MUNICIPAL MEDICAL SCHOOL

INSPECTION.*

BY NORVELLE WALLACE SHARPE, M.D., St. Louis.

WH

INTRODUCTION.

HILE it is true that municipal school inspection for the detection of disease is the result of scientific knowl

edge and research brought down to date, yet in a thesis upon such a policy, it is, without doubt, best to view its purpose and advantages from a very simple, practical and utilitarian standpoint, not emphasizing nor elaborating the scientific detail which, accumulating through the years, has finally in its culmination so equipped the medical man that he can and does speak authoritatively when he demands systematic school in spection for the detection of disease in behalf of the public weal. It is worthy of note that through the ages the Medical Faculty has been the willing and loyal servant of the public. The gratuitous service it has rendered to man is incalculable. In

times of national or world-wide distress, in the peril of contagion, in the daily needs of the general public, the medical man is, with the rarest exception, found ready and willing to shoulder responsibilities and burdens, render skilled aid, and extend to the careless, indifferent, and oft-times ignorant laity

the beneficient results of scientific research and knowledge. The logical result of this policy should be that the dictum of the Faculty, calm, dispassionate and scientific, be received with profound respect and appreciation, and its recommendations for the public good be speedily and firmly established by legislative bodies, the administration of the resulting laws being vested in the hands of skilled and conscientious men, not under the control of the professional politician nor subject to the caprice of any man nor party who, vulture-like, battens on the state for aggrandizement and the gratification of purely selfish ends. Strange to relate, this condition does not in any sense obtain. contra, such a result would be considered by many worthy citizens, otherwise well intentioned, as a delusion, a mental mirage, the utopian dream of a theorist or idealist. Note the limited power of health boards, the lack of wise and scientific municipal, state and national health laws, the widespread, bland and infantile indifference to the patent and potential value of a national department of public health. This excursion may seem to the offhand observer not germane to the subject. But to the more diligent seeker after truth it is borne home that, unfortunately, this is a vital as well as

Per

*Read before the Medical Society of City Hospital Alumni, March 16, 1899.

a just prelude to a consideration of municipal medical inspection of schools.

DIFFICULTIES.

Reflection upon the manifold difficulties and augean obstacles cast in the path of inspection, in other cities where it has been proposed; the politician, in his protean guise, ignorant of the fundamental and basic laws of health and hygiene, triumphing over the disinterested advice and urgent appeals of the scientific medical man; and the painful, sluggish indifference of the lay public to such a simple and yet efficient method of prophylaxis, bids us pause and wonder if our vaunted nineteenth century civilization and culture are what they are claimed to be. How long shall uninformed school boards ignore the right of the child to hygienic surroundings? How long are the children of the state, helpless under the caprice or indifference of the average school director, to be exposed to contagion?

PLAN.

Varying with local conditions, the plan of municipal medical school inspection comprises a daily inspection, by an accredited doctor of medicine, of all sick children of every public school in a given town. The inspector to be vested with authority to make competent examination of the sick child, under favorable surroundings, and, if necessary, to

dismiss the child from school, with advice to the parents to consult the family physician and to restrain the child from attending school until well.

RESULTS.

The practical results from this plan are: (1) Early detection of sickness in its varied forms. (2) An earlier institution of treatment in diseased conditions. conditions. (3) A checking of disease in the acute and subacute stages. (4) A diminution of chronic affections. (5) A diminished number of days of absence from school. (6) The limitation, if not actual destruction, of endemics and epidemics. (7) Improved health standard of schools. (8) Improved scholastic attainment of schools.

(1) Early detection of sickness in its varied forms.-That this result would be secured is manifest. Daily, rigorous inspection by a competent physician of all ailing or complaining children, and of those who, through an inherent stoicism or reticence, may only disclose their need objectively to the teacher, will more accurately designate diseased states, than can possibly be secured by any other means.

(2) An earlier institution of treatment in diseased conditions.-The inspector should be authorized to dismiss the sick child from school with a message to parent or guardian to consult the family physician for such treatment as may be indicated. Too often under a regime not equipped

by medical inspection, a child will attend school for several days, irritable or listless, fretful or indolent, this status not dependent upon ill-nature, but upon an actual or oncoming illness. It is but a bare statement of a fact to mention that an elevated temperature indicative of an indisposition, if not an actual infection, may often be detected in children who are perfunctorily sent to school by parents whose ignorance is their only excuse. Such children should not be permitted to remain at school, a burden to themselves, and too often a menace to the health of the entire community.

(3) A checking of disease in acute and subacute stages.-Daily inspection of a competent character will produce this result.

(4) Diminution of chronic affections will logically follow from subdivision 3.

(5) Diminished number of days of absence from school.-Early treatment effecting earlier cures will abbreviate the daily "absent record." Superficially, it may seem that a child sent home when merely unwell increases the school "absent from duty" average; yet this is not so, for the return to duty is hastened.

(6) The limitation, if not actual destruction, of endemics and epidemics, will be secured by isolating from school at the earliest date (and subsequent institution of proper home treatment) the fons et origo mali, the primary case or cases.

(7) Improved health standard of schools.-Dismissal of the actual sick and merely ailing children, raises the health average of a school.

(8) Improved scholastic attainment of schools. By retaining only the healthy child in school, higher efficiency in the daily task will be noted. Mens sana in corporoe san produces, everything else being equal, high grade work.

DEMANDS OF THE CHILD.

It is also worthy of mention that the sick child demands dismissal from school; the healthful child demands that the sick be dismissed-the first on account of its physical necessities, the second for self-preservation. Our children are justified in expecting truly hygienic school surroundings. It is their right, In no other fashion can this condition be secured than by competent daily medical supervision.

REQUISITES.

Inspection to attain a high degree of efficiency should be made under favorable conditions. The physician should not be compelled to examine children in the class-room, halls, or wardrobes. A room of suitable dimensions, reasonably secure from noise, and properly equipped, shouldbe provided for him. The equipment need not be elaborate, an ample window, an argand burner with reflector and bull's eye condenser, running

water and a sink, small table, cotton, wooden tongue depressers (to be burned after each examination), gauze, antiseptic tablets and bandages (for emergencies), and suitable culture tubes and slides (for the detection of bacterial infections), towels, stationery and two or three chairs, would doubtless be sufficient for all ordinary needs. Arrangements should be made with the local health board by which inoculated culture media should be promptly received at the laboratory, and a suitable report returned to the school and to the inspector, at the earliest opportunity. The inspector should be informed so that, cognizant of the revealed condition, he may intelligently control present and future measures; the principal of the school should also be made aware of the findings, that he may keep an accurate record, which, in the monthly report, will check the more scientific record of the medical man. Upon the discovery of a communicable disease, the infected child should be rigidly restrained from attending school, and with the co-operation of the local health board, adequate fumigating and sterilizing treatment of the school should follow, with general vaccination of the pupils in case of discovered small pox.

MEASURES OF CONTROL.

The dictum of the medical inspector should be authoritative and absolute in all schools under his supervision, in order to secure efficient and tangible results. In extraordinary issues he should be guided and controlled by a medical advisory council, to whom, under all circumstances, he is responsible; said council itself having general oversight of the entire inspection system and assuming all responsibilites for thorough and scientific results. The personnel of the medical advisory council would doubtless vary with local conditions; but the acting health commissioner, acting superintendent of the public schools, and the presiding officer of the representative medical society of the town (one lay and two medical members), would constitute a compact and efficient. body. The schools of the town should be thrown into districts, each district to be under the control of an inspector, contiguity of the schools, and their individual numerical size to control district peripheries. A small reserve or alternate staff of inspectors should be appointed, to serve as substitutes when the regular inspectors are forced by illness, absence from the city, or an emergency case, to forego the performance of their daily duty.*

*The plan of having the school inspectors form a body for the discussion of themes akin to their inspection service is in vogue in Boston, and is yielding satisfactory results. In view of the fact that such subjects, including sanitation and general hygiene, are of vital importance to the public, it is advisable that the meetings of such a body be open; and that arrangement be made whereby the proceedings be accessible to the reading and thinking public.

REMUNERATION.

The inspector should be paid for his service, from that portion of the municipal funds designated for school use and controlled by the board of education. Remuneration may be furnished in the form of a stated monthly or yearly salary, or upon a per capita basis, the number of sick children furnished by the principal and examined by the inspector to serve as a guide. The former plan would doubtless be the simpler; the latter is characterized by the greater equity. Under either system, monthly bills should be formulated by the individual inspectors upon official blanks and, after endorsement by advisory council, should be paid by the board of education, or by the constituted proper authority.

DUTIES OF THE REPRESENTATIVE OF THE SCHOOLS.

Though in the vast majority of cases the presence of a third party is unnecessary, yet it would probably be wise to enforce the personal cooperation and presence of the principal or some accredited representative at all examinations. He should, upon official blanks, furnish the school board a monthly record of the action upon and final disposition of each case under observation, said record to serve as a check upon the more elaborate and scientific memoranda furnished to the medical advisory council by the inspector.*

RESTRAINTS UPON THE INSPECTION SERVICE.

In order that the interest of the general medical profession should not be impaired, and that the right of the family to select and employ its own physician be held inviolable, the inspector should be forbidden the privilege of treating any case at the school, to solicit the child or the child's family to become a member of his private clientele, or to suggest, or outline any treatment or plan of treatment in response to the appeals of child, parent or guardian made upon the school premises. Necessarily such applications for professional care that are made at the inspector's private office, or in the thousand-and-one avenues of approach beyond and outside of the limits of the duties of his inspection service, are not under the supervision of the medical advisory council; and the inspector would be justified in acting independently in these extra-official capacities. He

*The usual objections raised by school authorities, that the principal is already overburdened with work, and can hardly assume this additional duty, should not be considered by the public. Adequate and satisfactory arrangements can readily be made; and no such trivial obstacle should be permitted to act as a bar to the beneficient results obtained by a proper medical supervision.

[APRIL 29, 1899 should, however, be permitted to serve, yielding temporary medical aid, such accident or emergency premises engaged in inspection. After the temcases as may arise while he is upon the school porary needs have been met, the child should be dismissed into the hands of the regular and proper authorities, no further services from the inspector to be permitted.

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INSPECTION DATA.

The first school inspection service performed in this country was instituted in Boston, November 1, 1894, after surmounting incredible obstacles, and only then under the stress of a severe epidemic of diphtheria. Efficiency was manifest from the beginning. Comparatively recently the Boston plan has been copied in other towns, notably New York city. Reports from the latter place denote complete satisfaction. The only plan of inspection which simulates this method is in vogue in Brussels, where "school doctors" are employed, to whom pupils are sent when suspected of being ill from infectious diseases. Those doctors are under the control of the bureau of hygiene. In this city (St. Louis) an inspection service extending over a period of eleven weeks was instituted by the Medical Society of City Hospital Alumni, and carried out under the sanction and co-operation of the local board of education. The purpose of this inspection was to demonstrate to said board of education the importance of establishing an adequate medical inspection service over the local schools. The following extract from the report of the Committee on Medical Inspection of the Medical Society of City Hospital Alumni compactly summarizes the results that were secured:

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"In the plan of organization of this service, after mature consideration, a number of schools were selected which, from their location and other circumstances, were deemed fully and fairly representative of all classes and conditions of pupils to be found in the local public school population. Schools thus selected were ten in number, and comprised those situated next north of the line of Washington avenue, extending from the river to the western city limits, the school population thus represented, embracing all classes and nationalities, and ranging from those in the eastern part, where the home conditions are of the worst, to those near the western suburbs where the home conditions are of the best. The map

submitted herewith shows the location of those schools and their relation to the municipal territory, while the figures appended hereto show the enrollment of pupils during the opening week, and at the end of the first quarter in November."

10 o'clock, and the principal must be at once notified of the presence of the physician.

3. Every pupil found ailing or thought by the teacher to be indisposed will be brought promptly to the notice of the physician for inspection-such facilities as the school may afford for the examination in private being placed at his disposal-and the principal, or his or her representative, must be present at every examination.

4. Cultures shall be taken in every suspicious case of throat disease for the purpose of bacteriological tests by the health department.

5. Wooden spatulas shall be used in making examinations of the throat, and these, when once used, must be immediately destroyed.

6. No medicine shall be given nor medical treatment extended by the physician to the pupils during such calls, but every case of illness must be at once reported to the principal with appropriate suggestions as to the proper care or disposition of the pupils found ailing; emergency aid may, however, be rendered on request of the principal.

7. No inspection of school buildings or premises on complaint of sanitary defects shall be made by the physician under any circumstances.

8. Careful records shall be kept by the physician of every case examined, which records shall include the name, age, sex and residence of the pupil, the principal symptoms observed, the ailment or disease found or suspected to exist, the action taken and recommendation made in each instance.

9. Weekly reports shall be made to the society, and a monthly synopsis of the returns submitted to the board of education.

It will be seen from an examination of the table which accompanies the report,* and which gives the complete figures for the eleven weeks' service, that a total of 1565 pupils were examined, and 1601 cases of ailments and diseases were disclosed, while it was recommended that 156 pupils in all be sent home on account of existing infirmity or disease, deemed dangerous either to the child affected or to his school associates (10 per cent). Of the total morbidity fuond, only 76 were of the kinds included in the class termed Specific Infectious Diseases, which embraces those maladies that are most to be feared among the school population, as diphtheria, scarlet fever, measles, whooping cough, etc. The cases of diphtheria found were capable of exact identification only by means of culture tests, the symptoms being mild to a degree that would not suffice to detain the child at home, but, nevertheless, were potent for continuous wide-spread communication of the infection to susceptible associates. During December, influenza manifested itself to a degree un

*Published in the MEDICAL REVIEW of February.