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to derive full benefit from schooling, upwards of 10 per cent. of the whole are the subjects of uncleanliness, and 10 per cent, also are malnourished. Disease has laid its mark on large numbers of the nation's school-going children. Probably not less than half the children are in need of dental treatment, and a substantial number, which cannot be less than half a million, are urgently so. Upwards of half a million children are so defective in eyesight as to be unable to take reasonable advantage of their lessons. Many need spectacles, some ophthalmic treatment, some should attend special 'myope classes," and all require careful attention and supervision. Next must be added diseases of the ear, throat and lymphatic glands, another quarter of a million in a relatively serious condition. Then there come skin diseases, disorders of the heart, infectious disease, and tuberculosis. Many of these children suffer from more than one disability, but a year ago a moderate computation yielded not less than a million children of school age (not, be it observed, children in school attendance) as being so physically or mentally defective or diseased as to be unable to derive reasonable benefit from the education which the State provides. In some areas successful attempts are being made to cope with this serious state of affairs, but in other districts medical treatment is in abeyance or is wholly ineffectual. Child wastage begins long before the child comes to school and continues long after he has left. Probably many local education authorities view him as “a bird of passage.” Certainly before the child comes under the observation of the school doctor he is often marked or maimed by his previous experiences. Moreover, it must be remembered that authorities are only partners in the concern of child conservation and child care, sharing responsibilities with parents and guardians or other authorities having collateral or concurrent powers. We urgently require a unification of all powers for child protection. Before the child's school days there is the great question of maternity, of the birth of the child, of the safeguarding and management of its infancy, and of its early training and nurture. The second stage comprises the nine years of school life
when the great army of child recruits comes within the prescribed control and powers of the local education authority. The third stage, when the child leaves school and passes into industry, brings with it questions of employment, of continued education, and of continued supervision in respect of physical training and medical treatment. In each of these stages there is a tendency to overlapping and confusion. The treatment of the infant, of the child under 5, of the school child, and of the adolescent falls under different and sometimes competing authorities. What is needed, therefore, is an understanding of the whole problem as one and the same problem, and an administration of the law affecting it as a unified and co-ordinated administration in every locality. Such co-operation is facilitated by the Education Act of 1902, which first associated the work of education with the English system of local government, but there is urgent need for an extension of co-ordination and cooperation if adequate progress is to be attained. It is also essential that each local education authority should have before them a clear view of the steps which are necessary from a medical point of view in order to secure the full value of the School Medical Service to every child of school age in the area. Sir George Newman seeks to formulate what he considers the irreducible minimum which will yield such results as the nation requires. They are these.: (1) That every child shall periodically come under direct medical and dental supervision, and, if found defective, shall be “ followed up”; (2) That every child found malnourished shall,, somehow or other, be nourished, and every child found verminous shall, somehow or other, be cleansed; (3) That for every sick, diseased, or defective child, skilled medical treatment shall be made available, either by the local education authority or otherwise; (4) That every child shall be educated in a wellventilated schoolroom or classroom, or in some form of open-air schoolroom classroom; (5) That every child shall have daily, organized physical exercise of appropriate character; (6) That no child of school age shall be employed for profit except under approved conditions; (7) That the school environment and the
local education authority, while the last two are supported by means of voluntary funds aided, in the case of day nurseries, by Government grants. Since 1914 the Board of Education have been in a position to pay a maintenance grant of 4d. per child per attendance of not less than nine hours. With regard to the findings of medical inspection in 1916, the following conclusions are presented : (a) The demands of the military authorities and consequential changes have deprived the School Medical Service of many members of its medical and nursing staff. Not a few children's care committees have also been stripped of useful workers. (b) As a result of a reduction in the inspecting staff an increased burden and responsibility has fallen upon the doctors, nurses and teachers remaining, which has of necessity meant less thoroughness and system. (c) In a certain number of areas it has been possible to continue the routine medical examination of age groups of children, at any rate, of the 8-year-old and leaving groups. Elsewhere the method adopted has been the inspection of “ailing" children only, and such children have been selected for medical examination by doctors, nurses, and teachers. (d) Whilst the method of inspecting ailing children brings to light the greater proportion of obvious defects and serves to retain at least the basis of an organized scheme of inspection, it possesses, as we have seen, grave disadvantages which preclude it from permanent adoption. (e) Under the circumstances it is not possible to measure or even estimate the findings of inspection for 1916, for the simple reason that it was concerned in the main with selected and defective groups of children only. This is particularly unfortunate in view (1) of the national necessities in regard to the physical condition of the people, and (2) of the exceptional circumstances obtaining in regard to the food and wages of the great
mass of the population. Speaking generally, it may be said that the percentage of defect and disease appears not
be less than in 1915, although there are some indications of slight improvement, in particular areas, in regard to malnutrition, uncleanliness, and diseases of the ear and throat. It is to be feared, however, that the disable
means of education shall be such as can in no case exert unfavourable or injurious influences upon the health, growth, and development of the child. These constitute a policy of child welfare-a minimum standard of the physical claims of the individual child. The Report provides a comprehensive view of the administration of the School Medical Service under existing conditions. The number of children in average attendance at public elementary schools during the year 1915-16 was 5,306,4'11. The number of children medically inspected during the year ending December 31, 1916, was 1,446,448. The number of medical officers, “whole-time" and "parttime," engaged in 1916 in the work of the School Medical Service was approximately 1,213, of whom 441 were employed on work of a special character. Of the remaining 772, which figure represents the number of doctors holding appointments as school medical officers and assistant school medical officers, 122 were women (working in sixty-five different areas), seventy being “ whole-time" officers. In addition there were 193 medical practitioners who undertook work at the London treatment centres. Seven women dentists were employed in five areas, and according to the Board's records there were 1,527 school employed by 286 authorities. The expenditure on the School Medical Service for 1915-16 amounted to £417,870, while the total grants in 1916 reached to £196,893. The grants for 1917 to 252 schools for mothers were £10,945 8s. 6d., and 108 day nurseries £8,077 45. 7d., or a total of £10,022 135. id. Sir George Newman devotes a section to the consideration of the care and training of children under 5, a subject which, in view of Mr. Fisher's Bill now before Parliament, deserves the fullest study. Apart from the supervision of infants by means of the Notification of Births Act and its administrative machinery, and the efforts made by infant and child welfare centres, there exist at present three types of institution available for the service of the healthy little child below the regular present school age : (1) The Infant Department of the Public Elementary School; (2) The Day Nursery; and (3) The Nursery School. The first is, of course, provided by the
ment arising from these conditions, and particularly from such disabilities as defective vision, carious teeth, rickets, rheumatism, and tuberculosis still remains serious. A highly informing section is devoted to an exposition of medical treatment and a record of the work accomplished. The organization of treatment comprises the following : (1) An adequate scheme of medical inspection and diagnosis; (2) Reference of the defective child
medical practitioner; (3) Establishment of school clinics (medical, surgical, and dental); (4) Arrangements with hospitals for treatment of school children where the private practitioner and the school clinic are unavailable and inappropriate; (5) The supply of spectacles, gratuitously or at reduced rate; (6) Remedial treatment centres for physical deformity; (7) Special schools for blind, deaf, dumb, feeble-minded, epileptic, tuberculous, or debilitated children requiring institutional treatment. Every local education authority should approach the consideration of the organization of treatment in its area from the point of view of the defective child: (1) There is the relative importance and urgency of the defect as it concerns life, health, and education; (2) There are the means already existing in the area, and which should be used before new machinery is created; and (3) there is the extent to which parents are able or willing to avail themselves of the means. Local education authorities have the duty of inspection and the power of providing treatment. For those authorities which exercise their power, Sir George Newman indicates that the following questions should be answered : (1) How many children inspected in the year are found to require medical treatment ? (2) How many of these children are, in fact, brought under treatment, either by the authority or otherwise ? (3) How many children so brought under treatment are cured, or how many are found to require treatment of a kind which is not available, or at least not availed of? (4) How many children inspected in previous years required and received treatment, and how many have been allowed to drift on without treatment? A comprehensive and effective school clinic should include the following : (1) Inspection clinic. (2) Minor
ailment clinic. (3) Dental department. (4) Skin and X-ray department. (5) Ophthalmic department. (6) Aural department. (7) School section of tuberculosis dispensary.
a study of school medical officers' reports Sir George New. man arrives at a conclusion which leads him to submit the following for the consideration of authorities : (1) Substantial and most encouraging progress has been made by many authorities, which is yielding an immeasurable volume of benefit to the children at their present age, and is safeguarding in large degree their future as healthy citizens. (2) Some authorities have not, however, made any provision for treatment and appear to be unappreciative of their responsibility to the children and to the State. Moreover, it is difficult from the reports, inspection records, and other data available to find any authority whose provision in organization or working can be considered adequate and complete. (3) Generally speaking, there seems, in view of the immediate future, to be widespread need for education authorities to pass in careful review and examination their existing arrangements for the medical treatment of school children, with the object of determining how far these arrangements are securing radical and preventive reform instead of being only palliative and temporizing To provide spectacles, to excise adenoids, to cleanse verminous children, to extract decayed teeth is good, but not the best. It is part, but not the whole. It is palliative, but not preventive. It is imperative in the time of reconstruction lying before us that we should turn off the tap as well as remove the flood, that we should stop the production of disease and prevent what is preventable. The time may be at hand when it will be incumbent upon the Board to assess its grants in aid not only on basis of the amount of expenditure incurred with the prescribed limits, but on a basis of the character and adequacy of the expenditure. (4) Further, there is still a widespread failure to apprehend, on the one hand, the intimate relation of medical treatment to the system, appliances and apparatus of education; and on the other, the absolute necessity of effective co-ordination between all agencies and authorities concerned with the health
of the child from infancy to adolescence. The child and adolescent problems are one, and the fundamental and primary issue is physical. It is an astonishing fact that anyone should expect to secure healthy adolescence, which is admittedly necessary to the very existence and future of the nation, whilst we fail to treat and remove a vast mass of disabling disease among the six million children in the State schools, partly because our understanding of treatment is too narrow, and partly because the agencies concerned are not co-ordinated and concentrated upon the focal point. (5) Lastly, a study of this great business of the medical treatment of children brings into striking relief the comprehensive and manifold services of nurses, teachers, and care committees, and regarding these Sir George Newman expresses the opinion that their work is invaluable and indispensable. The question of dental disease is dealt with in a special section. The following conditions are indicated as necessary for the carrying out of a satisfactory dental scheme : (1) The arrangements, including the keeping of records, should be under the control and supervision of the school medical officer, on whose staff the dentist undertaking the work should be formally appointed. (2) Dental inspection should be carried out by a qualified dentist, preferably by the dentist undertaking the treatment. In exceptional circumstances the Board are prepared, in the case of rural areas, to consider proposals for the school medical officer or assistant school medical officer to undertake dental inspec. tion, provided that it can be shown that they are conversant with the indications pointing to the need for conservative dental treatment, and are competent to perform (a) adequate dental examination with probe and mirror; (b) proper dental recording. Dental inspection should, as a rule, take place on the school premises and in school hours. It is not advisable that children should be sent to the private houses or surgeries of dentists. (3) Attention should be concentrated in the first instance on the group of children from 6 to 8 years of age. Some dentists prefer to begin with 5-year-old children. The “critical age” is, of course, the time of the emergence of the permanent teeth. (4) An accurate record should be
kept of each mouth examined and of the treatment carried out. (5) The treatment should be conservative in character, and accordingly the bulk of the treatment work should be by filling rather than by extraction. Conservative dentistry includes also preventive measures, such extraction work as contributes to the preservation of the dentition as a whole, and any mechanical devices necessary to regulate the teeth. (6) A school nurse, or other qualified attendant, should be present to assist the dentist at the time of treatment. The attendance of a qualified nurse is desirable for two purposes : (a) Attending to children before, during, or after anæsthesia, and dealing with nervous children. (6) Assisting the dentist and saving his time by sterilizing instruments, preparing filling materials, filling up charts and treatment registers. The substitution of an unqualified assistant for a properly trained nurse may be inevitable on occasion, but the arrangement cannot be regarded as satisfactory. Apart from the greater experience of the latter in dealing with frightened nervous children, there is always the possibility of hæmorrhage or other complications to be considered. In such emergencies an inexperienced substitute may be a source of anxiety and confusion. (7) General anæsthetics, if required, should in all cases be administered by one of the authority's medical officers, or by some other qualified medical practitioner. In regard to the need for experienced anæsthetists for the purpose of general anæsthesia, the following suggestions may be taken as furnishing the proper standard : (a) When any general anæsthetic is necessary, it should not be given by the operator, except in case of exceptional emergency. (b) The proper course for the local education authority is to appoint a qualified medical man (whether a competent member of their staff, a local medical practitioner, or a specialist) as anæsthetist for all general anæsthetics in school dental clinics. (c) If nitrous oxide gas is the only general anæsthetic used, there is no objection to one of the appointed school dentists giving the gas for another dentist. (8) Provision should, as far as practicable, be made for the re-examination at intervals of not more than a year, of children who have received dental treatment, and for supplementary treatment if such is found to be necessary. The annual re-inspection of children also who have passed through the dentist's hands is at least as important as the inspection and treatment of new cases; if this work is allowed to get seriously into arrears the benefit of conservative work done will be largely nullified. The periodical inspection of children with healthy dentures is most important; the consent of parents who at the time of the previous inspection refused to have their children treated should again be sought. (9) The accommodation proposed for a dental clinic should include as a minimum (a) a playroom or waiting room, (b) an operating room (with good north light preferably), and (c) a small rinsing room, which can be used also for recovery after the administration of an anæsthetic. (10) The dental scheme should be appropriately co-ordinated with the whole scheme of treatment devised by the authority, particularly that part of it concerned with the therapeutics of the ear, nose, and throat, the tuberculosis dispensary, and institutions such as open-air schools, children's sanatoria, and residential recovery schools. An adequate account of the work carried out should appear in the school medical officer's annual report to the Board. A special section is devoted to special schools for blind, deaf, defective and epileptic children. With regard to the blind, the following recommendations are given of the Departmental Committee on the Welfare of the Blind appointed in 1914: “To consider the present condition of the blind in the United Kingdom and the means available for (a) their industrial or professional training, and (6) their assistance, and to make recommendations : (a) The attention of elementary education authorities should be drawn to the imperative necessity of seeing that all possible steps are taken to discover the aptitudes of blind pupils. (6) Residential institutions should be regarded as preferable to day centres for the majority of young children. (c) The employment of blind teachers wherever practicable should be encou
couraged, and the salaries of blind teachers should be on an equality with those of sighted teachers. (d) The Committee have no doubt that the Educa
tion Department will give their closest attention to the need for Braille books, which the National Institute for the Blind is endeavouring to meet. (e) The education authorities should take steps to increase the number of schools or classes for the separate treatment of myopic and partially sighted children. (1) The provision of a system of public elementary education in Ireland should be established at the earliest opportunity. (g) A uniform scheme of after-care should be initiated in the elementary education system, and we recommend that a detailed register should be made of all the children in the elementary schools, and that, by means of paid visitors, the elementary education authorities should keep in touch with the children leaving elementary schools until they are transferred to the care of either a secondary education authority or some recognized organization for the blind. The central authority (the establishment of which is recommended by the Committee) should work out details of this scheme in conjunction with the education departments."
. A highly suggestive section deals with modern views and methods of so-called open-air education. It is shown that the open-air method of education is applicable for children in public elementary schools in the following ways : (1) Classes held in playgrounds of public elementary schools for the instruction of children who are normal or apparently suffering from malnutrition or other physical defects. (2) Classes held in public parks or open spaces. (3) "School journeys " which provide for the withdrawal of children from public elementary schools for periods varying from one day to three weeks for instruction at the seaside or in the country. (4) Holiday camps, night camps, &c. (5) Open-air classrooms in public elementary schools. (6) Open-air day special schools. (7) Openair residential school of recovery for the treatment and education of children suffering from severe debility or other disabling conditions. A timely exposition appears on “ The Teaching of Mothercraft," and in these days should receive special consideration. Here is Sir George Newman's conclusion : Whilst there is need for various types of institution for promulgating this gospel of healthy