value of personal hygiene and 
 in self-respect. The same is true of such other simple practical 
 matters as the daily brushing and cleansing of the teeth, which 
 is a subject well worth careful treatment in many of our 
 elementary schools. 
 
 16. Practical amelioration is already undertaken by Local 
 Education Authorities in checking the spread of infectious 
 disease by exclusion of affected or susceptible children, super- 
 vision and medical examination of ' contacts]', disinfection of 
 schoolrooms, and so on. Again, the modification of the teach- 
 ing and work of the school and its adjustment to the physical 
 capacity of the scholars is a form of ' treatment ' which, in 
 the end, will bear much fruit. Thus the defective visual 
 acuity of children, particularly young children, calls for early 
 correction at the instance of the Education Authorities either 
 alone or in conjunction with some voluntary society ; but the 
 rational treatment of some of these children will as a rule be 
 an educational modification which avoids the necessity of 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 313 
 
 spectacles, such modification for example as will diminish the 
 prevalence of the bad habit of working the eyes at near dis- 
 tance, or ensure the adoption of suitable type of letterpress for 
 the reader's eyes. Antecedent even to the discovery of such 
 visual defects should come the removal, as the result of 
 medical inspection, of unsatisfactory conditions of school life 
 which are a common cause of fatigue and of injured eyesight. 
 Obviously, such remedies are of greater importance to the 
 eventual health of the community than the specific medical 
 treatment of individuals. 
 
 17. Lastly, it must not be forgotten that Parliament itself 
 has recognized the necessity of imposing some share of responsi- 
 biUty upon Education Authorities as to treatment in the 
 broader sense in which the term is being used in this para- 
 graph, by the special legislation provided in the Elementary 
 Education (Blind and Deaf) Act, 1893, and the Elementary 
 Education (Defective and Epileptic) Act, 1899. The powers 
 conferred by these Acts are mde and furnish Authorities with 
 the means of placing needy cases under special treatment. The 
 Board of Education have approved in various county boroughs 
 arrangements under the last-named Act, and in other districts 
 the subject is receiving attention. Nor must it be forgotten 
 that in respect of defective nutrition considerable powers have 
 been conferred on Local Education Authorities under the 
 Education (Provision of Meals) Act, 1906. In all questions 
 relating to the practical means of amelioration and in some 
 even affecting the arrangements for medical inspection, the 
 Board are satisfied that the efficient local administration of 
 the Act will depend in no small measure upon the good offices 
 of School Managers, many of whom have already done so 
 much in this sphere, and to whose interest and sympathy they 
 cordially commend the new work. 
 
314 MEDICAL INSPECTION OF SCHOOLS 
 
 B 
 
 EXTRACTS FROM CIRCULAR TO LOCAL 
 EDUCATION AUTHORITIES 
 
 SCHEDULE OF MEDICAL INSPECTION 
 
 Circular 582 
 
 Board of Education. 
 
 Whitehall, London, S.W., 
 
 2^rd January, 1908. 
 
 4. In the accompanying Schedule the Board indicate the 
 particulars, attention to which they regard as constituting 
 the minimum of efficient medical inspection, and they con- 
 sider that at least these particulars should be included in any 
 other Schedule which the Local Education Authority may 
 authorize for use in their Schools. It deliberately excludes 
 many points of anthropometric or statistical interest which 
 are worthy of attention, and which it is hoped may receive 
 attention in suitable districts. Nor does it profess to lay down 
 the Unes of a clinical study or of a scientifically complete 
 medical examination. It is intended to indicate the methods 
 which, in the Board's opinion, should be followed and the 
 particulars which should be attended to for the purpose of 
 determining the fitness of the individual child for school Kfe, 
 to guide the Authority in adapting education to the pecuUari- 
 ties or abnormalities of the child, and to prepare the way for 
 measures for the amehoration of defects in the child or its 
 environment. ... 
 
 It is considered that the inspection of each child should 
 not occupy on the average more than a few minutes, and that 
 the child need only, as a rule, have its clothes loosened or be 
 partially undressed. Time may be saved in the actual inspec- 
 tion by the Medical Officer if the entries in some of the spaces 
 are filled in by the school authorities before his visit. The 
 four columns in the Schedule are designed for the four inspec- 
 tions required during school life. 
 
 With regard to items 17 to 24 of the Schedule, while it is 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 315 
 
 necessary that all indications of diseased or unsound conditions 
 should be thoroughly investigated, needless medical examina- 
 tion of healthy children should, for obvious reasons, be 
 avoided. 
 
 6. Where children are found to belong to that class of 
 ' defectives ' for whose education special provision is or 
 ought to be made under the Statutes relating to such children, 
 such cases should be made the subject of a special report to 
 the Local Education Authority. 
 
 7. All entries of the results of inspection in each individual 
 case must he regarded as confidential. 
 
 SCHEDULE OF MEDICAL INSPECTION 
 
 {Accompanying Circular 582) 
 Notes for Inspecting Officer 
 
 Reference 
 Number 
 of Note. 
 
 1. Date of bii'th to be stated exactly, date of month and year. 
 
 2. ' Other illnesses ' should include any other serious disorder which 
 must be taken into account as affecting, directly or indirectly, 
 the health of the child in after-life, e. g. rheumatism, tuberculosis, 
 congenital syphilis, small-pox, enteric fever, meningitis, fits, mumps, 
 &c. The effects of these, if still traceable, should be recorded. 
 
 3. State if any cases of, or deaths from, phthisis, &c., in family. 
 
 4. Note backwardness. 
 
 5. Age to be stated in years and months, thus, OxV- 
 
 6. Insufficiency, need of repair, and uncleanliness should be recorded 
 
 (good, average, bad). 
 
 7. Without boots, standing erect with feet together, and the weight 
 
 thrown on heels and not on toes or outside of feet. 
 
 8. Without boots, otherwise ordinary indoor clothes. 
 
 Height and weight may be recorded in English measures if 
 preferred. In annual report, however, the final averages should 
 be recorded in both English and metric measures. 
 
 9. General nutrition as distinct from muscular development or 
 
 physique as such. State whether good, normal, below normal, or 
 bad. Under-nourishment is the point to determine. Appearance 
 of skin and hair, expression, and redness or pallor of mucous mem- 
 brane are among the indications. 
 10. Cleanliness may be stated generally as clean, somewhat dirty, 
 dirty. It must be judged for head and body separately. The 
 skin of the body should be examined for cleanliness, vermin, &c. ; 
 and the hair for scurf, nits, vermin, or sores. At the same time 
 ringworm and other skin diseases should be looked for. 
 
316 MEDICAL INSPECTION OF SCHOOLS 
 
 11. General condition and cleanliness of temporary and permanent 
 
 teeth, and amount of decay. Exceptional features, such as 
 Hutchinsonian teeth, should be noted. Oral sepsis. 
 
 12. The presence or absence of obstruction in the naso-pharynx is the 
 
 chief point to note. Observation should include mouth-breathing ; 
 i nflammation, enlargement, or suppuration of tonsils ; probable or 
 obvious presence of adenoids, polypi ; specific or other nasal 
 discharge, catarrh, malformation (palate), &c. 
 
 13. Including blepharitis, conjunctivitis, diseases of cornea and lens, 
 
 muscular defects (squints, nystagmus, twitchings), &c. 
 
 14. To be tested by Snellen's Test Types at 20 feet distance ( = 6 metres). 
 
 Result to be recorded in the usual way, e.g. normal V. =- 
 Examination of each eye (R. and L.) should as a rule, be under- 
 taken separately. If the V. be worse than g, or if there be signs 
 
 of eye strain or headache, fuller examination should be made 
 subsequently. Omit vision testing of children under 6 years of age. 
 
 15. Including suppuration, obstruction, &c. 
 
 16. If hearing be abnormal or such as interferes with class work, sub- 
 sequent examination of each ear should be undertaken separately. 
 Apply tests only in general way in case of children under 6 years 
 of age. 
 
 17. Including defects of articulation, lispmg, stammermg, &c. 
 
 18. Including attention, response, signs of overstrain, &c. 
 
 The general intelligence may be recorded under the following 
 heads : — (a) Bright, fair, dull, backward ; (6) mentally defective ; 
 (c) imbecile. Omit testing mental capacity of children under 6 years 
 of age. 
 
 19. Under the following headings should be inserted particulars of 
 
 diseased conditions actually present or signs of incipient disease. 
 The extent of this part of the inspection will largely depend upon 
 the findings under previous headings. 
 
 20. Include heart sounds, position of apex beat, anaemia, &c., in case 
 
 of anything abnormal or requiring modification of school conditions 
 or exercises. 
 
 21. Including physical and clinical signs and symptoms. 
 
 22. Including chorea, epilepsy, paralyses and nervous strains and 
 disorders. 
 
 23. Glandular, osseous, pulmonary, or other forms. 
 
 24. State particular form, especially in younger children. 
 
 25. Including defects and deformities of head, trunk, limbs. Spinal 
 curvature, bone disease, deformed chest, shortened limbs, &c. 
 
 26. Including any present infectious, parasitical or contagious disease, 
 
 or any sequelae existing. At each inspection the occurrence of 
 any such diseases since last inspection should be noted. 
 
 27. Any weakness, defect or disease not included above (e.g. ruptures) 
 specially unfitting child for ordinary school life or physical drill, 
 or requiring either exemption from special branches of instruction, 
 or particular supervision. 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 317 
 
 Schedule of Medical Inspection. 
 
 I. — Name 
 Address 
 
 Date of Birth 
 School 
 
 II. — Personal History : 
 
 (a) Previous Illnesses of Child (before admission). 
 
 Measles. 
 
 Whooping 
 Cough. 
 
 Chickenpox. 
 
 Scarlet 
 Fever. 
 
 Diphtheria. 
 
 Other 
 Illnesses.* 
 
 t 
 
 (b) Family Medical History (if exceptional).^ 
 
 1. 
 2. 
 3. 
 
 4. 
 
 5. 
 
 6. 
 
 7. 
 8. 
 
 9. 
 10. 
 
 11. 
 12. 
 
 13. 
 14. 
 15. 
 16. 
 
 17. 
 18. 
 19. 
 20. 
 21. 
 22. 
 23, 
 24. 
 
 Date of Inspection 
 
 Standard and Regularity of Attendance.* 
 
 Age of Child « 
 
 Clothing and footgear ^ 
 
 [III. — General Conditions. '\ 
 
 Height' 
 
 Weight 8 
 
 Nutrition * 
 
 Cleanliness and condition of skin ^^ . . . 
 
 Head 
 
 Body 
 
 [IV. — Special Conditions.'] 
 
 Teeth " 
 
 Nose and throat ^^ 
 
 Tonsils 
 
 Adenoids 
 
 Submax. and cervical glands . . . 
 
 External eye disease " 
 
 Vision " 
 
 R. 
 L. 
 
 Ear disease ^* 
 
 Hearing ^® . 
 
 Speech " 
 
 Mental condition ^^ 
 
 [V. — Disease or Deformity.} ^' 
 
 Heart and circulation^" 
 
 Lungs ^^ 
 
 Nervous system " . 
 
 Tuberculosis^^ 
 
 Rickets^* 
 
 Deformities, Spinal Disease, &c." . . . 
 Infectious or contagious disease.-' . . 
 
 Other disease or defect." 
 
 Medical Officer's initials 
 
 I. 
 
 II. IlIL 
 
 IV. 
 
 General Observations. 
 
 Directions to Parent or Teacher. 
 
318 MEDICAL INSPECTION OF SCHOOLS 
 
 c 
 
 EXTRACTS FROM CIRCULAR TO LOCAL 
 EDUCATION AUTHORITIES 
 
 Circular 596, 17th August, 1908. 
 (Supplementary to Circulars 576 and 582.) 
 
 Circular concerning : — 
 
 (A) The functions of the ' School Medical Officer ' ; 
 
 (B) Provision for Medical Inspection of school children 
 
 under the Code of 1908 ; 
 
 (C) The Local Education Authority's Annual Report of 
 
 Medical Inspection to the Board of Education ; and 
 
 (D) Arrangements for attending to the Health and Physical 
 
 Condition of School Children. 
 
 A. — School Medical Officer. 
 
 2. It will be observed that the ' School Medical Officer ' of 
 the Local Education Authority is for the first time recognized 
 in the Code of 1908 as an officer having specific functions in 
 the system of Public Elementary Education. This Officer is 
 defined in Article 44 (g) as ' a medical officer named by the 
 Local Education Authority, and recognized as such by the 
 Board.' The functions specifically assigned to him (or her) 
 by the Code are — 
 
 (i) Those of reporting on the working and effect of any 
 arrangements made under Article 44 (g) for edu- 
 cating children at ' an open-air school, school 
 camp, or other place selected with a view to the 
 improvement of the health and physical condition 
 of the children '. 
 (ii) The power of advising or approving the closure of 
 
 a school under Article 45 (6). 
 (iii) The power of authorizing the exclusion of certain 
 children from a school on specified grounds under 
 Article 53 (b), which grounds will be regarded as 
 ' reasonable grounds ' under Article 53 (a). 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 319 
 
 3. One of the objects which the Board had in view in intro- 
 ducing these provisions into the Code was to secure that the 
 responsibility for deaHng with certain medical questions con- 
 nected with Public Elementary Schools should, as far as 
 possible, be placed in the hands of a single officer responsible 
 to the County Council, County Borough Council, Borough 
 Council or Urban District Council who are the Local Education 
 Authority for the area in which a school is situated. The 
 expression ' School Medical Officer ' is therefore substituted 
 for the vague expression ' medical authority ', which was used 
 in Article 45 (b) of the Code of 1907. The Board, however, 
 also had in view the desirability of assisting Local Education 
 Authorities to concentrate and organize, in the department 
 of the School Medical Officer, all matters of school hygiene, 
 including medical inspection under the Act of 1907, and they 
 assume that the School Medical Officer will, in addition to 
 performing the specific functions assigned to him by the Code, 
 also be made responsible by the Local Education Authority 
 for supervising and controlling the general work of medical 
 inspection. . . . 
 
 But it is considered very important by the Board that 
 a single individual should be charged with the organization 
 and control of the whole machinery of the School Medical 
 Service and that he should be in a position to take responsi- 
 bility for the acts of all persons taking part in the work, 
 including those of Assistant Medical Officers, School Nurses, 
 Attendance Officers, and Teachers, so far as they perform 
 any functions in connexion with the School Medical Service. . . . 
 
 B. — Provision for Medical Inspection. 
 
 4. As regards Articles 25 (c) and 58 (6), which require, as 
 a condition of Grant, that satisfactory provision for the 
 medical inspection of children shall be made, it is obvious 
 that the best evidence of compliance with this condition 
 would be afforded by {a) the appointment in each area of 
 a competent School Medical Officer and a staff of quaHfied 
 and suitable assistants under his supervision and control, 
 and (6) the initiation of a carefully considered scheme for 
 covering the ground. For this purpose the Board will require 
 to be furnished with particulars of the appointments made 
 
320 MEDICAL INSPECTION OF SCHOOLS 
 
 by the Local Education Authority and with such information 
 as will enable them to judge of the efficiency of the organization 
 adopted. Forms to be used for this purpose have been pre- 
 pared and accompany this Circular (Form 9 M.L). When 
 this information is received, the Board will consider the system 
 adopted in each area broadly and on its merits, with due regard 
 to local circumstances and with no desire to impose a rigidly 
 uniform system on Authorities whose circumstances are 
 widely different. Even in cases where the system adopted 
 is not such as the Board would themselves have suggested, 
 they would be slow to withhold provisional approval from 
 experiments so long as they do not conflict with the general 
 principles laid down in Circular 576. 
 
 C. — Annual Report. 
 
 5. The Annual Report referred to in paragraph 13 {d) to (h) 
 of Circular 576 should be made by the School Medical Officer 
 to the Local Education Authority, who will send two copies 
 of it to the Board of Education, with any observations which 
 they may desire to submit, as soon as practicable after the 
 expiration of the year to which it relates. It will be under- 
 stood that Reports which are for the information of the Board 
 of Education may well include statements of local circum- 
 stances and conditions which would be superfluous if they 
 were intended only for the information of the Local Authority. 
 The Annual Report should relate to the calendar year, and 
 the first Annual Report should be made up to the 31st Decem- 
 ber, 1908. It is not the intention of the Board to prescribe in 
 detail the form which this Report should take, or to require 
 at present the adoption of particular methods of analysing 
 and tabulating the facts on which it is based. . . . 
 
 6. As regards the scope of the Report, however, the Board 
 consider that it is desirable that it should deal with the whole 
 subject of School Hygiene, and should cover as much as 
 possible of the ground indicated under the following heads. . . . 
 
 (a) General review of the hygienic conditions prevalent in 
 the Schools in the area of the Local Education Authority in 
 respect of such matters as surroundings, ventilation, lighting, 
 warming, equipment, and sanitation, including observations 
 on the type and condition of sanitary conveniences and 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 321 
 
 lavatories, water supply for washing and drinking purposes, 
 the cleanUness of schoolrooms and cloakrooms, arrangements 
 for drying children's cloaks and boots, and the relation of the 
 general arrangements of the School to the health of the 
 children. 
 
 (6) General description of the arrangements which have 
 been made for the co-relation of the School Medical Service 
 with the Public Health Service and for the organization and 
 supervision of medical inspection, and an account of the 
 methods of inspection adopted, including — 
 
 (i) A statement of the extent (if any) to which the Board's 
 Schedule of Medical Inspection has not been 
 followed and the reasons for such departure ; 
 (ii) A statement showing the assistance given to the 
 School Medical Officer and his assistants by 
 nurses, managers of schools, teachers, attendance 
 officers or other persons ; 
 (iii) A statement showing the methods adopted for securing 
 the presence of parents at the inspection and their 
 co-operation in the subsequent treatment of 
 defects, together with a review of the effect of such 
 methods ; 
 (iv) The extent to which disturbance of school arrange- 
 ments was involved by the inspection. (Art. 43 (b) 
 and 44 (h) of Code of 1908.) 
 
 (c) General statement of the extent and scope of the medical 
 inspection carried out during the year, including — 
 
 (i) The number of visits paid to Schools and Departments ; 
 
 (ii) The principle on which children have been selected 
 for inspection ; (at entrance, before leaving, by 
 selection according to ages or otherwise) ; 
 
 (iii) The number of children inspected (classified for age 
 at date of inspection and for sex) ; 
 
 (iv) The number of children referred for subsequent or 
 further examination ; 
 
 (v) The number of children in respect of whom directions 
 were given for treatment of defects, including 
 a classified statement of such defects ; 
 
 (vi) The average time per head occupied by inspection 
 
 (d) General view of the facts disclosed by medical inspec- 
 tion, under the headings contained in the Schedule to Cir- 
 
 HOGARTH Y 
 
322 MEDICAL INSPECTION OF SCHOOLS 
 
 cular 582, including tables showing the height and weight of 
 children inspected (according to age at date of inspection 
 and sex). 
 
 (e) General review of the relation of home circumstances 
 and social and industrial conditions to the health and physical 
 condition of the children inspected, so far as facts bearing on 
 this point have come under notice. 
 
 (/) Review of the methods employed or available for the 
 treatment of defects, such as defective eyesight, carious 
 teeth, nasal obstruction or adenoids, tonsilUfcis, discharging 
 ears, pediculosis, ringworm, and other skin diseases, including 
 an account of the action of school nurses in obtaining or 
 assisting in the treatment of such defects. 
 
 {g) Review of action taken to detect and prevent the spread 
 of infectious diseases, including reference to action taken 
 under Articles 45 (b), 53 (b), and 57 of the Code of 1908. 
 
 {h) Review of the methods adopted and the adequacy of 
 such methods for dealing with blind, deaf, mentally or physi- 
 cally defective and epileptic children under the Acts of 1893 
 and 1899. 
 
 {i) Review of — 
 
 (i) The methods and results of instruction in personal 
 hygiene and temperance in the Pubhc Elementary 
 Schools in the area ; 
 (ii) The methods and results of physical or breathing 
 
 exercises in the Schools ; 
 (iii) Arrangements for open-air schools, school camps, &c., 
 under Article 44 (g) of the Code of 1908. 
 {j) Account of miscellaneous work, such as the examination 
 of Scholarship candidates, Pupil-Teachers, or teachers of any 
 grade. 
 
 Two complete sets of any forms used by the Local Educa- 
 tion Authority in connexion with the School Medical Service 
 should be sent to the Board together with the Report. 
 
 D. — Arrangements for Attending to the Health and 
 Physical Condition of School Children. 
 
 (a) Improvement of the School Arrangements. — The School 
 Medical Officer will doubtless furnish the Local Education 
 Authority with valuable advice as to improvements which 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 323 
 
 can be made in the use of old school premises and in the 
 design of new school premises for improving the health of the 
 children educated in them. For instance, he will note and 
 report to the Authority cases in which the ventilation of 
 schools is defective, either as regards the means provided or 
 as regards the use and maintenance of those means, and, if 
 necessary, he will supply them with the results of scientific 
 tests. He will, of course, call attention to the physical efiects 
 of bad ventilation, such as the prevalence of headaches, 
 lassitude, and debility among the scholars, when they come 
 under his notice. He will observe and report instances of bad 
 positions in sitting and unsuitable design of desks or benches. 
 As regards cases of defective eyesight, he will indicate such 
 measures as can be taken to remedy or mitigate the defects by 
 altering the position of the children in the class, or improving 
 the lighting of the school in amount or direction, and he will 
 call attention to the strain imposed on eyesight by the use of 
 too small type in textbooks, the teaching of very fine sewing, 
 &c. He will also be able to estimate the effectiveness of 
 lessons on the subject of personal hygiene given in the school, 
 and may be able to suggest improvements in the curriculum 
 or in the methods of giving such lessons and bringing their 
 importance home to the children. He may also be able to 
 institute comparisons between school and school in respect of 
 the effect of physical exercises, and, in the case of children 
 of weakly physique, he may be able to indicate the kind and 
 amount of physical exercises which are suitable for them. 
 He will observe the effect of holding classes in the open air, 
 and call attention to cases in which the adoption of this 
 arrangement is desirable. He will also be able to suggest to 
 what extent and in respect of what children advantage should 
 be taken of the facilities afforded by Article 44 (g) of the Code 
 of 1908 for improving the health and physical condition of 
 the children, by means of open-air schools, school camps, &c., 
 and, in cases where facilities exist for baths and swimming, 
 he will sometimes find occasion to recommend a more extensive 
 use of such facilities. And the beneficial influence of the School 
 Medical Officer will not be exhausted even when he has done 
 everything included in this formidable catalogue. The mere 
 fact that the services of a specially skilled officer and staff^ are 
 devoted by the Local Education Authority to the oversight 
 
 Y 2 
 
324 MEDICAL INSPECTION OF SCHOOLS 
 
 of all matters affecting the health of the children in their 
 Pubhc Elementary Schools gives to the whole question of 
 school hygiene a dignity and importance which cannot but 
 produce a considerable effect on the minds of teachers, parents 
 and children ahke. From this point of view the School Medical 
 Officer should be not merely a functionary charged with 
 specific duties, but a pervading influence making, in the long 
 run, for better hygienic conditions in the school and in the 
 home. 
 
 (b) Exercise of Powers under Special Acts relating to School 
 Children. — Medical inspection will probably indicate the 
 necessity of having recourse to the BHnd and Deaf Children Act, 
 1893, and the Defective and Epileptic Children Act, 1899, in 
 the case of a considerable number of children who are at 
 present educated in ordinary Pubhc Elementary Schools. It 
 will emphasize the desirability of taking advantage of the wide 
 scope of the last-mentioned Act by estabUshing or contributing 
 to the establishment of special schools or classes for physically 
 as distinguished from mentally defective children. It will also 
 furnish the Local Education Authority with valuable informa- 
 tion as to the necessity of exercising their powers under the 
 Education (Provision of Meals) Act, 1906, and as to the best 
 methods and effects of such exercise. It is extremely desirable 
 that the School Medical Officer should be closely associated 
 with this last-mentioned work wherever it is undertaken, 
 though it is of hardly less importance that the methods adopted 
 should be such as will secure the greatest educational effect in 
 respect of the manners and conduct of the children concerned, 
 as well as the best physical results. 
 
 (c) Co-operation with the Sanitary Authority. — It is obvious, 
 as regards infectious diseases, that a School Medical Officer 
 who is occupied in carrying out a programme of systematic 
 medical inspection in the schools of the area will often be 
 unable to dislocate his programme in order to deal personally 
 with an outbreak of infectious disease in a particular school. 
 He must so organize his machinery that both he and the 
 Sanitary Authority shall receive immediate information of 
 any such occurrence (whether the disease is ' notifiable ' or 
 not) by duphcate notices or otherwise, so that the matter may 
 be dealt with ef!ectivelv and without confusion at the earliest 
 possible moment. Definite regulations should be made for this 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 325 
 
 purpose. Where the School Medical Officer is himself the 
 Medical Officer of Health of a Sanitary Area no difficulty will 
 arise, but where this is not the case it must be remembered 
 that the ultimate responsibility for preventing the spread of 
 infectious disease must remain with the Sanitary Authority, 
 which is at present the sole repository of compulsory powers 
 for closure of Public Elementary Schools of all kinds, or for 
 exclusion of individual children from them. 
 
 (d) Advice or Direction to Parents. — Where medical inspec- 
 tion reveals any defect or malady in a particular child, the 
 first step will naturally be to notify the parents. . . . 
 
 (e) The School Nurse. — A School Nurse is capable of per- 
 forming very useful and important functions, both in assisting 
 in the work of medical inspection, and (under medical instruc- 
 tions) in applying, or showing the parents how to apply, 
 remedies for minor ailments. ... So far as the School Nurse 
 can be regarded as assisting in the work of medical inspection, 
 the sanction of the Board to her employment is not required. 
 So far, however, as she is engaged in treating the minor ail- 
 ments, or in visiting the children's homes for purposes of 
 advice, her employment would require sanction as an ' arrange- 
 ment ' for attending to the health and physical condition of 
 the children. The Board would usually have no difficulty in 
 sanctioning any well-considered scheme for this purpose. 
 
 (f) Provision of Spectacles, &c. — In cases where medical 
 inspection shows that the provision of spectacles is necessary 
 for the treatment of defective eyesight, the Board will be 
 prepared to consider proposals from a Local Education 
 Authority to provide suitable and inexpensive spectacles free 
 of charge. ... 
 
 (g) Contributions to Hospitals, Infirmaries, Dispensaries, <&c. 
 . . . The Board will be prepared to entertain proposals for con- 
 tributing to the funds of hospitals, dispensaries, and nursing 
 associations, on terms of adequate advantage. Such contri- 
 butions are specially desirable in the case of Eye Hospitals 
 and Cottage Hospitals which are prepared to undertake minor 
 surgical operations. 
 
 (h) School Clinics. — School Clinics may serve two purposes. 
 They may be used for further and more scientific examination 
 of cases in which medical inspection has indicated the exist- 
 ence of defects in a child which cannot conveniently be investi- 
 
326 MEDICAL INSPECTION OF SCHOOLS 
 
 gated on the premises of an ordinary Public Elementary 
 School. For instance, the School Medical Officer may discover 
 at his first inspection that a child is afiected in respect of one 
 or more of the particulars numbered 17 to 24 on the Schedule 
 accompanying Circular 582, and it may be necessary for him 
 to ascertain by further examination whether the child is fit to 
 continue in attendance at a Public Elementary School, or 
 whether any special precautions should be taken in the case 
 of such a child if he continues to attend, or whether special 
 provision should be made for his education in some other 
 manner. Similarly, in the case of ocular defects, the detailed 
 examination of the child may often be more expeditiously 
 and thoroughly carried out at a School Clinic, where special 
 appliances are available. So far as a School Chnic is used for 
 such purposes, its establishment appears to fall within the 
 scope of provision for medical inspection, but such a clinic 
 should not be used merely for the purpose of enabling the 
 ordinary inspection of school children to be carried out else- 
 where than at the schools which they attend, nor, in ordinary 
 circumstances, will the Board be prepared to approve, for the 
 purposes of Article 44 (h) of the Code, attendance at a School 
 Clinic as an inspection centre. 
 
 The establishment of School Chnics for purposes of treat- 
 ment of defects revealed by inspection gives rise on the other 
 hand to questions of considerable difficulty, and, before sanc- 
 tioning the estabHshment of a School Clinic as an ' arrange- 
 ment ' under section 13 (1) (b) of the Act, the Board will 
 require to be furnished with detailed information as to the 
 methods and scope of the work which it is proposed to do. 
 They will, in particular, require to be informed — 
 
 (i) what precautions the Local Education Authority will 
 take to secure that only those children shall be 
 treated in a School CHnic for whose treatment 
 adequate provision cannot otherwise be made, 
 whether by the parents or by voluntary associa- 
 tions or institutions, such as hospitals, or through 
 the agency of the Poor Law ; 
 (ii) what precise diseases and defects will be treated ; 
 (iii) by whom and on what terms and conditions the treat- 
 ment will be carried out and what will be its 
 extent ; 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 327 
 
 (iv) what is the estimated cost of the clinic in respect of 
 buildings and equipment, maintenance and ad- 
 ministration, and treatment, and how it is proposed 
 to meet this cost, out of the rates or otherwise. 
 
 D 
 
 CHILDREN ACT [8 EDWARD VII] 
 
 Cleansing of Verminous Children. 
 
 Section 122. — (1) A Local Education Authority may direct 
 their Medical Officer or any person provided with and, if 
 required, exhibiting the authority in writing of their Medical 
 Officer, to examine in any Public Elementary School provided 
 or maintained by the Authority, the person and clothing of 
 any child attending the school, and if on examination the 
 Medical Officer, or any such authorized person as aforesaid, 
 is of opinion that the person or clothing of any such child is 
 infected with vermin or is in a foul or filthy condition, the 
 Local Education Authority may give notice in writing to the 
 parent or guardian of, or other person liable to maintain, the 
 child, requiring him to cleanse properly the person and clothing 
 of the child within twenty-four hours after the receipt of the 
 notice. 
 
 (2) If the person to whom any such notice as aforesaid is 
 given fails to comply therewith within such twenty-four hours, 
 the Medical Officer or some person provided with and, if re- 
 quired, exhibiting the authority in writing of the Medical 
 Officer, may remove the child referred to in the notice from 
 any such school, and may cause the person and clothing of 
 the child to be properly cleansed in suitable premises and 
 with suitable appliances, and may, if necessary for that pur- 
 pose, without any warrant other than this section, convey to 
 such premises and there detain the child until the cleansing 
 is efiected. 
 
 (3) Where any Sanitary Authority within the district of 
 a Local Education Authority have provided, or are entitled 
 to the use of, any premises or appliances for cleansing the 
 person or clothing of persons infested with vermin, the Sanitary 
 
328 MEDICAL INSPECTION OF SCHOOLS 
 
 Authority shall, if so required by the Local Education Author- 
 ity, allow the Local Education Authority to use such premises 
 and appliances for the purpose of this section upon such pay- 
 ment (if any) as may be agreed between them or, in default of 
 agreement, settled by the Local Government Board. 
 
 (4) Where, after the person or clothing of a child has been 
 cleansed by a Local Education Authority under this section, 
 the parent or guardian of, or other person liable to maintain, 
 the child allows him to get into such a condition that it is again 
 necessary to proceed under this section, the parent, guardian, 
 or other person shall, on summary conviction, be liable to 
 a fine not exceeding ten shillings. 
 
 (5) Where a Local Education Authority give notice under 
 this section to the parent or guardian of, or other person Hable 
 to maintain, a child, requiring him to cleanse the person and 
 clothing of the child, the authority shall also furnish him with 
 written instructions describing the manner in which the 
 cleansing may best be effected. 
 
 (6) The examination and cleansing of girls under this section 
 shall only be effected by a duly qualified medical practitioner 
 or by a woman duly authorized as hereinbefore provided. 
 
 (7) For the purposes of this section ' Medical Officer ' means 
 any officer appointed for the purpose of section 13 of the 
 Education (Administrative Provisions) Act, 1907. 
 
 E 
 
 REPORT OF THE INTERDEPARTMENTAL 
 COMMITTEE ON PHYSICAL DETERIORATION 
 
 Part III. Summary of Recommendations. 
 
 (3) Advisory Council The Committee are emphatic in 
 recommending the creation of an Advisory Council, repre- 
 senting the Departments of State, within whose province 
 questions touching the physical well-being of the people fall, 
 with the addition of members nominated by the medical 
 corporations and others, whose duty it should be, not only to 
 receive and apply the information derived from the Anthropo- 
 metric Survey and the Register of Sickness, but also to advise 
 the Government on all legislative and administrative points 
 
EXTRACTS FROM OFFICIAL DOCUMENTS 329 
 
 concerning public health in respect of which State interference 
 might be expedient ; and to them might be remitted for con- 
 sideration and report all the problems affecting pubUc health 
 which the requirements of a complex social organization are 
 constantly bringing to the front. Such a Council, the com- 
 position of which might be modelled to some extent on Le 
 Comite ConsuUatif d'hygiene fuhlique de France, would be, the 
 Committee believe, of great assistance, especially to the Local 
 Government Board, and would be calculated to supply the 
 knowledge and stimulus which are necessary in order to give 
 to the PubUc Health side of the Board's administration a pro- 
 minence which the multipHcity of its other functions may have 
 tended to obscure, and to attract to its work that measure of 
 public interest and support which has perhaps been lacking 
 hitherto. 
 
 F 
 
 Memorandum on School Closure and Exclusion of 
 Children for Infectious Disease. 
 

 ^ 
 
 o 
 
 a 
 
 H 
 *»} 
 
 P5 
 O 
 H 
 O 
 
 O 
 
 APPENDIX III 
 
 FORMS AND SCHEDULES i 
 
 Referred to in text (Chapter XIII) 
 
 hJ 
 
 
 O 
 
 
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 r> 
 
 C/J 
 
 OQ 
 
 ^ 
 
 H 
 
 
 S 
 
 kH 
 
 Fh 
 
 )-l 
 
 
 H 
 
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 HH 
 
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 O 
 
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 H 
 
 en 
 
 
 [No. 1 
 
 • 
 © 
 
 >> 
 
 
 Standard. 
 
 
 Age. 
 
 
 2 
 
 •F-l 
 
 a 
 
 
 ^ Note. — In this appendix are included some of the forms originally 
 adopted by the London Education Committee, but so far not in common 
 use by other authorities. 
 
FORMS AND SCHEDULES 331 
 
 [No. 2 
 
 School. Department. 
 
 Environment 
 of School. 
 
 
 Building. 
 
 
 Sanitation. 
 
 
 Artificial 
 lighting. 
 
 
 Window 
 
 lighting. 
 
 
 Heating. 
 
 
 Ventilation. 
 
 
 Desks, 
 seating, &c. 
 
 
 General. 
 
 
332 MEDICAL INSPECTION OF SCHOOLS 
 
 [No. 3 
 
 'CO 
 
 a 
 
 © 
 
 © 
 © 
 
 o 
 
 •»2 
 o 
 © 
 
 m 
 
 "© 
 
 ;2; 
 
 
 Remarks on 
 special cases. 
 
 
 Visits 
 
 to 
 homes. 
 
 
 Cases 
 
 of 
 ring- 
 worm. 
 
 1 
 
 Neglected 
 and dirty. 
 
 " 
 
 1 
 
 02 
 © 
 02 
 
 a 
 o 
 
 o 
 
 a 
 
 a 
 
 Bodies 
 
 and 
 clothing. 
 
 
 Nits. 
 
 
 Heads. 
 
 
 Number 
 
 of 
 
 children 
 
 examined. 
 
 
 Date of 
 visit. 
 
 
 -*3 
 
 p 
 
 
 
 o 
 o 
 
 o 
 OS 
 
 
 £ 
 
 O 
 
 o 
 
 4 
 
FORMS AND SCHEDULES 
 
 333 
 
 [No. 4 
 Scarlet Fever Return to illustrate Classroom Distribution. 
 
 School. 
 
 Sanitary District. 
 
 190 . 
 
 Eh 
 Ph 
 
 m 
 P 
 
 03 
 
 C 
 
 ■+-3 
 
 P 
 
 CLASSROOM. 
 
 <I5 
 
 00 
 
 © 
 
 02 
 
 w fl3 
 
 O T3 
 P cS 
 
 B 
 
 
 OQ 
 © 
 03 
 
 o 
 
 O '-0 
 ^ © 
 
 P cS 
 
 c 
 
 © 
 tic 
 
 © 
 
 03 
 
 o 
 
 •— < H 
 
 O '^ 
 
 © C! 
 ^ © 
 
 51 
 
 Notes. 
 
 [No. 5 
 Return of Cases oi- Measles to indicate Classroom Distribution. 
 School. Department. 
 
 
 Age. 
 
 Date of Analysis. 
 
 Date of Analysis. 
 
 Classroom. 
 
 Cases. 
 
 Last 
 Attend- 
 ance. 
 
 Total. 
 
 Cases. 
 
 Last 
 Attend- 
 ance. 
 
 Total. 
 
 A 
 B 
 C 
 
 
 
 
 
 1 
 
 
 
334 MEDICAL INSPECTION OF SCHOOLS 
 
 Notice to 
 The Parent or Guardian of 
 
 [No. 6 
 
 From 
 The Head Teacher (Infants' Dept.), 
 
 School, 
 
 As a case of measles has occurred among the scholars in the class 
 
 which your child attends, it is possible that may have contracted 
 
 the disease. As it requires about twelve days for measles to develop 
 after infection, you are requested to pay particular regard to the state of 
 your child's health during the NEXT THREE WEEKS, and upon the 
 slightest sign of illness to abstain from sending to school. 
 
 Date 
 
 Signature. 
 
 NOTE. 
 
 Measles may be a very serious illness in young children, and many 
 die from it. The early symptoms are those of a cold, which may be 
 at first slight ; there is generally running at the eyes and nose, sneezing 
 and possibly cough. Many children lose their lives because parents allow 
 them to go out of the house, thinking that the indisposition is only 
 a slight cold, when it is really measles. 
 
 [No. 7 
 
 Notice to 
 The Parent or Guardian 
 
 From 
 The Head Teacher 
 
 Dept., 
 School. 
 
 Diphtheria being present in the district, and your child having 
 exhibited some symptoms of the disease, namely, sore throat, you are 
 requested, in the interests of your own child and of the other children, 
 
 to keep at home. A medical certificate, based upon bacteriological 
 
 examination, stating that is free from infection, should be obtained 
 
 before presenting the child for re-admission to school. 
 
 This certificate can be obtained, free of cost, from the Medical Officer 
 of Health for the district by those who have no private doctor. 
 
 Show this card to the doctor. 
 
 Date 
 
 Signature. 
 
FORMS AND SCHEDULES 
 
 335 
 
 [No. 8 
 
 NoivnNATioN Form for Physically Defective Children. 
 
 This form should be filled up and forwarded 
 to the Medical Officer {Education), Education 
 Offices, Victoria Embankment, W.C. 
 
 [Children under five should not be nomi- 
 nated for admission to a Special School.} 
 
 o 
 
 w 
 
 © 
 
 © 
 
 PhO 
 cj © 
 
 No. 
 
 1. Name of child. 
 
 2. Address in full. 
 
 3. Date of birth. 
 
 4. How long has the child attended 
 
 (a) this School ? 
 
 (6) any other School ? 
 
 5. What is the mental capacity of the 
 
 child ? 
 
 (a) Reading. 
 (6) Writing, 
 (c) Calculation. 
 
 6. For what reason is the child sent 
 
 up for medical examination ? 
 
 7. Does attendance at an ordinary 
 
 school appear prejudicial ? If 
 so, in what way ? 
 
 8. Does the child suffer from fits ? If 
 
 so, have they occurred frequently 
 or in school ? 
 
 9. Is any near relative, dead or living, 
 
 known to have suffered from 
 Insanity, Fits, Gout, Spitting of 
 Blood, Consumption, Scrofula, 
 or any other hereditary disease ? 
 
 10. Remarks. 
 
 (a) 
 (6) 
 
 Equal to Standard 
 
 
 MEDICAL OFFICER'S NOTES. 
 
 Signed. 
 School. 
 
 Department 
 Date 
 
336 MEDICAL INSPECTION OF SCHOOLS 
 
 [No. 9 
 
 Nomination Form for Mentally Defective Children, 
 
 This form should he filled up arid forwarded 
 to the Medical Officer {Education), Education 
 Offices, Victoria JEmbankment, W.C. 
 
 [Children under five should not he nomi- 
 nated for admission to a Special School.] 
 
 N.B. — In filling up this form avoid general 
 terms such as ^ fair,^ ^moderate,' &c., and say 
 in the simplest terms what a scholar can do. 
 
 U <33 
 
 O 03 
 
 .2 © 
 
 CO cS 
 
 No. 
 
 1. Name of child. 
 
 2. Address in full. 
 
 3. Date of birth. 
 
 4. How long has the child attended 
 
 (a) this School ? 
 
 (6) any other School ? 
 
 5. What is the appearance of the child — 
 
 Stupid or bright ? 
 
 6. Is the child : 1. Obedient ; 2. Mis- 
 
 chievous ; 3. Spiteful ? 
 
 7. Are the habits of the child correct 
 
 and cleanly ? 
 
 8. Are the propensities of the child 
 
 peculiar or dangerous ? 
 
 9. What is the mental capacity of the 
 
 child ? 
 
 1. Observation. 
 
 2. Imitation. 
 
 3. Attention. 
 
 4. Memory. 
 
 5. Reading (Equal to Standard). 
 
 6. Writing 
 
 7. Calculation „ „ 
 
 8. Colour. 
 
 9. Special Tastes. 
 
 10. Is the child affectionate or otherwise ? 
 
 11. Has the child any moral sense ? 
 
 12. Have you any other information 
 
 bearing on the case ? 
 
 MEDICAL OFFICER'S NOTES. 
 
 Head Teacher. 
 School 
 
 Department. 
 Date 
 
FORMS AND SCHEDULES 
 
 337 
 
 [No. 10 
 
 MEDICAL REPORT UPON DEFECTIVE CHILD 
 
 (After Admission to Special School). 
 Name (in full) 
 
 1. GENERAL ASPECT AND EXPRESSION— 
 
 2. PHYSICAL STATE— 
 
 General health and nutrition. 
 
 Congenital deformities. 
 
 Any physical or nervous peculiarities. 
 
 3. MENTAL STATE— 
 
 Response — slow or ready. 
 Educational attainments. 
 
 Speech. 
 
 Reading. 
 
 Calculation. 
 
 Writing. Manual 
 
 Peculiarities. 
 
 4. DIAGNOSIS— 
 
 Line of Training Indicated. 
 
 SHEFFIELD EDUCATION COMMITTEE. 
 
 : School, Department. 
 
 The undermentioned children, who have been examined by the 
 School Medical Officer and found by him to be suffering from 
 physical defects, have not yet received any treatment . . . 
 
 Name. 
 
 Address. 
 
 Parent or Guardian. 
 
 Name. 
 
 Occupation. 
 
 Treatment j 
 required for 
 
 {Signed) 
 190 . Head Teacher. 
 
 HOGARTH 
 
INDEX 
 
 Note : In this Index " Medical Inspection " is used as synonymous with 
 Medical Inspection of School Children. 
 In the same way Child, or Children, Scholar, or Scholars, is used instead 
 of School-child, School-children. 
 
 Abnormalities, observation of, 
 
 158, 162 
 Accidents and School Life, 288 
 Adenoids, aspect of child with, 286 
 causes and consequences of, 286 
 examination for, 161 
 treatment of, 248, 286 
 Administrative Medicine, School 
 Hygiene a branch of, 
 102 
 Administrative Routine, of Medi- 
 cal Inspection, 187 
 Accommodation for School 
 
 Doctor, 208 
 Annual Reports, 205 
 Cleansing Scheme : 
 Bodies, 200 
 Heads, 199 
 Examination of Candidates 
 
 (Teachers, etc.), 204 
 General Medical Inspection, 
 
 188 
 Infectious Disease rules, 192 
 et seq. 
 Diphtheria, 197 
 Measles, 197 
 Scarlet Fever, 195 
 Medical Register, 189 
 Ringworm, 201 
 School Nurses, 198 
 Secondary Schools ; 
 
 Pupil Teachers, etc., 205 
 Scholarship Candidates, 205 
 Training College Students, 
 205 
 
 Administrative Routine {continued) 
 Special School 
 
 Admission examination, 201 
 Centres, periodical examina- 
 tions, 202 
 Medical Certificates, 204 
 Vision Test, 190 
 Anaemia, causes and character of, 
 72, 76, 278, 279 
 and School Life, 16, 279 
 in Secondary Scholars, 72, 76 
 Annual Reports of School Doctors, 
 
 205, 320 
 Anthropometric survey of Scholars, 
 
 37, 44, 159 
 Anthropometry, Bibliography, 301 
 Apprenticeship, early nineteenth 
 
 century, 12 
 Argentina, Medical Inspection 
 Legislation in, 26 
 School Medical Board in, 104 
 Ascham, Roger, 10 
 Association for Supply of Cheap 
 Spectacles, 192, 223, 
 246 note 
 Astigmatism and School Life, 291 
 
 in Secondary Scholars, 70, 71 
 Attendance, School, Chronic Con- 
 tagious Diseases for- 
 bidding, 293 et seq. 
 Compulsory, Medical Inspec- 
 tion and, 39 
 growth of, 15 
 
 Increased, from results of 
 Medical Inspection, 48 
 
INDEX 
 
 339 
 
 Attendance (continued): 
 
 Intermittent, etc. ; backward- 
 ness from, 61 
 Rheumatism and, Poynton 
 
 on, 266 . 
 
 and Sore Throat, 28l" 
 at School Clinics, to be Volun- 
 tary, 240 
 at School Dentistry, counted as 
 School Attendance, 242 
 Audition, tests of, 157, 159, 160 
 Austria and Hungary, Medical 
 Inspection Legislation 
 in, 25-6 
 
 Backvvaedness, causes of, 51, 52, 
 53 
 
 Bacteriological examination essen- 
 tial in Diphtheria Sore 
 Throat, 283 
 
 Bale, School Dental Clinic at, 238 
 
 Barry, School Nurses at, 174 
 
 Basedow, educational system of, 
 11, 12 
 
 Beach, Dr. Fletcher, 19 
 
 Belgium, see Brussels 
 
 Bellinzona, Municipal Doctors at, 
 236 
 
 Bibliography, 298 
 
 Birmingham, School Nurses at, 173 
 
 Blepharitis and School Life, causes 
 and cure, 290 
 
 ' Blight,' 224 
 and School Life, 296 
 
 Blind Children, Special Schools 
 for, 277 
 Dumb, and Feeble-minded, the, 
 Royal Commission on, 
 19 
 
 Blindness, Educational, causes of, 
 277 
 
 Board of Agriculture, and Public 
 Health Work, 65, 97 
 
 Board of Customs, and Public 
 Health Work, 65, 66,97 
 
 Board of Education : 
 
 Circulars of {see also Appen- 
 dices) on 
 Amelioration of Conditions 
 disclosed by Medical 
 Inspection, 209, 311 
 
 Board of Education {continued) : 
 Annual Reports of School 
 
 Doctors, 205-6, 320 
 Medical Inspection : 
 
 to Local Education Author- 
 ities, 318 
 Schedule of the above, 
 314 
 School Medical Service, 141-2 
 Treatment of Minor Ailments 
 by School Nurses, 212 
 note, db see 181 
 Code of 1908 
 definition by, of School Doctor, 
 
 139-40 
 functions of the same deter- 
 mined under, 140-1 
 Investigations made for, on 
 Visual Conditions of 
 Scholars, 221 
 Medical Department, 103, 105 
 Chief Medical Officer, 105, 
 
 108 
 Experts at. Medical and 
 
 other, 106, 107 
 Functions of, 103-4 
 Staff of : 
 actual, 105 
 required, 108-9 
 requisites in, 110 
 and Medical Inspection 
 Duties, 103-4 
 Memorandum on, 303 
 Regulations as to, 143, 144 
 Requirements of, as to Locale, 
 
 208 
 Slow action as to, 23 
 Special, desirable by, 47 
 Medical Officer appointed to 
 
 advise, 34 
 Necessity at, for knowledge and 
 investigation, 105 et 
 seq. 
 Nursery Schools, advised by, 
 
 107, 263 
 Regulations of, a defect in- 
 dicated, 187 
 as to Exclusion for In- 
 fectious Diseases, 143 
 as to Medical Inspection, ib. 
 and School Hygiene, 103 
 
 z 2 
 
340 
 
 INDEX 
 
 Board of Education and School 
 Hygiene {continued) : 
 Memorandum of, on the 
 
 above, 93-4 note 
 Model Department for, 109 
 Views of, on Municipal Co- 
 operation with Hos- 
 pitals as to Medical 
 Treatment, 234, 325 
 Board of Health, a desideratum, 
 66 (b note 
 Supreme, and the suggested 
 P. M. 0., 100 
 Body, Cleansing of, 200-1 
 
 Lice, etc., on, 294 
 Bone Tuberculosis, forms of, in 
 Children, 213, 266 
 and School Life, 225, 268-9 
 Boston, U.S.A., Medical Inspec- 
 tion Legislation in, 29 
 Organization of School Hygiene 
 in, 118-19 
 Bowditch, Prof., on Height and 
 Weight of American 
 Scholars, 16 
 Bradford School Clinic, routine of, 
 
 249-50 
 Brain-Affections, Rheumatic, 
 
 Symptoms of, 264 
 Brain-fag, some causes of, 86 
 Breathing : 
 Mouth, 284-5 
 
 Treatment, 161, 213, 248, 280 
 Nasal, 284-5 
 Breathing-exercises, precautions 
 
 as to, 285 
 Brighton, School Nurses at, 175 
 British Dental Association, in- 
 vestigations of, on 
 Teeth of Scholars, 219 
 Medical Association : 
 action of, on payment of 
 
 School Doctors, 136 
 
 views of, on Duties of School 
 
 Nurses, 181 
 
 on Municipal Co-operation 
 
 with Hospitals as to 
 
 Medical Treatment,234 
 
 Bronchitis and School Life, 269-70 
 
 Brussels, Dental Inspection in, 220 
 
 Pioneer in Medical Inspection, 31 
 
 Bulstrode, Dr. H. T., on the 
 Claim of the Individual 
 Child, 77 <fc note 
 
 Biirgerstein, Prof., Dr. L., 17 ; on 
 School Hygiene in 
 England, 95 
 
 Bulgaria, Medical Inspection 
 Legislation, 30 
 
 Cambridge, School Dentistry at, 
 221, 242 
 School Nurse at, duties of, 175-6 
 
 Card System for Medical Exam- 
 ination Statistics, 88 
 note, 166 {figs. 167-8), 
 189 
 
 Carter, Dr. Brudenell, examina- 
 tion by, of Visual Con- 
 ditions in London 
 Scholars, 221 
 
 Catarrh, Nasal, Sore Thi'oat from, 
 282, 284 
 
 Catlin, Kit, on Nasal Breathing, 
 284 
 
 Census, Physical, 36, 43, 44 
 
 Central Residential School for 
 Medical Treatment, in 
 Country Areas, 255 
 
 Certificates of Health issued after 
 second Medical Exami- 
 nation, 166-8 
 Medical, 64, 193, 204, 230-1, 
 283 
 
 Chadwick, Edwin, and National 
 Education, 18 
 
 Charity Organization Society and 
 Medical Treatment of 
 Scholars, 238-9 
 
 Chaux-de-fonds, La, School Poly- 
 clinic at, 238 
 
 Chest development, examination 
 of, 161 
 
 Chief Medical Officer of the Board 
 of Education, 105, 108 
 
 Chief School Doctor, the : 
 Duties, 141, 154 
 Qualifications, 154-5 
 
 Child, the Individual, the Claims 
 of, 70 et seq. 
 
 Child Study, founder of, 19 
 
INDEX 
 
 341 
 
 Children, Cleansing of, Heads and 
 
 Bodies, authority for, 
 
 199-201, 219, 295, 327 
 
 Condition of, early nineteenth 
 
 century, 3, 12 
 Diseases of, see also Diseases 
 affecting School Life, 
 cD under Names 
 Chronic and Infectious, neg- 
 lected by Public Health 
 Authorities, 63 etseq.,Ql 
 Nervous, in relation to School 
 Life, 270 et seq. 
 Epileptic, parentage of, 274 
 Strumous, Chronic Conjuncti- 
 vitis with granular lids 
 in, 296 
 Enlarged Glands in, 288 
 and Tubercular disease, 266, 
 
 268 
 Value of, to the State, 42, 67, 70 
 Children Act 1908, and the 
 Cleansing of Children, 
 199, 201, 219, 295, 327 
 Chorea, a Rheumatic symptom 
 Causes, 263 
 Symptoms, 264 
 and School Life, 265 
 Choroiditis, Disseminated, and 
 
 School Life, 290 
 Chronic affections needmg Treat- 
 ment, 212-13 
 Causes, 213-14 
 Oassification, 212-13 
 Importance, 213 
 Neglected by Public Health 
 Authorities, 63 
 Diseases of School Life, see also 
 U7ider each Disease 
 Common, 259 et seq. 
 Contagious, 293 et seq. 
 Epilepsy, consequences of, 275 
 Tonsilitis, Sore Throat from, 282 
 Class closure, 196, 198 
 Class-room Inspection, by School 
 
 Doctor, 169-71 
 Classification of Scholars, 54-5, 78, 
 
 82, 87-8 
 Cleanliness in Schools, 14, 64, 69 
 Cleansing of Verminous Children, 
 199-201, 219, 295, 327 
 
 Cleansing of Verminous Children 
 {continued) : 
 Schemes for : 
 Bodies, 201 
 Heads, 199-200 
 Clinical experience versus Dip- 
 lomas, for the School 
 Doctor, 151 
 Clinics, see Flying CUnics, Poly- 
 clinics, School, & 
 School Dental Clinics 
 Closure, see Class do., see also 
 School Closure, <fc Ex- 
 clusion 
 Cohn, Dr., examination by, of 
 Vision of German 
 Scholars, 221 
 on Eyesight of Scholars, 15, 16 
 Comenius, father of Modern Edu- 
 cation, 10, 11 
 Common Diseases affectmg School 
 
 Life, 259 et seq. 
 Communicable diseases, see also 
 Infectious diseases 
 
 IVIinor, 
 
 hitherto neglected, 63 
 prevention of, 64 
 Conferences of Teachers and 
 Parents with School 
 Doctors, 145 
 Congress(es), International, on 
 Hygiene (1883), 16 
 International, on School Hy- 
 giene! 1904 and 1907),32 
 
 Conjunctivitis and School Life: 
 Chronic, with ' granular lids', 296 
 Epidemic, 296 
 Phlyctenular, 289, 290 
 Purulent, 224 
 Contact Infection, 60, 61, 62 
 defined, 280 cfc note 
 various instances, 294, 296 
 Contagious Diseases, Chronic, of 
 School Life, 293 et seq. 
 Contmental pioneers in School 
 Hygiene and Educa- 
 tion, 10, 11, 12, 13 
 Convalescent Schools for Bone 
 Tuberculosis cases, 269 
 Convulsions, Epileptic, symptoms 
 of, 274-5 
 
342 
 
 INDEX 
 
 Co-operation of all concerned in 
 Education, in Medical 
 Inspection work, and 
 School Hygiene 
 Architect, 59 
 Child, 153 
 Parent, 145 
 
 School Officers, etc., of all kinds, 
 38, 59, 69, 85, 87, 88-9, 
 141, 143-4, 186, 240 
 Cornea, Inflammation of, and 
 
 School Life, 289-90 
 Cost of School Clinics, 250 et seq. 
 Estimates, 252-3 
 of School Dental Clinics, Jessen 
 
 on, 251 
 in relation to Medical Inspec- 
 tion, 90 
 County Areas, and Rural Districts 
 Organization of School Hygiene 
 for, 112, 124 et seq., 255 
 Boroughs, see Large Towns and 
 Councils, and School Hygiene, 
 124 
 Various Schemes considered, 
 125 et seq. 
 Medical Officers 
 
 Duties assigned to, 127, 128 
 Institutions supervised by, 
 130-1 
 Nursing Associations, suggested 
 scope of, 180 
 Country Children, Vision of, 47 
 Cretinism, 276 
 
 Cronin, Dr. J. J., on School care 
 versus Custodial treat- 
 ment, 257 
 on School Exclusion, New York, 
 49-50 
 Crowley, Dr., on the Bradford 
 
 School Clinic, 249-50 
 Cunningham, Dr., School Den- 
 tistry of, Cambridge, 
 242 
 
 Danish High Schools, over-pres- 
 sure in, Hertel on, 16 
 
 Darmstadt, Dental Inspection at, 
 220 
 
 Deaf Children, Special Schools for, 
 277 
 
 Deafness, and Adenoids, 286 
 Defective Teeth, 289 
 
 Prevalence of, and Treatment 
 for, 219-21 
 Vision [see also Defects, Visual), 
 Statistics of, 221 
 Thompson on, 47-8 
 Treatment of, 213, 221 
 Defectives, Mental and Physical, 
 Medical Inspection of, 
 107-8, 202-4 
 Defects in Scholars, 40, 41 
 
 Need for Detection of, 67, 70 
 
 et seq. 
 Remedies, 73-4 
 Physical, affecting Scholars, and 
 
 their work, 51 et seq. 
 Visual, and School Life, three 
 classes of, 289-92 
 Deficiency, Mental, and School 
 Life, 276-7 
 Administrative Routine re, 
 202-4 
 Deformities and School Life : 
 Acquired, 292 
 Congenital, 292 
 Pedal, 74 
 from Rickets, 213 
 Spinal, 74, 86, 293 
 ' Delicate ' children, in Secondary 
 Schools, 73 
 and Tubercular Disease, 268 
 Dental Clinics, School, see School 
 Dental Clinics 
 Conditions, Treatment of, 213 
 Inspection in Germany and 
 New York, 220 
 Dentists, accommodation for, in 
 
 School Clinics, 242-3 
 Deterioration, Mental, 5, 6 
 Physical, 24, 36, 43, 69 
 
 How best combated, 67-8 
 Interdepartmental Committee 
 on (1904), 36 S note, 
 328 
 Diphtheria and School Life, 283 
 Medical Inspection for, 197 
 Sore Throat from, 281 
 Diploma in Public Health, value 
 to School Doctor, 151 
 of School Hygiene, 151 note 
 
INDEX 
 
 343 
 
 Dirt and Neglect, consequences of, 
 see Parental Neglect, 
 and Verminous Condi- 
 tions 
 Diseases, Common, afiFecting 
 School Life, 259 et seq. 
 Chronic Contagious, 293 et seq. 
 General, 260 
 
 Nervous, 270 
 Notifiable, and Non-notifiable, 
 and the School, and 
 School Officials, 192, 195 
 Symptomatic or Local, 278 
 Dispensaries : 
 
 Poor Law, 229, 234-5 
 Provident, 226 
 Village, 255 
 District Nurses as School Nurses, 
 180 
 Nursing Associations, 255 
 Training in, for School Nurses, 
 182 
 Doctors, see Family, Municipal, 
 Parish, Poor Law, 
 School Doctors, and 
 M. 0. H. 
 Dresden, School Dental Clinic at, 
 
 238, 251-2 
 Dull Scholars, education of, 53-4 
 
 Special Scholars, 54-5, 277 
 Duties of School Doctors, 115, 138, 
 139 et seq. 
 
 Ear(s), see also Hearing 
 Discharging, 287 
 Causes, 75, 287 
 Consequences, 76, 287-8 
 Treatment, 288 _ 
 Diseases of. Chronic, 
 Consequences, 213, 224 
 Treatment, 213, 224 
 Examination of, by School 
 
 Doctor, 160 
 Foreign Bodies in, 288 
 Eczema and School Medical Treat- 
 ment, 225 
 Education Acts : 
 of 1870., 4, 19 
 
 * Necessary officers ' under, 
 
 20 
 Scope and omissions of, 15 
 
 Education Acts {continued) : 
 
 of 1893 (Blind and Deaf), 20, 
 
 140 
 of 1899 (Defective and Epilep- 
 tic Children), 21, 140 
 of 1902, outcome of, as to 
 
 School Hygiene, 21 
 of 1907, and Medical In- 
 spection, 7, 17, 34, 187, 
 209 
 Authority, Powers needed for 
 Enforcing Treatment, 
 241 
 School Clinics under, 237 
 Bill, of 1906, and Medical In- 
 spection, 24, 33, 34 
 Board of, see Board of Educa- 
 tion 
 Committees, and School Hy- 
 giene, 113, 115 
 Public School, aim of, 6 
 Purpose of, 82 
 
 Sanitary Committees and, 98 
 School Hygiene in relation to, 
 
 101, 113, 115 
 Science of, development of, 80, 
 
 109 
 in Training Colleges, betterment 
 of, 83 
 Educational Functions of School 
 Doctors, 145-6 
 Hygiene {see School Hygiene), 
 
 promotion of, 109 
 Methods, faulty, and unhy- 
 gienic, 85, 86 
 Medical Inspection and, 86 
 Physiology and Psychology 
 of, 81 
 Wastage, prevention of, 51, 53 
 Egypt, Medical Inspection Legisla- 
 tion in, 31 
 Elementary Education, see Educa- 
 tion 
 England, early Educationists in, 10 
 Health inspection in, 95 
 History in, of School Hygiene, 17 
 Medical Inspection in, 32 
 Legislation introduced, 33 
 Made Law, 34 
 Mouth- breathing in, prevalence 
 of. Osier on, 284 
 
344 
 
 INDEX 
 
 England {continued)'. 
 Public School ideal in, 6 
 School Hygiene in, Biirgerstein 
 on, 95 
 Enlarged glands, see Glands 
 
 Tonsils, see Tonsils 
 Epidemic Disease, see also In- 
 fectious Disease 
 Code of 1908 on School Doc- 
 tor's duties re, 140 
 Sore Throat, see Tonsilitis, Folli- 
 cular 
 Epidemic Grant, the, 22 cfc note, 217 
 Epilepsy, defined, 273 
 causes, 274 
 
 forms of, symptoms of 
 chronic, 275 
 grand mal, 274 
 latent, 274 
 petit mal, 274 
 and School Life, three classes 
 
 concerned, 275-6 
 two main problems of, Poynton 
 on, 276 
 Epileptic Colonies, 276 
 Fits, symptoms of, 274-5 
 Schools, 276 
 Eutropics, 46 
 Examination, Medical : 
 
 Daily, cost, etc., of, 59, 60 
 of Defectives, 107-8, 202-4 
 Periodical, regulations re, 144 
 First, 86, 141, 144, 156 
 Second, 87, 142, 144, 157 
 Weekly, routine, 64 
 Exclusion from School, 50, 64 
 
 Authorization of, by School 
 
 Doctor, 140 
 Diseases and conditions neces- 
 sitating, 55-6, 64, 198, 
 217, 224, 282, 293 efse^. 
 from New York Schools, 
 
 49-50 
 Problems of, 108 
 Regulations of the London 
 County Council on, 193 
 External Diseases of the Eye, 
 
 289-90 
 Eye affections and Diseases, affect- 
 ing School Life {see also 
 Ophthalmia), 63 
 
 Eye afifections and Diseases {con- 
 tinued) : 
 Chronic, special School care 
 needed, 277 
 Treatment of, 213, 223 
 Contagious, 296 
 Errors of Refraction, 289, 291 
 External, 289-90 
 Inflammation, 75 
 Internal, 290-1 
 Soreness, 75 
 
 Squinting, 75, 289, 291-2 
 Ulceration, 75, 290 
 Examination of, by School 
 Doctor {see also Vision 
 Tests), 160 
 Foreign Bodies in, and School 
 Life, 288 _ 
 Eyesight, see also Vision : 
 
 of German school-children, 
 
 Cohn's work on, 15, 16 
 
 and School work, Ware on, 13 
 
 note 
 Statistics as to, 43 
 utilization of, 47 
 Eye-strain, causes, 85 
 and Headache, 280 
 
 Factory Act, 1802, provisions of, 1 
 
 Family Doctor, the, and the 
 Scholar, 226-7, 257 
 in Switzerland, 227 
 
 Fatigue in relation to School 
 work, 82 
 
 Favus and School Life, 217, 294 
 Treatment, 212, 217-18 
 
 Feeble-minded {see also Idiots, 
 Imbeciles, Mentally De- 
 fective, <fcc.). Educa- 
 tion of, 14 
 
 Feeding, improper, and Malnutri- 
 tion, 260, 261 
 
 Feet, bare. Examination of, 162 
 
 Finance of Medical Inspection, 7, 
 8, 90, 133 et seq. 
 
 Finland, School Dental Clinic in, 
 238 
 
 Fits, Epileptic, symptoms of, 275 
 
 Flying Clinics, 255 
 
 Follicular Tonsilitis, Sore Throat 
 from, 281, 282, 283 
 
INDEX 
 
 345 
 
 Forbes, Dr. Duncan, on value of 
 
 efficient School Nurses, 
 
 175-6 
 Foreign Bodies in Ear, Nose or Eye, 
 
 and School Life, 288 
 Pioneer work in School Hygiene, 
 
 12 et seq. 
 Forms and Schedules, 330 
 France, early Educationists in, 10 
 Medical Inspection Legislation 
 
 in, 25, 26 
 Freeman, on Greek ideals of 
 
 Education, 10 
 Froebel, 12, 13 
 
 General Debility in Scholars, 76 
 
 Diseases, and School Life, 260 
 
 et seq. 
 
 Germany, see Berlin, Darmstadt, 
 
 Dresden, Miilhausen, 
 
 Strasburg, Wiesbaden, 
 
 <Lc. 
 
 Defective Teeth in Scholars in, 
 
 219 
 Defective vision in, 221 
 Dental Inspection in, 219 
 Health Inspection in, 94 
 Medical Inspection Legislation 
 
 in, 29 
 School Dental Clinics in, 238 
 ' Flying ' Dental Clinics, 255 
 Doctors in, 20 
 Hygiene in, pioneer of, 14 
 Girls, Short Hair for, 170, 218, 294 
 Glands, Cervical, etc.. Enlarged : 
 Causes, consequences and 
 cure, 161, 219, 286, 
 287, 288-9 
 Examination for, 161 
 Tuberculosis of, 267 
 
 and School Life, 267, 268 
 ' Grand mal' symptoms of, 274-5 
 Greenwood, Dr., report of, on 
 Sanitary Conditions of 
 Schools, 58 note 
 Greer, E., help of, acknowledged, 
 
 188 note 
 Guthrie, Dr. L., work by, on 
 Fimctional Nervous 
 Disorders of Childhood, 
 278 
 
 Gutsmuths, work by, on Physical 
 Education, 12 
 
 Haib, Short, advantages of, 294-5 
 
 for Girls, 170, 218, 294 
 Handwork for Dull Children, 55 
 Harrington, Dr., on School Nurses, 
 
 119 
 Hay ward. Dr., on the work of the 
 
 School Nurse 
 
 1. at School, 176 
 
 2. at Homes, 177 
 Head(s) Communicable affections 
 
 of, see Favus, and Ring- 
 worm 
 Verminous, 161, 170, 294 
 
 Cleansing Scheme for, 199-200 
 Contact Infection in, 294 
 Headaches and School Life, 16, 
 279-80 
 Causes and cure, 279-80 
 in Secondary Scholars, causes 
 and consequences, 72, 
 73 
 Health Certificates after Second 
 Medical Examination, 
 166-8 
 Committees of School, Duties to, 
 of the School Doctor, 
 142, 146 
 Inspection, Daily, at Schools, 
 cost of, 59, 60 
 in Germany, Sweden, and 
 Switzerland, how estab- 
 lished, 94 
 Local Government Board and, 
 
 102-3 
 and School Hygiene, inter- 
 dependence of, 98, 99 
 Health Visitors, 68, 69, 98, 146 
 Hearing, see also Ears 
 
 Defective, Backwardness from, 
 
 52, 71 
 Tests of, 157, 159, 160 
 Heart, the, Examination of, 162 
 Heart Disease, Rheumatic, symp- 
 toms of, 264 
 and School Life, 265-6 
 Height and Weight measurements 
 taken by School Nurse, 
 87 
 
346 
 
 INDEX 
 
 Hellas, Physical Education in, 9, 10 
 
 Heredity and Epilepsy, 274 
 and Neurasthenia, 271 
 
 Herbart, 12, 13 
 
 Herodotus, on Persian education, 6 
 
 Hertel, on Overpressure in Danish 
 High Schools, 16 
 
 Hip disease. Tubercular, 266 
 
 History of School Hygiene, 9 et seq. 
 
 Holidays, School, and decreased 
 spread of Disease, 
 Murphy on, 61, Kerr's 
 explanation, 61-2 
 
 Home, Contact Infection of, 61, 62 
 Hygiene, 68, 98 
 
 Home Office, and Public Health 
 work, 65, 97 
 
 Home-work, and overpressure, 271 
 
 Homes, Visits to, of School Nurses, 
 173, 174, 175, 176, 179, 
 Hayward on, 177 
 
 Hospitals, London, raison d'etre of, 
 229 & note 
 Pauperization by, 226 
 Suggested reorganization of, 
 
 231, 233-4 
 and Treatment of Chronic 
 Complaints of Children, 
 228-9 
 
 Hygiene {see also Home, Personal, 
 and School Hygiene), 
 International Congress 
 of (1883), 16 
 and Sanitation, definition of, 
 99-100 
 Teaching of, to Teachers 
 and Scholars, 83-4 
 
 Hypermetropia and School Life, 
 290, 291 
 
 Hysteria, School or Class, Symp- 
 toms of, 273 
 
 Idiots, Education of, 14 
 
 with Spastic Paralysis, 293 
 Ignorance, Parental, 40, 41, 67, 
 
 68, 74, 75, 76 
 Imbeciles, with Spastic Paralysis, 
 
 293 
 Impetigo, and School Life, 225, 
 295-6 
 Treatment of, 212 
 
 Industrial Age, the, 3 
 
 System of, effects of, 3 et seq. 
 Infant Scholars (and Schools) : 
 Medical Inspection of, 85 
 First and subsequent Ex- 
 amination of, 86, 87 
 Medical supervision of, 107 
 Rickets in, importance of, 
 262-3 
 Infantile Paralysis and School Life, 
 225, 292 
 Treatment of, 213 
 Infants, Teeth of, care of impor- 
 tant, 220 
 Infection, Contact, and Schools, 60, 
 61, 62, 294, 296 
 Definition, 280 cfc note 
 Infectious Diseases of Childhood 
 neglected by Public 
 Health Authorities, 63 
 and School Life : 
 Administrative Routine, 192 
 
 et seq. 
 After-effects of, 52, 296-7 
 Duties of School Doctors as to, 
 
 140, 143, 192 et seq. 
 Epidemic grant and, 22 & note, 
 
 217 
 Incidence and Spread of, need 
 
 of study of, 108 
 Medical Inspection of Scholars 
 
 returning after, 297 
 Prevention of, 38-9 
 Regulations for Teachers,'etc., 
 
 192 et seq. 
 School Epidemics, 60 
 Control of, 59-62 
 Specific, Sore Throat from, 281 
 Influenza and School Life, after- 
 effects of, 297 
 Sore Throat from, 281, 282, 284 
 Inspectors of Schools, Medical 
 
 Training for, 109 
 Interdepartmental Committee on 
 Medical Inspection and 
 Feeding of Children 
 attending Public Ele- 
 mentary Schools, Re- 
 port cited, 22-3 
 on School Nurses, 173 
 Internal Diseases of the Eye,290-2 
 
INDEX 
 
 347 
 
 International Congresses, see Con- 
 gresses 
 
 Invalid Children's Aid Associa- 
 tions, work of, 225 
 
 Iritis, and School Life, 290-1 
 
 Itch, see Scabies 
 
 Itinerant Clinical work in Schools, 
 256 
 System of Medical Inspection, 
 116-17, 125, 121 et seq. 
 
 Japan, Medical Inspection Legisla- 
 tion in, 28 
 School Medical Advisory Board 
 in, 105 tfc note 
 
 Jessen, Prof. Dr., on Cost of 
 Strasburg School Den- 
 tistry, 251 
 
 Joint- affections. Rheumatic, symp- 
 toms of, 264 
 
 Keratitis, and School Life, 
 
 289-90 
 Kerr, Dr. James, appointed School 
 M.O. at Bradford, 20 
 
 on Dental defects in London 
 Scholars, 219 
 
 on the Duties of the School 
 Doctor, 138-9 
 
 on practical points in Annual 
 Reports of School Doc- 
 tors, 206-7 
 
 Report on Visual conditions in 
 Bradford Scholars, 221 
 
 on Scarlet Fever and Holidays, 
 61-2 
 Key, Prof. Axel, on Physically 
 Defective children in 
 Swedish Schools, 16,17 
 Koppe's scheme for estimating 
 Nutrition and Physical 
 Condition, 158 
 
 Laissez-faibf, doctrine of, effects 
 of, past and present, 
 1, 2, 3, 232 
 Languages, two, habitually used 
 
 by Scholars, 163 
 Large Towns : 
 
 Medical Inspection in 
 
 Administrative Routine, 
 188 et seq. 
 
 Large Towns, Medical Inspection 
 {continued) : 
 Treatment in, means of, 
 226 
 Family Doctor, 226 
 Municipalization of Medi- 
 cal Services, 235 
 Out-patient departments 
 
 of Hospitals, 228 
 Poor Law Dispensaries, 
 229 
 Nurses in, duties of, 178-80 
 School Hygiene for 
 Organization of, 
 
 Duties of the School Medi- 
 cal Officer, 115 
 Foreign methods, 118 et 
 seq. 
 Laryngitis, Sore Throat from, 281, 
 
 282 
 Legislation on School Hygiene 
 Foreign, 25 
 Home, 32 
 Leipzig, Medical Inspection at, 20, 
 
 29 
 Lice of Head and Body, 212, 218, 
 
 294-5 
 Ling, Peter Henrik, Physical 
 training system of, 13 
 Liverpool, School Nurses at, 173 
 Local Government Board, and 
 Health Inspection, 
 
 102-3 
 and Public Health work, 65, 
 97 
 Locke, John, 10 
 
 work by, on Education, 11 
 London, Backward Scholars in, 
 need for classifying, 51 
 Defective Teeth in Scholars in, 
 
 Kerr on, 219-20 
 Hospitals of, raison d'etre of, 229 
 
 (fc note 
 Medical Inspection in 
 
 Administrative Routine of. 
 Notes based on, 188 et 
 seq. 
 Pioneer work of, 32 
 Treatment rare after Inspec- 
 tion, 211 
 
348 
 
 INDEX 
 
 London {continued) : 
 School Hygiene in 
 Organization of. 
 Preliminary, 32 
 Present, 120-1 
 Proposed eventual, 121-2 
 School Nurses in, 173, 174, 177 
 Schools, Verminous Conditions 
 
 prevalent in, 185 
 Secondary Schools in, Medical 
 
 Inspection of, 205 
 Special Schools in, for Blind and 
 Deaf, 277 
 London County Council, Educa- 
 tion Committee of, 188 
 7iote 
 Medical Officers under, 32-3 
 Regulations of, as to In- 
 fectious Disease in 
 Schools, 193 
 Treatment Inquiries, 238- 
 9, propositions and re- 
 commendations,239-40 
 London Education Committee, 
 Medical Officer and 
 Staff of, 121-2 
 London School Board, Medical 
 Officer appointed by, 
 20, report by, 21 
 School Nurses under, ap- 
 pointment and duties 
 of, 174-5, 177-8 
 Long Sight, and School Life, 291 
 Lorinser, Dr. Karl, pioneer in 
 
 School Hygiene, 14 
 Lovett, Dr., on apathy of average 
 Medical men as obstacle 
 to School Hygiene pro- 
 gress, 118 
 Lower-grade Schools, objects of, 
 
 55 
 
 Lucerne, Medical Treatment at, 
 system of, 245 
 School Dental Clinic at, 238, 252 
 Polyclmic at, 338, 252, 253 
 Lungs, examination of, 162 
 Lupus, 267 
 
 Mackenzie, Dr. Leslie, on Progress 
 of Medical Inspection, 
 22 
 
 Maclaren, A., Oxford Gymnasium 
 
 set up by, 17 
 Malnutrition and School Life, 
 260-2 
 Causes, 260 
 Results, 260 
 Symptoms, 260 
 Treatment, 261-2 
 Manchester School, the. Laissez- 
 faire policy of, 3 
 Manual training. Assistants for 
 study of hygienic edu- 
 cational modes of, 107 
 for Dull children, 55 
 in Infant Schools, 85 
 Measles and School Life 
 After-effects, 297 
 Age-incidence of, 61 
 Control of, 61, 198 
 Medical Inspection and, 197-8 
 Medical Certificates, 64, 193-5, 
 204, 230-1, 283 
 Department, Board of Educa- 
 tion, function of, 103-4 
 Staff of, 105 et seq. 
 Faddism, checks on, 106 
 Medical Inspection of Schools and 
 Scholars, 84-5 
 Administrative Routine of, 187 
 et seq., for sub-heads, 
 see that entry 
 Annual Reports 
 
 Circular of Board of 
 
 Education, 263-6 
 Kerr on practical points 
 in, 206-9 
 Cleansing Schemes : 
 Bodies, 200-1 
 Heads, 199-200 
 Detailed Inspection, 190 et 
 
 seq. 
 Diphtheria, 197 
 General Inspection, 188-9 
 
 Records of, 189 
 Infectious Diseases, Regula- 
 tions re, 192-5 
 Local Administrative ar- 
 rangements, 187-8 
 Measles, 197-8 
 Medical Register, 189-90 
 Room, 208 
 
INDEX 
 
 349 
 
 Medical Inspection of Schools and 
 Scholars. Administra- 
 tive Routine of {con- 
 tinued) : 
 Scarlet Fever, 195-7 
 School Nurses, duties of, 
 
 198-9 
 Secondary Schools, super- 
 vision of Students, 205 
 Special Schools 
 Admission to, 201 
 Centres, examinations at, 
 
 203 
 Medical Certificates, 204 
 Teachers in, examination 
 of, for Physical fitness, 
 204-5 
 Vision-testing, 190-2 
 Advocated by Virchow, 16 
 Aims of, 79, 80-1 et seq. 
 Analysis of, in relation to 
 (a) the State, 78 
 (6) the Local Authority, ib. 
 
 (c) the Parents, ib. 
 
 (d) the Children, ib. 
 Aspects of, Educational and 
 
 Hygienic, 84-6 
 Bibliography, 298 
 Board of Education's Memo- 
 randum on, 303 
 Regulations as to, 143, 144 
 Case for 
 
 a priori, 35, 40, 41, 42 
 a posteriori, 78 
 and Compulsory Attendance, 
 
 39 
 Daily, Cost of, 59, 60 
 of Defectives, Physical and 
 
 Mental, 107-8, 202-4 
 Examinations of Defectives, 
 203 
 Periodical,regulationsre, 144 
 First, 86, 141, 144, 156 
 Second, 87, 142, 144, 
 
 157, 159 et seq. 
 Weekly, 64, 169 
 Terminal, or Annual, 169 
 Time occupied, 166 
 Facts and Statistics on, utili- 
 zation of, 46-7 
 Finance of, 7, 8, 90, 133 et seq. 
 
 Medical Inspection of Schools and 
 Scholars. Administra- 
 tive Routine of {con- 
 tinued) : 
 Fundamental idea of, 90-1 
 General advantages of, 89 
 Itinerant, versus Local, 116-17, 
 
 125, 127 et seq. 
 in (a) Large Towns, 116 
 (6) Small Towns, 124 
 (c) Rural districts, 124 
 Legislation on, 
 Foreign, 25 
 Home, 32 
 National duty of, 7, 43 
 
 gain from, 56 
 Objections raised against, 90 
 in Preparatory Schools, 74 
 Principles of, 79, 84 et seq. 
 Routine, or Systematic, 55-6, 
 64, 73, 77, 78, 84, 85, 
 88-9, 169 
 of Scholars retui-ning after 
 Infectious Disease, 297 
 of School Buildings, 58 <fc 
 
 note, 59, 78, 84, 85 
 in relation to School Hygiene, 
 
 23, 80, 98-9, 101 note 
 Scopeof, 80, 81 e^seg-. 
 Treatment of conditions dis- 
 closed by, problejn of, 
 209, 210, 211, see also 
 Medical Treatment 
 Two courses open in, 7, 8 
 Medical Ofiacers, appointed by 
 School Boards, 19-21 
 Results of work of, 48 
 Medical Officers of Health : 
 
 Duties of, as to Health In 
 spection, actual and 
 suggested, 96, 98, 99, 
 115, 123, 126-7 
 as to Infectious Disease, 
 
 192-5 
 as to Verminous Children, 
 200 
 Lack of opportunities for 
 study of School Life, 
 60-1 
 and Unrecognized diseases 
 of Childhood, 67 
 
350 
 
 INDEX 
 
 Medical Officers of Health {con- 
 tinued) : 
 of London Education Com- 
 mittee, Staff of, 121-2 
 Principal, in Large Towns, 
 functions of, 100 
 Medical Practitioners in poor dis- 
 tricts, standing of, as 
 affecting Treatment of 
 Scholars, 230 
 Register, 89, form and use of, 
 
 189-90 
 
 Room for Dentists, at School 
 
 Clinic, 242-3 
 
 for Physicians, 241-2 
 
 for School Doctor, 208, 240 
 
 Services, Municipalization of, 
 
 231 235—6 
 Staff of School CUnic, 243-4 
 Statistics, Superintendent of, 
 required at Board of 
 Education, 108 
 Superintendent of Large Town 
 Schools, 114, best not 
 Medical Officer of 
 Health, 115, 123 
 Supervision for Blind and Deaf 
 School children, 277 
 Medical Treatment at School, 209 
 et seq. 
 Diseases and Conditions im- 
 peratively requiring, 
 212 et seq. 
 Chronic conditions 
 of Ear, 224-5 
 of Eye, 223-4 
 others, 225 
 Defective Teeth, 214-21 
 
 Vision, 221-3 
 Favus, 217-18 
 Ringworm, 214-17 
 Scabies, 219 
 Skin affections, 225 
 Verminous Conditions, 218 
 Family doctors and, 226, 257 
 Free, pros and cons of, 257-8 
 in Large Towns, Means for 
 securing, 226 
 Existing, 
 
 Family Doctor, 226 
 
 Medical Treatment at Schools — 
 in Large Towns, 
 
 Existing (continued) : 
 
 Out-patient Departments 
 
 of Hospitals, 228 
 Poor Law Dispensaries, 
 227 
 Suggested, 
 Laissez-faire, 231 
 Hospital reorganization, 
 
 231, 233 
 Municipalization of Medi- 
 cal Services, 231, 235-6 
 Poor Law reorganization, 
 231, 234 
 Parental neglect as to (see 
 
 also Neglect), 230 
 and the Poor Law, 229-30, 
 
 235 
 Problem of, 211-12 
 Factors in, 230-1 
 Solutions suggested, 231 et 
 seq. 
 School Clinics for (q.v.), 237 
 in Switzerland, 227 
 Medicine defined by Plato, 1 
 Memorandum on School Closure 
 and Exclusion of 
 Children for Infectious 
 Disease, 329 
 Meningitis, Tubercular, 267 
 Mental Capacity, examination of, 
 162, 164 
 Classification of, 165 
 Deficiency and School Life, 53, 
 
 276-7 
 Deterioration, 5, 6 
 Dullness, and Adenoids, 286 
 Status of Scholars, Warner's 
 investigations, 18, 19 
 Mentally Deficient Children 
 
 Medical Inspection of, 107-8 
 Certificates for, 204 
 Registration of, 202-3 
 Metropolitan Asylums Board 
 Ringworm Schools, 
 length of stay at, 215 
 Migraine in latent Epileptics, 274 
 Minor Ailments, Treatment of, by 
 School Nurses, 181, 212 
 ct' note 
 
INDEX 
 
 351 
 
 Montaigne, on Collaterals of Educa- 
 tion, 10 
 on Science of Life, 68 
 Mouth, Examination of, by School 
 
 Doctor, 160 
 Mouth- breathing and School Life 
 Causes and forms of, 284 
 Sore Throat and, 280 
 Treatment, 161, 213, 248, 285 
 Mulcaster, Richard,' 10 
 Miilhausen, Dental Inspection at, 
 220 
 School Dental Clinic at, 238 
 Mimicipal Doctors, at Bellinzona, 
 
 236 
 Municipalities and Medical Treat- 
 ment, 
 Case for, 257, 258 
 Co-operation with Hospitals in, 
 
 233, 234, 236 
 and Operative Treatment, 
 248-9 note 
 Municipalization of Medical Ser- 
 vices, 231, 235-6 
 Murphy, Sir Shirley, on Holidays 
 and decreased Spread 
 
 O^ Dl863iSG 6 X 
 
 Myopia, and School life, 291, 292 
 
 Nasal Breathing, advantages of, 
 285, CatUn on, 284 
 Catarrh, Sore throat from, 282, 
 284 
 
 Neck, examination of, aim of, 161 
 
 Neglect, Parental, 75, 76, 190, 
 210, 211, 218, 221, 222, 
 223,224,225,230,294-5 
 
 Neglected Children, School Nurses 
 and, 190 
 
 Nerve-signs, Warner's, observa- 
 tion of, 164 
 
 Nervous Diseases of Childhood, 
 and School Life, 270 
 et seq. 
 Instability of Childhood, 270 
 System, state of. Examination 
 of, 162, 164 
 
 Neuchatel, School Clinic at, 253 
 
 Neurasthenia and School Life, 
 272-3 
 Causes, 271-2 
 
 Neurasthenia (continued) : 
 Definition, 271 
 Results, 272 
 Symptoms, 272 
 Neurotic Temperament, defined, 
 270 
 Headache of, treatment for, 
 
 280 
 Onset of, 270 
 Treatment, 270-1 
 New York, Dental Inspection at, 
 220 
 School Exclusion at, 49-50 
 Newman, Dr. George {See also 
 Board of Education, 
 Chief Medical Officer), 
 93-4 note. 
 Night Terrors, causes of, 271, 274 
 Non-notifiable Diseases, co-opera- 
 tion of the Teacher 
 and School Doctor re, 
 195 et seq. 
 Nose, Chronic Diseases of. Treat- 
 ment of, 213 
 Foreign Bodies in, and School 
 Life, 288 
 Normal and backward scholars, 
 
 52 
 Norway, Medical Inspection Legis- 
 lation in, 27 
 Notifiable Diseases and the School, 
 
 192 et seq. 
 Number of Children, Medically 
 Inspected at one time, 
 166 
 Nurses, District, as School Nurses, 
 180 
 School : 
 
 Accommodation for, 184-5, at 
 
 School Clinics, 240, 243 
 
 Appointed under the London 
 
 School Board, 174-5, 
 
 177-8 
 
 Co-operation of Teachers with, 
 
 186 
 Definition of, 172, 180 
 District Nurses ae, 180 
 Duties of, 174-5, 177-8, 198 
 Cleansing of Heads and 
 
 Bodies, 199-201 
 in Large Towns, 178-9, 183 
 
352 
 
 INDEX 
 
 Nurses — Duties of (continued) : 
 in Small Towns, 180 
 Ringworm, 201 
 in Rural Districts, 180 
 Systematization of, 199 
 Evolution of, 172 
 Examinations by, 87, 157, 
 159, 174, 175, 176, 201 
 Harrington on, 119 
 History of, 172 et seq. 
 in London, organization of, 121 
 Methods and Routine of, 183 
 and Neglected Children, 190 
 Qualifications and Training 
 
 of, 180, 182-3 
 at Reading, 174 
 in Rural Districts, 180 
 Supervision of, by School 
 Doctors, 142, 145 
 tact required, 149 
 Treatment by, of IVIinor Ail- 
 ments, 181, 212 & note 
 Work of, aims, scope, limita- 
 tions, 181 
 Nursery Schools, 263 
 
 Medical Supervision of, 107 
 Nursing Staff of School Clinic, 244 
 Nutrition, estimate of, 158-9 
 
 Obstinacy of Parents, 76 
 
 Official Documents, etc., Extracts 
 from, on Medical Ex- 
 amination of Scholars, 
 303 
 
 Open-air Recovery Schools, 73-4, 
 cases suitable for, 262, 
 272, 279, 280 
 
 Operative Treatment, Municipali- 
 ties and, 248-9 note 
 
 Ophthalmia, 63 
 
 Oral Instruction for Dull and 
 Backward Children, 55 
 
 Organization of School Hygiene, 
 111 ei seq. 
 Aims of, general, 112, 113-14 
 Finance of, 133 
 Schemes for, in 
 
 (1) Large towns and county 
 
 boroughs, 112, 114-23 
 
 (2) Small towns, 112, 124 
 
 (3) Rural districts, 112, 124-33 
 
 Organization of School Hygiene — 
 Summary, 131-2 
 School Doctors 
 
 Appointment of, aim of, 
 116-17 
 duration of, 117 
 Professional jealousy unlikely, 
 117 
 System of Medical Inspec- 
 tion versus Itinerant, 
 116-17 
 Osier, Prof., on Flying Clinics, 255 
 on Prevalence of Mouth- breath- 
 ing in England, 284 
 Otorrhoea, and School Life, causes, 
 consequences, treat- 
 ment, 224, 287-8 
 Overpressure in Schools, 16, 18, 81 
 Causes, 85, 271 
 Consequences, 265, 271, 280 
 Symptoms, 271 
 
 Paralysis, Infantile, and School 
 Life, 213, 225 
 Special Schools for, 292 
 
 Remedial Exercises in, 292 
 Treatment, 213 
 Spastic, 292-3 
 Parents, Conferences of, with 
 Teachers and School 
 Doctors, 145 
 Co-operation of, in Health Edu- 
 cation, 145 
 Difficulties with, 148 
 Ignorance of, 40, 41, 67, 68, 74, 
 
 75,76 
 Knowledge of, by School Doc- 
 tor, 152 
 Neglect by, 75, 76, 190, 210, 211, 
 218, 221, 222, 223, 224, 
 225, 230, 294-5 
 Obstinacy of, 76 
 Presence of, at first Examina- 
 tion, 86, 141, 156 
 Pride of, 185 
 
 Rights of, as to Children at 
 
 Elementary Schools, 64 
 
 Paris, School Hygiene work in, 
 
 116, 119-20 
 Parish Doctors under Poor Law, 
 limitations of, 230 
 
INDEX 
 
 363 
 
 Payment of School Doctors, 114, 
 135, action on, of 
 British Medical Asso- 
 ciation, 136 
 Pearse, Miss, Superintendent of 
 London School Nurses, 
 on Verminous Condi- 
 tions in Scholars, 185 
 Pedal Deformities, need for early 
 
 recognition of, 74 
 Periods for Medical Examination 
 of Scholars, 64, 86, 87, 
 141, 142, 144, 156, 157 
 Personal Hygiene, 68, 69 
 Pestalozzi, 12, 13 
 ^ Petit mal,' symptoms of, 274 
 Pharyngitis, Acute, Sore Throat 
 
 from, 281, 282 
 Phlyctenular Conjunctivitis and 
 
 School Life, 289, 290 
 Phthisis, symptoms of, 266 
 Physical census, 36, 43, 44, 78 
 Condition, estimate of, 158-9 
 Defects of Scholars, 51 e^ seq. 
 Medical Inspection of, 107-8 
 Special Schools for. 
 Admission to, 202 
 Certificates for, 204 
 Examinations for, 202-3 
 Registration of, 202-3 
 Physical Deterioration, 24, 36, 43, 
 69 
 Combated by Physical Edu- 
 cation, 67 
 Interdepartmental Committee 
 on (1904), 36 a> note, 
 328 
 Physical Education or Training 
 Aim of, 67-8 
 Boston methods, 118 
 Greek, 9, 10 
 
 Gutsmuths' work on, 12 
 Importance of, 82, 83 
 Medical Expert to Study, 107 
 Scope of, 68 
 School Nurses to be trained 
 
 in, 180 
 Value of Earliness in, 68 
 Physical Exercises, due proportion 
 of, 85 
 
 Physicians, Consulting room for, at 
 School Clinics, 241-2 
 Private, limit of responsibility 
 of, 147 <fc note 
 ' Pink-eye ' and School Life, 296 
 Plato, on Medicine, 1 
 Playgrounds, etc., Supervisors of, 
 
 Boston, 118 
 Pocket-handkerchief, the, in cure 
 of Mouth- breathing, 
 284, 285 
 Points to note in Medical Inspection 
 Detailed examination 
 First, 86 
 Second, 87-8 
 Routine, Infant Scholars, 86-7 
 Older scholars, 88-9 
 Poor Law Dispensaries, 229, 234-5 
 Poor Laws, the, and Medical Treat- 
 ment, 229 
 proposed reorganization, as 
 to, 231, 234 
 Parish Doctors under, 230 
 Royal Commission on. Report 
 of, 1909, omission in, 
 as to Medical Treat- 
 ment of Scholars, 235 
 Post-graduate courses for School 
 
 Doctors, 118 
 Pott's disease, 267 
 Poynton, Dr. F. J., on Rheuma- 
 tism and School At- 
 tendance, 266 
 on two main problems of 
 Epilepsy, 276 
 Precocity and Tuberculosis, 267, 
 
 269 
 Predisposition to Rheumatism, 
 
 Symptoms of, 263-4 
 Preparation for School Life, 53, 54 
 Preparatory Schools, futile Medical 
 
 Inspection in, 74 
 Preventible Diseases, duties of 
 
 Doctors towards, 67 
 Prevention better than Cure, 1, 2, 
 76 et prosvi 
 of Educational Wastage, 51, 53 
 Oi Infectious Disease, in relation 
 to Schools, 38-9, 59 
 et seq. 
 
 HOGARTH 
 
 A a 
 
354 
 
 INDEX 
 
 Principal Medical Officer, a desi- 
 deratum, 100 
 Prize and Medal system, con- 
 demned, 48 
 Prosecution for Verminous Con- 
 ditions, 200 
 Provident Dispensaries, 226 
 Psychological Research, Super- 
 intendent of, required 
 at Board of Education, 
 108 
 Public Health Administration 
 Authorities responsible for, 65 
 Communicable Diseases hitherto 
 
 neglected by, 63 
 and School Hygiene, 99 
 Suggested reorganization of, 66 
 Preventive measures, 64 
 Public Health, Diploma in, value 
 to School Doctor, 151 
 Health Visitors, 68-9, 98, 146 
 Physical Education in aid of, 
 
 67-8 
 Science of, defined, 57 
 
 extended definition, 63, 65 
 and Schools 
 
 Prevention of Infectious Dis- 
 ease, 59 
 School Sanitation, 58 cfc note, 59 
 State view of, 66 
 Public Medical Services 
 
 Lack of co-ordination in, 96 
 Unification of, 125, 130 
 Pulmonary Tuberculosis, 266 
 and School Life, 267 
 
 Early Diagnosis important, 
 269 
 Pupil of Eye, to dilate, for Vision- 
 testing, 291 
 Pupil-Teachers, Medical Super- 
 vision of, 205 
 Purulent Conjunctivitis, 224 
 
 Queen Victoria's Jubilee Nursing 
 Association, and the 
 School Nurse, 172 
 
 Rabelais, 10 
 
 Rates, the, and Medical 
 spection, 134 
 and the School Clinic, 256 
 
 In- 
 
 Reading, School Nurse at, 174 
 Recreation, due proportion of, 85 
 Recruits {see also Soldiers), Re- 
 jection of, reasons for, 
 43 
 Refraction, Errors of, and School 
 
 Life, 289, 291 
 Reports : 
 
 Annual, of School Doctors 
 Circular on, of Board of 
 Education, 205-6, 320 
 Kerr on practical points in, 
 206-9 
 of Interdepartmental Com- 
 mittee on Physical De- 
 terioration, 328 
 Research work, expected from 
 School Doctors, > 110, 
 121-2, 144, 145, 152 
 Residential Schools, Medical Ex- 
 amination in, 74-5 
 Rheumatism and School Life, 
 264-6 
 Causes, 263 
 Considerations on, Poynton on, 
 
 266 
 General, 264 
 Symptoms, 265 
 Treatment, 265 
 Rickets, 262-3 
 Causes, 262 
 Results, 213, 262 
 Symptoms, 262 
 Treatment, 213, 263 
 and School Life, 262-3 
 Ringworm and School Life, 63, 64, 
 212, 213, 214, 215, 
 293-4 
 Examination for, by School 
 Nurses, 174, 175, 176, 
 201 
 Methods, 184 
 Treatment of, 212, 213, 214 
 by Rontgen Rays, 216, 217, 
 243, 244, 246, 247-8, 
 252 
 Ringworm Schools of Metropolitan 
 Asylums Board, length 
 of stay at, 215 
 Rontgen Rays, Treatment by 
 of Favus, 218 
 
INDEX 
 
 355 
 
 Rontgcn Rays {continued) : 
 
 of Ringworm, 216, 217, 243, 
 
 244, 246, 247, 248, 252 
 
 Roumania, Medical Inspection 
 
 Legislation in, 31 
 Rousseau, J. J., Educational 
 
 theories of, 11 
 Routine, Administrative, of Medi- 
 cal Inspection, 187 et 
 seq. 
 of School Clinic, 244 et seq. 
 Royal Commission on 
 
 Blind, Dumb, and Feeble- 
 minded, 19 
 Poor Laws, Report of (1909) 
 Omission in, on Medical 
 Inspection, 235 
 Rural Districts and Medical Treat- 
 ment, 254, 255-6 
 Organization of School Hy- 
 giene for, 112, 124 
 et seq. 
 School Clinics impossible in, 
 254 
 Alternatives to, schemes 
 for, 254-5 
 School Nurses in, 180 
 Russia, Medical Inspection Legis- 
 lation in, 30 
 
 Salaries of School Doctors, 114, 
 
 135, 136-7 
 Sanitary Committees, and Educa- 
 tion, 98 
 Sanitary Inspection of Rural 
 Schools, and Medical 
 Officer of Health, 126 
 Sanitation and Hygiene, Definition 
 of, 99-100 
 and Public Health, 57 
 of Schools, 57, 58 db note, 59, 
 78, 84 
 Scabies, Causes, 295 
 
 Treatment, 212, 219, 295 
 Scalp, appearance of, in 
 Favus, 293 
 Ringworm, 294 
 Scarlet Fever and School Life, 283 
 After-effects, 297 
 and Holidays, Kerr on, 61-2 
 ■^ Sore Throat from, 281 
 
 Aa 
 
 Science of Education, building-up 
 
 of, 107 
 Scoliosis and School Life, causes 
 
 and cure, 293 
 School (s), see Infant, Preparatory, 
 Public, Secondary, Re- 
 sidential, and Special 
 Schools 
 Absence from, backwardness 
 
 due to, 51 
 Attendance, see Attendance 
 Authority, the, position of, as to 
 Medical Inspection, 44 
 note 
 Buildings, Sanitation of, 57, 58 
 cfc note 
 Medical Inspection and, 59, 
 78, 84, 85 
 Cleanliness in, and in Scholars, 
 
 14, 64, 69 
 Cleansing of Verminous Scholars, 
 
 199, 201, 295 
 Closure of {see also Exclusion), 
 
 48, 329 
 Contact and spread of Disease, 
 
 61, 62 
 Nurseries of the nation, 68 
 Prevention of Infectious Dis- 
 ease in, 59 et seq. 
 Work at, of School Nurse, Hay- 
 ward on, 176 
 School Attendance officers. School 
 Nurses to replace, sug- 
 gested, 179 
 School Boards, Medical Officers 
 
 appointed by, 19-21 
 School Building and Equipment, 
 Medical expert for 
 Studying, 106 
 School care of children, versus 
 Custodial Treatment, 
 Cronin on, 257 
 School or Class Hysteria, 273 
 School Clinic, the, 237 
 Accommodation in 
 
 Dentist's Consul ting Room, 242 
 Operating room, 242-3 
 ' Spiihl Zimmer,' 243 
 Operating room, 242-3 
 Physician's or Surgeon's Con- 
 sulting Room, 241-2 
 
 2 
 
356 
 
 INDEX 
 
 School Clinic, the — Accommoda- 
 tion in (continued) : 
 School Doctor's Room, 208, 
 
 240 
 School Nurse's Room, 240, 243 
 X-ray work room, 243 
 Waiting-room, 243 
 
 Advantages, 256 et prcevi 
 Economic, 257 
 
 Attendance at, to be Voluntary, 
 240 
 
 Authority for, 237 
 
 Bradford, Crowley on, 249-50 
 
 Building and Equipment of, 241 
 
 Cost, 250 et seq. 
 Estimates, 252-3 
 
 Ideal form of, 237-8 
 
 Impossible in Rural districts, 254 
 
 Number of, 254 
 
 Objections to, 256, 257-8 
 
 Recommendation of, by L.C.C. 
 Committee, 240 
 
 Routine for, three methods, 246 
 et seq. 
 
 and the School Nurse, 180 
 
 Service of, 244-5 
 
 Staff, 243, 244 
 
 Treatment to be Free, 241 
 School Dental Clinics, in Germany, 
 Sweden and Switzer- 
 land, 238 
 
 Cost in two former, 251-2 
 
 at Strasburg, 243, 252 
 School Doctor, see also School 
 Medical Officer 
 
 Accommodation for, 208, 240 
 
 Attitude of, towards Treatment 
 of Conditions disclosed 
 by his work, 210 
 
 Classes of, two, 139 
 
 Difficulties of, 148-9 
 
 Duties, 113-15, 138, 139 efscg., 169 
 Summary, 144-5 
 
 Medical Inspection by, see that 
 head 
 
 Medical Officer of Health as, 115, 
 123, 126-7 
 
 Methods of, 156 et seq. 
 
 Number of, in London, 121 
 
 Numbers dealt with at one 
 Inspection, 166 
 
 School Doctor [continued) : 
 
 Post-graduate courses to be 
 
 imperative on, 118 
 Qualifications, 146 
 
 Personal, 148, 170-1 
 Professional, 149 
 Temperamental, 148 
 Summary, 152-5 
 Remuneration, 114, 135, 136-7 
 Research work expected from, 
 110,121-2,144,145,152 
 Social Duties, and experience of, 
 
 145-6, 151-2 
 Work of, wide scope of, 89-91 
 School Districts, London, 121 
 School Exclusion, see Exclusion 
 School Headaches, causes and 
 consequences, in Sec- 
 ondary Schools, 72, 73 
 School Hygiene, Apathy of 
 average Medical man 
 to, Lovett on, 118 
 Bibliography, 299 
 Board of Education Memoran- 
 dum on, 93-4 note 
 in relation to, 103-4 
 suggested Model Depart- 
 ment in, 109 
 Building up of, 109 
 Diploma of, 151 Twte 
 in England, Biirgerstein on, 95 
 Factors in, 80-1. 
 Historical notes on, 9 et seq. 
 International Congresses on 
 
 (1904 & 1907), 32 
 and Medical Inspection, 23, 
 
 98, 99, 101 7wte 
 Organization of : 
 Central, 101 
 Local, 111 et seq. 
 
 Financial problems, 133 
 et seq. 
 Preliminary methods in 
 foreign large towns, 
 118 et seq. 
 Relation of, to Education, 10 
 to Public Health, 99 
 to Stale Medicine, 92 et seq. 
 Research work expected of 
 School Doctors, 110, 
 121-2, 144, 145, 152 
 
INDEX 
 
 357 
 
 School Life, Common Diseases 
 affecting, 259 et seq. 
 Chronic Contagious, 293 et seq. 
 General, 260 
 
 Nervous, 270 
 Notifiable and other, 192, 195 
 S)-mptomatic or Local, 278 
 Preparation for, 53, 54 
 School Medical Board in 
 Arsrentina, 104 
 Japan, 105 
 School Medical Officer, see also 
 School Doctor 
 in England, 113 et seq. 
 Duties, 113-14, 115 
 Remuneration, 114, 135,136-7 
 Medical Officers of Health and, 
 
 115-16 
 in Sweden, 113 
 in Switzerland, ib. 
 School Nurses, see Nurses, School 
 School Polyclmics, in Switzerland, 
 
 238 
 School- work, Fatigue in relation to, 
 
 82 
 Scholars, Classification of, 54, 55, 
 78, 82, 87-8 
 Difficulties with, 148 
 Medical Inspection of, see that 
 
 head 
 Numbers of, for which School 
 Doctors are responsible, 
 various foreign towns, 
 118 et seq. 
 Teachmg of, in Hygiene, 83 
 Scholarship Candidates, Medical 
 Supervision of, 205 
 
 Secondary Schools : 
 
 Defects of Scholars, need for 
 recognition, 70 et seq. 
 Remedies, 73-4 
 in London, 205 
 
 Medical Examination in, futile, 
 74 
 Systematic, reasons for, 73 et 
 proevi 
 Seguin, Dr., pioneer in Education 
 
 of Idiots, 14 
 Semi-blind Children, special School 
 treatment for, 277 
 
 Semi-deaf Children, special School 
 
 Treatment for, 277 
 Service of a School Clinic, 244 et 
 
 seq. 
 Short Sight, and School Life, 70, 
 
 71,291 
 Shuttleworth, Dr., 18 
 Skin Diseases {see also wider 
 names), 63, 225, 294, 
 295 
 Small Towns, Organization of 
 School Hygiene for, 112, 
 124 
 School Nurses in, 180 
 Social duties and experience of 
 School Doctor, 145-6, 
 151-2 
 Soldiers {see also Recruits), Rejec- 
 tions of, 44 
 Sore Eyes, and School Life, 
 causes and cure, 75, 
 290 
 Sore Throat and School Life, 280 
 Association of, with Impetigo, 
 
 295-6 
 Causes, 280 
 Classification of, 280-1 
 Severe, 281 
 
 Causes, 281 
 Slight, 281 
 Causes, 281-2 
 
 subdivision of, ib. 
 School exclusion and, 282 
 Medical Certificates on, 283 
 Precautionary routine as to, in 
 Schools, 282-3 
 Sores, Infectious, and School Life, 
 
 295-6 
 Spastic Paralysis, 292-3 
 Special Schools, Aim of, 54-5 
 Examination of Scholars 
 
 (1) for Admission, 201 
 
 (2) at Centres of, 203 
 Medical Certificates for, 204 
 School Nurses for, 179-80 
 Teachers for, Physical fitness 
 
 examination of, 204-5 
 for Blind and Deaf Children, 277 
 Convalescent, 269 
 for Epileptics, 276 
 for Infantile Paralytics, 292 
 
358 
 
 INDEX 
 
 Special Schools (continued) : 
 Lower-grade, 55 
 for Mental Defectives, 276-7 
 Nursery, 107, 263 
 Open-air, 73,74, 262, 272, 279, 280 
 for Ringworm, 215, 217 
 for Scoliosis, 293 
 Speech, Defects of, 163 
 Stammering, 277-8 
 Stuttermg, 278 
 Spectacles, best suited to Scho- 
 lars, 291 
 for Squint, 291 
 Prices for, 246 dh note 
 Provision of, 222-3 
 
 Association for, 192, 223, 246 
 cfc note 
 Spine, Deformities of, 74, 86, 293 
 Examination of, 162 
 Tuberculosis of, 267 
 ' Spoiled ' children, in Secondary 
 
 Schools, 73 
 Squint and School Life, 
 Causes and cure, 291-2 
 in Infant scholars, 222 
 Risk from, 75 
 Stammering, defined, 277-8 
 State, the. Responsibility of, for 
 National Health, 42 et 
 seq. 
 Value to, of Children, 70 
 State Aid for Medical Inspection, 
 133-4, 135 
 Control of Health Inspection, 
 
 basis of, 35 
 Education, true place in, of 
 Medical Inspection, 79 
 a\Iedical Service (or Municipal), 
 organization of, 236 
 State Medicine, bodies responsible 
 for [tuble), 97 
 Central Department for, 
 
 needed, 96 
 Definition of, 95-6 
 Organization of, problem of, 98 
 School Hygiene in relation to, 
 
 92 et seq. 
 Subjects included under, 
 95-6 [table), 97 
 State-provided Medical Treatment, 
 231 
 
 Statistics in Annual Reports, Kerr 
 on, 207 
 of Medical Examination, Card 
 system for, 88 note, 
 166 {figs. 167-8), 189 
 of Medical Inspection, utiliza- 
 tion of, 46-7 
 Stewart, Dr. G., on Enlarged 
 Tonsils and associated 
 conditions, 287 
 Stockholm, School Dental Clinic 
 
 at, 238 
 Strasburg, Defective Teeth in 
 Scholars at, 219 
 Dental Inspection at, 220 
 School Dental Clinic at, 238, 243 
 Cost of, Jessen on, 251 
 Strumous Children : 
 
 Chronic Conjunctivitis in, 296 
 Enlarged Glands and, 288 
 Tuberculosis of, 266, 268 
 Street Contact and Spread of 
 
 Disease, 61, 62 
 Stuttering, defined, 278 
 Styes in the Eye, 290 
 Sweden, Health Inspection in, 94 
 Medical Inspection in, 126 
 
 Legislation on, 25, 27 
 Origin of Physical training in, 
 
 13, 14 
 Physically defective Children in 
 Schools of, Key's re- 
 port, 16, 17 
 Switzerland, Health Inspection in, 
 94, 126 
 Medical Inspection Legislation, 
 
 28 / 
 
 Medical Treatment in, 211, 22?/ 
 School Polyclinics in, 238 / 
 
 Symptomatic or Local Diseases and 
 School Life, 278 et seq. 
 
 Teachers, Conferences of, with 
 Parents and School 
 Doctors, 145 
 Co-operation of, in School 
 Hygiene work, 59, 64, 
 87, 106, 107, 157, 159, 
 160, 186 et passim 
 
INDEX 
 
 359 
 
 Teachers {continued) : 
 
 Duties to, and relations with, 
 of School Doctors, 83-4, 
 142, 148-9, 205 
 Handicap to,ofbadHealthCon- 
 ditions in Scholars, 77 
 Medical Supervision of, 205 
 Teaching of, in Hygiene, 83-4 
 Head, action of (usual) as to 
 Non-notifiable Dis- 
 eases, 195, 197-8 
 Duties of, as to Infectious 
 Disease, 193 et seq. 
 Teeth, see also Dental Conditions 
 Care of, teaching of, to Children, 
 
 220, 221 
 Defective, 71, 72, 219, 289 
 
 Treatment of, 219-21 
 Examination of, by School 
 Doctor, 160-1 
 Thomas, Dr. C. J., and Control of 
 
 Measles, 61 
 Thompson, W., on Defective 
 
 Eyesight, 47 
 Time occupied by Medical Ex- 
 aminations, 166 
 Time-tables, Medical Supervision 
 
 of, 85 
 Tonsilitis and School Life 
 Chronic, 282 
 Follicular, 281, 283 
 Tonsils, Enlarged, causes, conse- 
 quences, cure, 287 
 Examination of, by School 
 Doctor, 161 
 Tooth-brush, the, role of, 221 
 Town Children, Vision of, 47 
 Towns, see Large, and Small, 
 Towns 
 and Cities, growth of, and 
 results, 3, 4 
 Trachoma, 224, 296 
 Training, of School Nurses, 182 
 Training Colleges, improvement in 
 Education at, 83 
 Medical Supervision of, 205 
 Treatment, see Medical and Opera- 
 tive Treatment, see 
 also School Dental 
 Clinics, and School 
 Clinics 
 
 Tremors, 164 
 
 Tubercular Bone Affections, 266, 
 268-9 
 Treatment of, 213, 225 
 Children, Treatment for, 225 
 Meningitis, 267 
 Tuberculosis in Children, and 
 School Life, 267-9 
 Various forms, 266 
 Causes, 266 
 Results, 267 
 Symptoms, 266-7 
 Treatment, 268-9 
 Twitching of Fingers, 164 
 
 Uncleanliness, coping with, 64, 
 199-201, 219, 295, 327 
 
 Under-feeding, 39, 260 
 
 Unhealthy conditions and defects 
 in Scholars, 40 
 
 United States of America [see also 
 Boston, and New 
 York), Medical Inspec- 
 tion Legislation in, 29 
 
 Urbanization and its effects, 4 
 
 Ventilation, problem of, 38 
 Verminous Conditions and School 
 Life, 294 cC- note 
 Prevalent in London Schools, 
 
 185 
 Removal of, 199-201, 212, 
 219, 293, 327 
 Authority for, 219, 295 
 Village Dispensaries, 255 
 Virchow, Prof., in support of 
 Medical Inspection, 16 
 Vision {see also Eyesight), of 
 Country, and of Town 
 Children, 47 
 Defective in Scholars, 
 
 Backwardness from, 52 
 in England, and Germany, 
 
 221-3 
 Need for Recognition of, 70, 
 
 71, 76 
 Thompson on, 47-8 
 Three Classes of, 289-92 
 Treatment of, 213, 221 
 in Soldiers and Recruits, 15 
 
360 
 
 INDEX 
 
 Vision {continued) : 
 Tests of, 157, 159 
 
 Season for, and Methods of, 
 190-2 
 Visits of School Nurses, 173, 174, 
 175, 176, 179, Hay ward 
 on, 177 
 to Schools, of School Doctors 
 
 (1) periodical, 169 
 
 (2) annual or terminal, 169-70 
 Visual Exercises in Schools, 47-8 
 Voluntary versus Compulsory 
 
 Health Inspection, 94 
 
 Waiting-room at School Clinic, 243 
 
 War Office Memorandum, on Re- 
 jection of Recruits, 43 
 
 Ware, John, on Eyesight and 
 School work, 13 note 
 
 Warner, Dr. Francis, Investiga- 
 tion of, on Mental 
 Status of Scholars, 18 
 ' Nerve-signs ' of, 164 
 
 Whole- versus part-time Medical 
 Officerf or Schoolduties, 
 122 
 
 Whooping-cough, after-effects of, 
 and School Life, 297 
 Age-incidence of, 61 
 Widjies, School Nurses at, 174 
 Wiesbaden, Dental Inspection at, 
 220 
 Medical Inspection at, 29 
 School Hygiene in, Model organi- 
 zation of, 129 
 Wimbledon, School Nurse at, 
 scheme for, 174, exten- 
 sion of, 176-7 
 ' Word- blindness,' 276 
 ' Word-deafness,' 276 
 
 X-RAY Treatment for Ringworm 
 
 (and Favus), 216, 217, 
 
 218, 243, 244, 246, 247, 
 
 248, 252 
 
 Cost of Installation for, 252 
 
 Room for, in School Clinic, 243 
 
 Zurich, School Dental Clinic at, 
 238, 252 
 
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